Keywords

1 Approaching Affective Sexual Health and Cultural Diversity

Applying a health promotion approach in the sphere of international health care and immigrant populations —in which the subjects covered are often associated with significant cultural baggage and emotional burdens—requires leveraging social construction processes from an intercultural and gender perspective. In doing so, the participating population abandons its role as a potentially ill or at-risk population and instead becomes an agent for the transformation of its health condition. These processes, especially with regard to affective sexual health (ASH), are influenced by a number of different biological, psychological, social, cultural, economic, historic, religious, and spiritual determining factors (Health Department, 2013). Working across all of these dimensions is a challenge that requires participative, innovative, and creative methodologies within the community through co-creation processes, with the goal of producing citizens who are capable of expressing themselves, identifying their problems and needs, drafting proposals, and contributing to decision-making with regard to health jointly with health care services and other sectors of civil society.

Artistic expressions are inherent to and essential for humans, and they offer a broad range of highly valuable and powerful tools to express feelings and communications between individuals and groups and to achieve change in people’s lives. Art is a part of community life (see Chap. 1, Sect. 1.1). Deliberate, methodological use of these expressive outlets promotes health and self-knowledge among people for mental, emotional, physical, spiritual, and social well-being (Ganim 1999; Gysin and Sorín 2011; Knill et al. 2005; Solari 2015).

The Diverxualitat program emerged from the melding of art and co-creation in the fields of international health care, affective sexual health, and interculturality. Diverxualitat is a part of the innovative Espictools-Actua health promotion program—from the ESPiC team (equip salut pública i comunitària/community and public health team) of the International Health Unit Drassanes – Hospital Universitari Vall d’Hebron (Barcelona)—which generates evidence-based educational tools (Espictools) through a scientific-based process of artistic co-creation with the communities and in which different art forms are used throughout its different phases (Avaria Saavedra and Gómez i Prat 2008; Gómez i Prat et al. 2001; Gómez i Prat et al. 2015; Ouaarab Essadek et al. 2017; Sanmartino et al. 2015). These educational tools are a part of the community intervention strategies that can be combined with different informative, educational, or communicative actions (Claveria Guiu et al. 2017; Essadek et al. 2018).

Before delving into the details of the Diverxualitat Espictools program, we provide some background on the Espictools-Actua model to elaborate on the framework that guides the co-creation process in this program.

2 Espictools-Actua

Espictools-Actua (educational tools – community interventions) is a model developed by the authors in 2017 that uses art and culture as instruments to facilitate the creation of new tools and strategies to promote health through a process of artistic co-creation among migrant populations, local artists, and members of the health team. It is especially focused on immigrant populations facing a situation of vulnerability by supporting their own development, based, in turn, on the theories of co-creation (Beran et al. 2018; Holmboe et al. 2016), peer education, and communications models as strategies for social change (Boyle et al. 2011; Kirby et al. 2006; Sriranganathan et al. 2010). Espictools-Actua is structured in two phases, described below.

2.1 Phase 1—Espictools: Creating the Educational Tool

To begin, it is worth discussing needs analyses and asset analyses. One of the most common errors when it comes to starting community interventions is to believe that we (the health team members) are the community’s only resource or its most important resource, and that health is the community’s main center of interest; in reality, the community has many other concerns, and educational, social, cultural, or leisure resources may play an even more relevant and prominent role than health care. Self-knowledge and knowledge of others, the environment, extant policies and programs, active organizations, social spaces, available means of communication, and a “mapping” of the relationships maintained by different figures of society throughout the area allows us to carry out an analysis of the landscape from another point of view, helping to define potential areas for change and providing individuals and groups with assistance when it comes to discovering their potential and that of others. Therefore, based on any needs that have been detected, educational tool development is carried out in two stages as follows.

