Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, USA
*Corresponding author: Megan T. Ebor, Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California, 760 Westwood Plaza, Los Angeles, CA 90095, USA
Received Date: 28 January, 2021; Accepted Date: 10 February, 2021; Published Date: 16 February, 2021
Objectives: The focus of this paper is to describe the development of a culturally congruent narrative educational film entitled, “TRY,” (an acronym for “Translating Research for You”) which is intended to translate public health intervention research for underserved Black and Latinx persons living with HIV during the COVID-19 global pandemic.
Study Design: This is an exploratory study using Entertainment-Education (E-E) communication strategies, the health belief model, and social cognitive theory to develop an educational film designed to complement the manualized content of an ongoing, evidence-based public health intervention entitled, “Healing our Hearts, Minds, and Bodies.,” (HHMB). Healing our Hearts Minds and Bodies is a novel blended, culturally congruent, evidence-informed care model that has a hybrid Type 2 effectiveness/implementation study design (Hamilton AB, Brown A, Loeb T, Chin D, Grills C, Cooley-Strickland M, et al. Enhancing patient and organizational readiness for cardiovascular risk reduction among Black and Latinx patients living with HIV: study protocol. Prog Cardiovasc Dis 2020; 63:101-108).
Methods: Multi-disciplinary public health researchers invited media professionals, local artists, and community-based organizations to collaborate in creating a narrative film using an E-E communication strategy. The film was developed to translate the HHMB public health preventive intervention to reinforce the uptake of health affirming strategies taught through psycho-educational group sessions that were initially in-person but -- because of COVID-19 guidelines -- are now being implemented virtually.
Results: Using the five elements for effective E-E via narrative film, local artists, media professionals, community-based organizations and researchers/interventionists were able to successfully collaborate at each stage of the educational filmmaking process. Through this process, a culturally congruent, custom-tailored film was designed to address the needs of Black and Latinx persons living with HIV with histories of trauma and cardiovascular disease risk during the COVID-19 pandemic.
Conclusions: Public health researchers and healthcare providers have had to modify traditional methods and develop innovative practices to implement COVID-19-era safe strategies. This paper reports on the translation of an existing intervention for a vulnerable population by developing and integrating film as a novel artistic component. The feasibility and potential benefits of involving the arts in public health research through a virtual platform is a meritorious approach for promoting health and wellness that should be encouraged.
Black and Latinx people living with HIV; Cardiovascular risk; Entertainment-Education; Film; Intervention; Trauma
COVID-19 is a rapidly evolving global public health crisis that poses disproportionate risk for those who are immunocompromised and/or living with underlying medical conditions; they are at greater risk for more severe illness and possibly death . In the United States (US), a group vulnerable to the adverse health effects of COVID-19 is People living with HIV (PLWH), particularly those who are Black and Latinx. Emerging research indicates a heightened risk for racial/ethnic minorities who have long experienced health disparities, chronic diseases, and co-morbidities that drive COVID-19 related mortality [2-5]. Although Black and Latinx people comprise 13% and 18% of the US population, respectively, they have COVID-19 mortality rates that are 2.1 and 1.1 times higher, respectively, than Whites [6,7]. This disparity in US mortality rates is even higher when comparing Black and Latinx PLWH with White PLWH.  Given these challenges, novel prevention methods are needed in public health that specifically target these highly vulnerable populations. Culturally relevant, theoretically-driven methods that involve the arts hold tremendous promise . Importantly, these methods must follow COVID-19 prevention guidelines, such as those established by the Centers for Disease Control and Prevention .
Researchers and healthcare providers have had to adapt traditional methods of practice to implement COVID-19-era safe strategies for engaging, treating, and researching patients in the medical community. Examples include the delivery of virtual programming in social services,  modifying intervention implementation in research,  and telehealth in the health and mental healthcare professions . However, many of these modified methods rely on a level of access to resources (e.g., Internet, software, hardware) that is not equal among patient populations. In the US, 66% of Black and 61% of Latinx people have Internet access in their homes as compared to 79% of White people. Research shows that racial minorities, persons with lower income and educational levels are less inclined to have home-based Internet service . This represents an inequity that compounds access to public health services during the COVID-19 pandemic.