Participative research study

This study is conducted through workshops/focus groups carried out in the educational, health care, and community fields. Each workshop or focus group is facilitated by different professionals (e.g., art therapists, community workers, nurses, community health agents, physicians, and anthropologists). Recruitment for these groups is carried out by all the people involved in the program, taking into account the profile of the people they are working with and their needs. These workshops are intended to provide a forum for creativity and mutual exchange in which resources that may contribute to improving or maintaining their well-being can be brought to light. Through different exercises, projects, and forms of artistic expression, participants approach the core subject of the work by exposing their personal and group realities and discovering new possibilities to approach them, along with offering tools that help promote health with regard to the topic being discussed. At the end of this stage, the attitudes and responses from the participants are collected, in a structured way.

Designing and creating an educational tool

These tools may be created by professionals who participated in the first stage (using the results that have been obtained). Alternatively, workshops can be organized with participants from the first phase, conducted by a team of professionals with expertise in community work and health care educational materials. Throughout these workshops, new tools (e.g., educational videos, animation videos created by participants using mobile applications, and board games) are produced from an intercultural point of view in collaboration with participants. These new tools stem from the entirety of the information and results that were collected throughout the first phase and take into account the proposals concerning the format, content, and structure of the type of tool that could help improve access to the subject in question and its quality in the participants’ environment. At the end of this stage, a number of workshops are carried out with different community groups, as well as a pilot test to assess the effectiveness of the tools and to rate their impact through several surveys. Once the effectiveness of the newly created tools has been assessed, they will be used in the next phase of action by participants and by professionals from the subject areas in their environments.

2.2 Phase 2—Espictools-Actua: Actions and Implementation of the Tools in the Community

Based on the results of the first phase, the following stages are carried out in Phase 2 of Espictools-Actua.

Training in the use of the new tools

This training involves a basic training action intended for health care professionals in order to qualify them to use this tool in their professional practice, as well as another broader training program intended for active members of the community in order to qualify them as peer educators so that they may act in their environments using the newly created tools.

Interventions and actions with and for the community

Trained participants carry out a number of workshops and activities at the individual, group, and community levels through the action plan, using the new tools for the promotion of health—especially in the covered subject area—from an intercultural and gender perspective, in their environments.

Throughout these phases, questionnaires are used to assess participants’ satisfaction. At the end of the process, a joint assessment report with all the parties involved in the project is drafted concerning the most relevant aspects to be maintained, improved, or modified in the future with regard to the design and development of the program.

2.3 The Espictools-Actua Programs: Different Educational Tools for Different Needs

Espictools-Actua is currently developed through different health promotion programs in the international and immigration health spheres, mainly in the city of Barcelona and in Catalonia. Each program contains a variety of educational tools on subjects of interest that can be established and adapted as appropriate to different community groups, and which are provided to professionals and active members of the community working in this field. The following is a list of the available programs and educational tools (www.espictools.cat):

  1. 1.

    The XarChagas (ChagasNet) program, which is intended to guarantee access to comprehensive care for Chagas disease. It contains the following Espictools:

    • Music: “El viatge de l’heroi” (The Hero’s Trip) (Catalan); “A vida da gente poder ser melhor” (Our Lives Can Be Better) (Portuguese); and “Las palabras no dan miedo” (Words Are Not Scary) (Spanish). These songs have been composed specifically to raise awareness about Chagas disease and its reality.

    • Documentary film: “Saber o no saber: me siento bien, dicen que tengo la enfermedad de Chagas” (To Know or Not to Know: I Feel Good, They Say that I Have Chagas Disease). Through the experiences of the characters in the film (people affected by Chagas disease), viewers can learn about the reality of the disease far from their countries of origin.

    • Spots: “Accessibilitat al diagnòstic i tractament de la malaltia de Chagas” (Accessibility to the Diagnosis and Treatment of Chagas Disease) and “Transmissió congènita malaltia de Chagas” (Congenital Chagas Disease Transmission). These two spots—with the participation of a public figure (football/soccer player Leo Messi)—are used to reflect on the reality of Chagas disease in the world and raise awareness of the subject.

  2. 2.

    The “Tbactiva’t” (TB activation) program, which is intended to strengthen networking for active surveillance against tuberculosis. This program contains the following Espictools:

    • Video: “TB” (available in Spanish, Arabic, Urdu, Chinese, and Romanian), an educational film with a fictional story that provides knowledge about tuberculosis and its determining factors, assisting in detection and follow-up for affected people. It is structured around two parts: a 30-minute fictional story and a 7-minute guide video in which a number of subjects to be discussed are proposed based on specific questions.

    • Teaching guide: “Manual TB” (available in Spanish, Arabic, Urdu, Chinese, and Romanian), a teaching guide intended to promote understanding of tuberculosis. It has been drafted as a companion document to the video “TB.”

  3. 3.

    The “Around Me” program seeks to put all aspects related to the determining factors of health on the table through collective reflection. It contains the Espictool “Around Me,” a game that covers the determining factors of health in a dynamic way. It is available in Catalan, Spanish, English, French, and Italian.

  4. 4.

    The Diverxualitat (diversity and sexuality) program, intended to improve access to affective sexual health. This program will be explained in detail in the next section and contains the following Espictools:

    • Animated features: “Broken Condom” and “The Photograph”

    • Board game: “SIDAJoc”

    • Teaching support tool: “Heparjoc”

3 The Diverxualitat Program: Improving Access to ASH

The Diverxualitat program is intended to improve access to ASH within the various communities of immigrants residing in Barcelona and Catalonia. Diverxualitat is focused on the process of co-creation with the community based on the methodological framework of the Espictools-Actua model aforementioned. It is grounded in two principal concepts: The first is the fact that the definitions and perceptions of the community exert significant influence on the context of the affective sexual health of the population. Aspects such as fostering women’s ability to make decisions affecting their health or improving the perception of preventive measures such as condoms are clear examples of actions to be carried out at both the individual and community levels. The second concept is the use of expressive arts from an intercultural perspective in the scope of ASH that is available to most of the population, thus generating creative processes led by the community and giving rise to a number of highly valuable and effective tools based on both scientific knowledge and the humanities—namely, Diverxualitat Espictools.

3.1 Diverxualitat Espictools: The Tools of the Diverxualitat Program

The following Espictools have been created for the Diverxualitat program:

  1. 1.

    SIDAJoc (available in Catalan, Spanish, English, French, and Portuguese) is a game based on pictures and questions to gain in-depth knowledge about different situations associated with HIV/AIDS in order to promote reflection and knowledge of this disease. It is intended for immigrants, especially those from sub-Saharan Africa. It emerged from a need that was detected during daily practice for educational support material to provide engaging information and education in order to improve testing and promote healthy attitudes toward prevention. The research process that was the basis for this educational tool emerged as a consequence of an initiative to train African women as community health agents—through the Drassanes-Vall d’Hebron International Health Unit (ICS) and ACSAR (Catalan Association of Solidarity and Assistance to Refugees) in Barcelona; AIDS & Mobility in Amsterdam; the Service Social des Étrangers in Brussels; and AIDES (www.aides.org) in Paris—between the years 1999 and 2000, with the support of the EEC (European Commission) and the AIDS Prevention and Assistance Programme of the Ministry of Health of the Catalan Regional Government.

    SIDAJoc is among the first HIV/AIDS prevention materials that are provided to African women residing in Barcelona after their immigration. We know that, in a relaxed and dynamic working environment, participants are much more open when it comes to verbalizing their beliefs and doubts. This is especially relevant when it comes to covering subjects such as HIV/AIDS, which often evoke significant emotional and cultural baggage. That is why SIDAJoc is intended to draw people closer together through its visual format (drawings representing different situations such as sexual relations, pregnancy, and drugs, all of which are related to the situations to be covered when delving into the reality of HIV/AIDS) (Fig. 14.1), thus allowing people to identify with the different situations being put forth.

    This game is intended to facilitate dynamic, playful health information sessions while assessing the knowledge of participants. In addition, it provides a tool that is able to consider and adapt to the peculiarities of the cultural differences of various ethnic groups. This tool is most commonly used in the context of workshops.