While the devastating and disproportionate impact of COVID-19 on racial and ethnic minorities is recognized, economic and social deprivation in relation to these disparities have been underexamined. A recent study conducted by the CDC found that area-level deprivation could intensify the ethnic and racial inequalities in COVID-19 morbidity and mortality [14-17]. Among those with COVID-19 as well as HIV, one of the greatest mortality risk factors is poverty [18,19]. Black and Latinx PLWH (BLPLWH) are over-represented in the poverty level [20,21] making them more susceptible to COVID-19 infection and mortality. Poverty is also associated with increased illiteracy and decreased access to resources that promote health and well-being . Creative methods are essential for engaging and maintaining their participation in life-saving preventive health interventions, as Black and Latinx people are notoriously challenging to recruit and retain in research protocols [23-25], in part due to historic maltreatment and resultant distrust of scientific research studies [25-27].
Arts-based methods for health promotion and prevention for BLPLWH in the US are underutilized yet promising. For example, they such approaches circumvent the literacy challenge and depending on how they are developed and applied-may be culturally and contextually relevant, and highly engaging. These are factors that may increase public health intervention participation and retention rates for Black and Latinx populations, in part because they compensate for the perceived power differential between those who typically develop the interventions and those who receive them. Lack of awareness or consideration of nuanced challenges experienced by Black and Latinx populations contributes to the poor uptake of formal mainstream interventions. It creates a need for alternate, culturally congruent interventions and their application. A novel and creative approach that involves the arts and has been applied to public health is Entertainment-Education (E-E). Entertainment Education is an approach that integrates educational content into arts or entertainment media by using communication purposefully to change or reinforce beliefs, values, attitudes, or social practices of the audience . E-E provides a unique methodology that may be used to deliver evidence-based principles to under-resourced populations in a culturally congruent and relatable manner. E-E projects have been used as early as 1970 to improve health; most have been implemented within resource constrained and developing countries. E-E methods designed for health promotion can facilitate emotional responses that may increase uptake in challenged communities, as the intervention content is presented as realistic and culturally relatable . Examples of successful implementation of E-E methods in public health that have integrated culturally tailored media effectively include programming to improve weight management, physical activity, HPV vaccination series completion rates among African Americans, and increased awareness and knowledge of HIV [30-34].
It is critically important to ensure that racial/ethnic groups that are disproportionately impacted by both HIV and COVID-19 have access to information that is contextualized to their needs, culture, and environment. Film is a particularly relevant art form when it involves characters and scenarios that audiences identify with and emotionally attach to.  Public and behavioral health practitioners who utilize E-E methods are uniquely positioned to develop intervention strategies by merging the arts and research to address the intersecting vulnerabilities of BLPLWH and the COVID-19 pandemic. One such methodology is currently being implemented and evaluated in public health clinics serving BLPLWH and AIDS including patients living in deep poverty. This manuscript describes the development of a culturally congruent E-E film that builds upon ongoing research funded by the National Institutes of Health. A novel blended, culturally congruent, evidence-informed care model entitled, “Healing our Hearts, Minds and Bodies” (HHMB; funded by the National Heart, Lung, and Blood Institute [NHLBI] is being used to address the intersecting issues of BLPLWH patients’ trauma histories, barriers to care, and Cardiovascular Disease (CVD) risks . This research is a secondary level intervention. HHMB provides the foundation on which the film content and sample population are drawn and also provides the virtual devices/equipment needed to mitigate technological deficits among participants. The sample will consists of African American or Black and Hispanic, Latino, or Latinx men and women ages 18 to 75 with a diagnosis of HIV or AIDS. Potential participants will be recruited from three HIV service organizations in Southern California. Outlined are the components for utilizing E-E in film for health promotion specific to BLPWH with histories of trauma and cardiovascular risks. The method used to develop the narrative educational film entitled, “TRY,” (an acronym for “Translating Research for You”) during the COVID-19 global pandemic is described as a model for using educational film to translate public health intervention research to underserved populations.
One of the primary purposes of E-E is to use entertainment to persuade or educate a targeted audience in an intentional manner. Elements of E-E include: (1) predetermined outcomes; (2) theoretical underpinnings; (3) high-quality artistic production; (4) research-based communication; and (5) establishing the artistscientist/interventionist collaboration to develop social change goals . Each of these components is necessary to successfully translate the artistic form for an intervention. The following outlines how the process was executed for the HHMB study.
In step one of the E-E approach, the content for a given arts modality-in this case film-must be created purposefully with predetermined outcomes. Because TRY was based on the HHMB curriculum, it was established prior to the film’s development that it would reinforce HHMB’s health-affirming concepts and strategies in a culturally congruent manner. The visual media content complemented the HHMB program and encouraged health promotion among participants through real life exemplars. Research indicates that E-E dramas may be persuasive because actors demonstrate behavioral change for the betterment of their lives . Borrowing from a participatory methodology, interviews with participants were conducted to amplify their voices ensuring accurate representation within the narrative. Racial/ethnic actors representative of the participants were cast in the film and depicted using problem solving techniques, therapeutic modalities for stress and anxiety management/regulation, overcoming setbacks, and setting heart health goals for overcoming life’s obstacles along their personal journeys. The script was written at an unprecedented time in US history (i.e., during a global pandemic, heightened racial injustice, civil/social unrest specific to police brutality). Prior to the film’s completion, HHMB participants communicated that these events had adversely impacted their personal health goals. As such, scenarios referencing these events were woven into the narrative; again, with the intent to echo the participant’s voices and honor the issues that they expressed were most pressing and personal to them.
Producing a film in which BLPLWH may identify racially, ethnically, economically, culturally and environmentally increases the likelihood of their buy-in to the curricula. For example, the actors, settings, and themes of the script were inspired by the lives of BLPLWH who participated in previous HHMB groups. Research suggests that E-E is efficacious in reaching marginalized populations . This type of messaging also provides a shared experience among participants that may motivate sustained practice of the evidence-based health practices taught in the HHMB intervention and reinforced in the film. It may increase their sense of community and accountability through social support systems. HHMB intervention outcomes will be compared between two groups of participants: Those who did and did not see TRY. The evaluation will include the following outcomes: (1) Adoption of the health affirming strategies demonstrated in the film; (2) knowledge of CVD risks; (3) sustained use of the health affirming strategies at the 3-month post-intervention assessment; and (4) the impact of COVID-19 in maintaining health goals. The Institutional Review Board at the University of California, Los Angeles, approved this study.
TRY was conceived, written and directed by the first author. The film was developed based on social cognitive theory,  the health belief model,  and E-E methods . Funding for the film was provided via a diversity supplement grant to the NHLBI funded parent grant. The goal was for TRY to serve as an adjunctive intervention support that translated, reinforced, and enhanced the adoption of evidence-based health promoting concepts and strategies presented in the 5-session HHMB curriculum. Central to developing the development of the educational film was one of the core concepts within social cognitive theory- that people learn through observation. The film’s producer/director observed participants in prior HHMB preventive intervention treatment groups, co-led intervention groups, interviewed clinic staff and past participants, then wrote the educational film script. In so doing, the health belief model- commonly used when developing public health and health-affirming interventions- was foundational. It posits that a person’s likelihood of engaging in a health-related behavior is determined by six variables: (1) Perceived susceptibility; (2) perceived severity; (3) perceived benefits; (4) perceived barriers; (5) cue to action; and (6) self-efficacy (confidence in one’s ability to perform the new behavior) . Components of the health belief model were integrated in the script to strengthen the narrative approach and make this research translational to the lives of those disproportionately affected by HIV. E-E practitioners have found that observing the success of others who attempt and master a new behavior can lead to self-efficacy, thereby increasing one’s belief in their ability to change . HHMB participants who view TRY are expected to have greater treatment gains than those who do not see the film.