  2. 2.

    HEPARJoc (available in Spanish and English and including an animation video available in Spanish, English, Catalan, Urdu, Arabic, French and Romanian) is a game based on pictures and questions whose purpose is to share knowledge about viral hepatitis, especially hepatitis B (HB), and to raise awareness of the importance of diagnosing these infections early on. It is a teaching support tool in digital format to raise awareness among immigrant populations and to promote the detection of hepatitis among vulnerable groups. It emerged from a need that was detected due to the high prevalence of HB in the sub-Saharan immigrant population in Barcelona (Manzardo et al. 2008). HEPARJoc was created based on qualitative research carried out through a number of groups drawn from the sub-Saharan African immigrant population. A qualitative, descriptive, and interpretive study with a phenomenological focus was conducted in May 2015 through focus groups (Ouaarab Essadek et al. 2017). Immigrants of different ages and genders from sub-Saharan Africa who reside in Catalonia were recruited through community health agents. Their knowledge and opinions on HB were analyzed, along with strategies to motivate people from their community to undergo screenings. Conclusions included messages to be worked on and a lack of knowledge of basic facts, modes of contagion, diagnosis, treatment, and means for prevention.

    HEPARJoc features a “kit” of five dynamic activities that are carried out in a workshop lasting approximately one hour. The first four activities are games based on pictures that participants must associate with or identify. The fifth activity is an animation feature that was produced to promote hepatitis screenings (Fig. 14.2). The workshop is based on guided participation by a group coordinator who involves participants in the processes of the game in a fun and dynamic way. HEPARJoc requires a monitor (health care personnel, normally a community health agent), as well as access to diagnosis for vulnerable populations.

  3. 3.

    DIVERXUAL is geared toward full integration by improving access to ASH among the immigrant population in Catalonia and providing practical knowledge and tools to health care professionals. It emerged from the need to draw health care services closer to the immigrant population with regard to ASH. It contains the animation videos “The Photograph” (Fig. 14.3) and “Broken Condom” (available in Catalan, Spanish, and English). The videos are the result of a research process based on a qualitative, descriptive pilot study whose objective was to evaluate health care approaches for access to sexual and reproductive health rights for women of reproductive age and of immigrant origin in Catalonia (Gómez i Prat et al. 2015). In order to create these videos, a diagnosis was carried out through interviews and discussion groups with a number of professionals and the immigrant population from September to November 2014. This diagnosis gave rise to the following: 1) the creation of a guide whose goal is to provide access to the proper tools for health care professionals to improve access to ASH for immigrant men and women, and 2) the creation of the two animation videos mentioned above. Both videos are geared toward health care professionals and those who cover cases of violence (from a health care perspective) who seek to allow access to sexual and reproductive health rights for these women.

    These animation videos were created with the writer and screenwriter Mario Torrecillas, his PDA (Pequeños Dibujos Animados – Small Cartoons) team, and its artists and animators. The animations were voiced and the script was completed through an eight-hour workshop with young immigrants of different origins. Through this workshop, the PDA-FILMS production company, with the technical cooperation of the Community Health Unit of Salut Internacional Drassanes – Vall d’Hebron, considered the barriers that young immigrants face when it comes to accessing affective sexual and reproductive health. A group of ten young people from different countries (Morocco, Pakistan, Romania, Bolivia, Ecuador, Senegal, and Equatorial Guinea) were selected for the purpose of creating the materials (Fig. 14.4). The definition of access to affective sexual and reproductive health provided by the WHO (2007) was used as the common thread for the workshop, as well as the scripts that were suggested.

Fig. 14.1
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Board game SIDAJoc

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Fig. 14.2
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The HEPARJoc menu

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Fig. 14.3
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A frame from the animation video. (“The Photograph” (2015))

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Fig. 14.4
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Voice recording with young people from the Diverxual workshop (Barcelona, 2015)

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The videos reflect the barriers and difficulties confronted by both immigrants attempting to access affective sexual and reproductive health care, and by health care professionals when they perform sexual health tasks with immigrants. This unique material reflects two different experiences of the same encounter. The purpose of the two pilot videos is to draw the attention of both immigrants and professionals so that they have a chance to reflect on the stories told in the animation videos.