E-E experts strongly recommend a high-quality approach in the production of dramas in order to attract and retain the attention of the target audience [28,29]. Following suggested guidelines for managing E-E production artistic integrity, the following were priorities: (1) Appointment of a panel to review the script for accurate educational content and artistic/production quality; and (2) collaboration with community and content experts. As a result, the review panel included six people: One person living with HIV; two facilitators with extensive experience working in the field of HIV; a community outreach person; an HIV interventionist, practitioner, clinical psychologist; and one lay person from the community. The review panel members read the script and provided feedback focused on the following: (1) accurate portrayal of the community and the people who reside within the community; (2) language used by the population; (3) avoidance of perpetuation of negative stereotypes; and (4) overall relatability. To ensure production quality, a professional production team with expertise in social change was hired to film, edit, and oversee the final postproduction process and workeding closely with the film’s director, a doctoral-level social science researcher and award-winning documentarian .
E-E strategies are research-based and allow for both preliminary/formative research involving potential audience members prior to the development of the media content as well as summative research aimed to measure the E-E messaging outcomes [28,29]. The formative process began as the first author and writer of TRY observed a 5-week HHMB intervention group. This in-person experience permitted a thorough understanding of participants’ knowledge and behavior in relation to their HIV statuses, cardiovascular risks, trauma histories and their experiences with the curriculum content. Training for the film’s writer was provided by one of the curriculum’s co-authors to ensure an in-depth understanding of the overall educational content and methods taught for health promotion. Excerpts from the script were used to pre-test and evaluate the overall film content during interviews with potential audience members -- as well as past HHMB group members -- to validate the use of relevant and relatable film content. Consistent with the methods of implementing effective E-E, summative research involving participant feedback was used to increase the film’s impact and will be assessed throughout the viewing process once the virtual screening program is implemented . A mixed-methods approach will be used to evaluate the intervention outcomes, including knowledge acquired and behavior change.
Social and behavioral change communications experts posit that successful employment of E-E requires collaboration between professionals in media and health promotion strategists and/or social change agents . In this instance an alliance was built between the researcher/interventionist and media experts to develop educational and social change goals during the development of TRY. This was an iterative process involving negotiation between the researcher/interventionist, creative artists, and the production team to provide a relatable product to meetthat is able to meet the needs of the participants while focusing on the established goals embedded within the film. For example, to determine who would be involved in making this film, it was important to hire a diverse team of professionals in front (actors) and behind the camera (production team). As an intervention serving Black and Latinx populations, it was paramount that the production team reflected the participants served through HHMB (i.e., racially/ ethnically, sexual orientation, and gender). The objective of the film was discussed with both the production team and actors to gain their buy-in, establish the importance of using film for health promotion for a marginalized population, reiterate that the stories were inspired by real life scenarios and should be handled with care, and encourage each person to engage in a participatory approach in order to produce the best quality film cinematically, all while observing CDC guidelines for COVID-19-era safety. This approach facilitated a high level of vested interest; each member of the cast and crew felt safe and valued as a contributor to the film’s success.
Using E-E communications methodology, an educational film was developed to be integrated into the HHMB 5-session, manualized, public health prevention intervention study. Consistent with the extant literature a narrative approach was employed that portrayed a realistic, culturally appropriate, and creatively produced film in order to positively influence health behaviors . Indeed, marginalized populations have successfully been reached through the use of E-E strategies.  The five critical steps were applied to address intersecting issues in relation to HIV, CVD, and trauma for deeply impoverished Black and Latinx participants. Because TRY works in tandem with the HHMB curricula it was predetermined that intervention strategies would be demonstrated through the use of culturally and ethnically relatable actors to positively influence behaviors. This is consistent with the literature that posits an increased likelihood of self-efficacy for participants who see relatable characters engage in positive behavioral change . The systematic approach described in the development of TRY is expected to produce important information and provide a model for other evidence-informed films designed to translate health-affirming strategies for under-resourced communities serving a diverse and economically oppressed constituency.
Further, through the process of conducting formative and summative research a participatory approach in the development of the media content involved time spent in the clinical setting with potential viewers and past participants of the program from which the content of the film was also drawn. A reciprocal process involving preliminary research with potential viewers to inform the content, gain feedback, and integration of the feedback within the final film content was paramount. Similar to participatory approaches to research, the use of E-E strategies in the development of the film entailed the process of intentionality—which involved the participation of marginalized individuals and the communities affected by the inquiry, in this case PLWH, with histories of trauma and CVD risks—to ensure the reflection of their viewpoints specific to barriers to care, issues of importance in relation to the maintenance of their health goals, and cultures . Additionally, summative research to measure the effects of E-E messages on the intended viewers is vital for evaluating the utility of the film and the uptake of health promotion strategies introduced through the HHMB curricula. Because predetermined outcomes is identified as one of the five necessary elements for implementation of an effective E-E strategy , the evaluation component will assess for the adoption of health affirming strategies demonstrated in the film, evaluate participant’s knowledge of CVD risks, examine the sustained use of the health affirming strategies at a three-month post-intervention follow up, and the impact of living through a global pandemic as it relates to the maintenance of individual health goals.
Finally, in developing a high-quality production encompassing artistic integrity there is a delicate balance needed to merge the arts and educational content. Thus, it is important for researchers/ interventionists to collaborate with industry media practitioners in order to create a well balanced production that blends entertainment values with educational content . To this end, successful development of the film entitled, “TRY,” which translates intervention research for BLPLWH during the COVID-19 pandemic was designed and created for virtual consumption in order to provide a safe space for participants that are immunocompromised, to adjust to social/physical distancing mandates, and to address the ramifications of COVID-19 in relation to their existing health vulnerabilities.
The purpose of this manuscript was to describe the development of a culturally congruent narrative film as a model of how to use the arts to translate public health intervention research to underserved Black and Latinx persons living with HIV. Racial/ ethnic minorities who have long experienced health disparities, chronic diseases, and co-morbidities that drive COVID-19 related mortality must have accessible and personalized content to provide relevant and relatable interventions and education specific to their culture and needs, thus beginning to rebuild the historical distrust of participating in research studies. The development of the TRY film project was successfully employed based upon the methods used in E-E, grounded in social cognitive theory and the health belief model. Future research plans include the implementation, data collection and evaluation phase of TRY. A limitation of this manuscript is that the impact of the film has yet to be evaluated. Thus, the focus of this paper reports on the adaptation of an existing intervention for a vulnerable population by translating and incorporating an artistic component. Overall, the feasibility and potential benefits of involving the arts in public health research is an innovative and meritorious approach for promoting health and wellness that should be encouraged.
We would like to acknowledge the following:
Funding provided by the National Heart, Lung, and Blood Institute under Grants 3U01HL 142109-02W1, 2020, and 3U01HL142109- 02S1, 2018.
The PIs of the HHMB study, Drs. Gail E. Wyatt, Alison B. Hamilton, and Arleen Brown. The community organizations that supported this work. The cast and crew of the TRY film project. The participating advisory board. Isabella Viducich for technical support.
At the time of this study, the first author was an Affiliate Scholar with the HIV/AIDS, Substance Abuse and Trauma Training Program (HA-STTP), at the University of California Los Angeles; supported through an award from the National Institute on Drug Abuse (R25DA035692).
Statement of conflict of interest: None of the authors has any conflicts of interests with regard to this publication.
Citation: Ebor MT, Cooley-Strickland M, Norwood-Scott, E (2021) Using Film to Translate Intervention Research for Black and Latinx Persons Living with HIV during COVID-19 Pandemic. Rep Glob Health Res 4: 127. DOI: 10.29011/2690-9480.100127