3.2 Diverxualitat Actua: The Interventions of the Diverxualitat Programs

3.2.1 Train to Act

In order to transform perceptions and attitudes—both in people and in communities (territories in which a determined population lives, has certain requests and needs, and which may or may not rely on given resources)—it is necessary to have an educative process that supports this transformation. The intention is to achieve the generation of another reality and paradigm by parting from a previous reality and paradigm (Diaz Bordenave 1998). This work in the community should gradually improve the acceptability of the health care system to its people, which consequently will cause access to the health care system to improve (Tanahashi 1978).

The different Espictools from the Diverxualitat program (SIDAJoc, HEPARJoc, and the animation videos) or from other programs (e.g., the song “Las palabras no dan miedo”) are designed, within the framework of a community intervention, to educate. From the standpoint of community health teams, it is important to train health care professionals—including active community members and peer educators— in processes of artistic co-creation and intercultural competences so that they are able to carry out the different community interventions in health based on co-creation processes to promote affective sexual health along with entities of civil society. For this purpose, our team created “Train to Act” in 2008 with the goal of training peer educators in the use of the different educational tools (Espictools) so that they may serve in the community with their peers.

Health professionals

Training health professionals is a key factor when it comes to integrating health in the community. One training strategy used is a workshop on sexual health and cultural diversity. The workshop begins by viewing the two animated videos aforementioned to later generate a discussion space. By providing health care professionals with knowledge and practical tools related to ASH, they have the opportunity to change their attitudes toward cultural diversity. This, in turn, allows health system users to be treated with more understanding. In 2018, three cycles of training were performed for primary health care professionals in the city of Barcelona. Over 300 professionals attended the course; one of the topics covered was sexuality and cultural diversity. There was a significant level of interaction from participants, and there are numerous examples of interactions from the debate forum of the two videos that have reinforced the role of artistic expression in knowledge acquisition. One participant said:

It is true that, in our daily life, we occasionally contact people from different countries and ethnicities. Communication is sometimes difficult, as they cannot understand what we are attempting to explain to them and we cannot understand what they are telling us, as words, expressions and needs are different for both of us. This often makes providing quality care difficult if nobody is around to help us ‘interpret’ each other. We should never underestimate the knowledge, doubts or fears of our patients; this will make us better professionals and allow us to provide better care, earn their trust and encourage them to return whenever they have problems, especially with regard to sexual health, which is still a taboo among many people nowadays. It is important to attend [to] people as a whole.

Another participant said:

We often put ourselves in other people’s shoes but we fail to take cultural values into account. Some things that are very simple for us may be baffling to someone else. This has made me think.

Finally, another participant stated:

These videos invite us to reflect on the person in front of us and in whose shoes we sometimes fail to put ourselves. We should be able to understand their bio-psycho-social situation and be open to interculturality.

Peer educators

Training peer educators is the key to reaching the most vulnerable groups and empowering the community. This training is aimed at different groups of vulnerable immigrants. The objective is to intervene in the community using educational tools formed through a co-creation process inside of the community. In 2018, the project “Pilot Hepatitis C Micro-Elimination Strategy in Pakistani Immigrants in Catalonia through the Implementation of a Community Intervention” began, with the goal of implementing and assessing the acceptability, effectiveness, and costs of a community intervention based on HCV prevention and screening and linking to care (LTC) focused on Pakistani immigrants in Catalonia . In order to do this, two people from the Pakistani community (one community health agent and one peer educator) were trained through the program “Train to Act.” Their goal was to carry out community interventions with their respective peers through a one-hour workshop using the educational tool HEPARJoc, and administer quick tests afterward for hepatitis C (Fig. 14.5a).

Fig. 14.5
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(a) Preparation of the community health agent to administer the quick test (top); community intervention: (b) HEPARJoc workshop (bottom, left, 2018) and (c) execution of quick test (bottom, right, 2019)

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The way the program is conducted currently, using the development of HEPARJoc in 2015 as a starting point, people in the community are detected through community health agents and peer educators, who were previously trained to conduct a workshop using the HEPARJoc tool (Fig. 14.5b, c). They involve different entities of civil society in the Pakistani community throughout the entire process of this project.

3.2.2 Community Actions

Once they have been trained in the use of the educational tools in the Diverxualitat program (SIDAJoc and HEPARJoc), peer educators and community health agents conduct a number of workshops and activities at the individual, group, and community levels, using the educational tools for which they have been trained in order to promote affective sexual health from an intercultural and gender perspective with their peers in their own environments. Normally, through social networks (associations, parties, family homes, and public places), community health agents call people to attend the different workshops. Figure 14.6 shows one example of one workshop with SIDAJoc (Fig. 14.6). These strategies allow us to reach hard-to-access populations, thus promoting affective sexual health among vulnerable populations that operate on the margins of the health care system with regard to these subjects.

Fig. 14.6
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SIDAJoc workshop with a Pakistani peer educator trained in the workshops

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4 Conclusion

The Espictools-Actua program is a model for an innovative and dynamic co-creation artistic process that promotes an intercultural, global, and interdisciplinary/intersectoral educational approach—involving peer educators, community health agents, community workers, anthropologists, sociologists, art therapists, artists, the community, designers, community nursing, epidemiologists, and medical doctors. It is a program that is adapted to the needs and particularities of each specific community for more integral, fair, and sustainable care. Incorporating art in both research and in the tool itself implies added value that opens new approaches for the promotion of health.

Each phase of Espictools-Actua takes into account a point of return to the community, either by organizing dissemination exhibitions of project participants’ artistic creations, or by carrying out community interventions using the tools created based on community proposals. These actions may allow for the creation of a network of community assets for fair affective sexual health promotion using these educational tools. In addition, the fact that this approach allows for a boost in the capacity of the target population to start from its own needs and realities to understand and manage what is happening (including the effects of inequality), to face these needs and realities by becoming aware of their own capabilities and of what must be changed, and to work jointly with professionals and other assets from different sectors will ensure that the approach will endure over time.

The specific features of this experience may be applied to other groups by tailoring the length, methodology, and tools to suit the specific needs of the population being acted upon (according to age, gender, type of group, place of residence, etc.).

These interventions have been framed within broader work on information, education, and communication, which has been conducted since the beginning of the current study in ESPiC. This education process becomes necessary to overcome the psycho-social and cultural barriers that are present. Programs like this, with community health agents, have also been used successfully for other diseases such as HIV in adolescents and in other types of health care, such as primary care and mother/child health care (Austin-Evelyn et al. 2017; Koon et al. 2013; Mwai et al. 2013). This suggests that the presence of community health agents improves the effectiveness of community interventions.

In any case, we have been able to verify how difficult it is to incorporate this approach systematically. Despite the variety of experiences that point toward art as a key element in the success of health programs through community empowerment, there is still a need for more studies that describe their results in detail. This situation reflects one of the problems that appears in different studies that discuss the lack of clear evaluative criteria, and whether or not these can be interpreted as an effect of art. Because of this, it is necessary to evaluate the success of these community interventions further than their impact on health by examining their social effects on the community and analyzing their consequences for promoting autonomy. It is also necessary to strive to standardize, as much as possible, a methodology that guarantees maximum correlation between the objectives and the results.

As we highlighted at the beginning of this chapter, we know that artistic expressions are inherent and essential to humans, and that art of all forms are a part of community life. For this reason, the bio-psycho-social and multidisciplinary approach of these community interventions requires a multidisciplinary team. Community-based interventions, involving community health teams with a holistic approach, are highly useful in improving access to screening, increasing knowledge of ASH, and combating the psycho-social and cultural barriers to diagnosis. The intervention explained in this chapter is a viable way to work dialogically between health teams and communities.