ABSTRACT
Integration of online resources with established frameworks of community participant-based health promotion suggests a promising solution for improving population-wide health outcomes in Southeast Alaska. Frameworks of community participant-based health promotion, like those of the Planned Approach to Community Health (PATCH), Community-Based Participatory Research (CBPR), and Mobilizing for Action through Planning and Partnerships (MAPP), recognize that unhealthy behaviors often stem from environmental, social, and cultural characteristics of communities. To enact long-lasting changes in these behaviors, it’s recommended to seek community participation through partnership, knowledge sharing, skills, and perspectives. Online resources provide a valuable platform for increasing community partnership, particularly in the remote communities of Southeast Alaska.

KEY WORDS:​ Health Promotion, Community Participation, Southeast Alaska, Planned Approach to Community Health (PATCH), Community-Based Participatory Research (CBPR), Mobilizing for Action through Planning and Partnerships (MAPP), Social Media, Network Community

INTRODUCTION
Southeast Alaska is rich in many things: culture, ecology, natural resources, beauty. It’s the dream vacation of many international travelers and draws millions of tourists to its picturesque settlements sandwiched between glacial mountain and ocean. There are thriving and resilient rural communities sprinkled throughout the region, many home to 100 people or less. Even the “big cities” of Southeast Alaska are small enough to create close-knit communities where seeing a family friend or your third-grade teacher at the supermarket is nearly inevitable.

Despite its modest population size, the region does not lack in diversity. In the city of Petersburg, also known as ‘Little Norway’, there’s a “Mayfest” each year celebrating the Norwegian ancestry of the majority of its population13​​. Every June, Native people throughout the region from the Tlingit, Haida, and Tsimshian tribes convene in Juneau, sporting traditional regalia and sharing cultural songs, dances, arts, crafts, and food. Filipino migrants have continuously settled in Ketchikan and Juneau since 1929, even through periods of diminished economic growth; unsurprisingly, Tagalog is the 3rd most spoken non-English language in Alaska​¹. The cultural groups of Southeast Alaska embrace and share their heritage, culture, customs, and traditions, making the region remarkably plural for its rural nature.

In the winter months, Southeast Alaska turns into something out of a Steven King novel: damp, dark, and obscured by a fog that almost certainly has something lurking in it. Flights are frequently delayed due to low visibility and the ever-increasing costs of marine travel keep residents isolated in their landlocked communities. Without the influx of cruise ship tourists, many businesses close their doors for the season, making communities that serve as ports of call into something just short of ghost towns. For those disinclined to snowy recreational sports, there are few options for entertainment outside the home. It’s little wonder that drinking, eating, and Netflix are the primary sources of amusement and social activity throughout Southeast Alaska’s long Winter.

This eccentric cultural and social setting presents a unique challenge to health researchers attempting to improve the well-being of Southeast Alaskan residents: how do they create educational materials and programs that effectively target a population that is not only geographically separated, but also marked by significant social, cultural, even seasonal, differences?

Southeast Alaska suffers from a prevalence of preventable disease, such as chronic liver disease/cirrhosis, cancer, and heart disease, which are aggravated by modifiable risk factors like unhealthy eating and alcohol abuse. Nine out of ten of the leading causes of death in Alaska could be partially alleviated through lifestyle changes, whether it be changes in diet, drinking or smoking cessation, safer ​sex practices, or increased physical activity​8. In a setting where the unhealthy habits influencing the health struggles of its inhabitants are so enmeshed with their daily and social life, it’s a tall order to ask individuals to change their lifestyle in a way that may isolate them from their community. Opting for an approach to health education that prioritizes community participation mitigates the burden on the individual and promotes long-term improvement in the health of the population as a whole.

Comprehensive community health planning initiatives like the Planned Approach to Community Health (PATCH), Community-based Participatory Research (CBPR), and Mobilizing for Action through Planning and Partnerships (MAPP) have proven to be effective strategies for improving community health outcomes¹²​ . These programs provide guidelines for public health workers and researchers to form partnerships with the communities they serve and to develop health interventions targeted to diverse socio-cultural settings. Advancements in technology have also made it possible for health researchers to expand their audience and reach members of isolated communities, thereby encouraging participation in health promotion. The objectives and the strategic components of MAPP, CBPR, and PATCH, combined with the networking capacity of social media and other online platforms, warrant further discussion for the promising solution they present to the pressing health issues of Southeast Alaskan communities.

COMMUNITY PARTICIPATION IN PUBLIC HEALTH
Community participation is a foundational principle in public health. Since the mid-1980’s, public health researchers have agreed that community participation is essential in the development and implementation of health programs. Not only does it lessen the burden on the individual, it results in ​ health promotion that is better tailored to the community it is intended to reach​¹⁵. Implementing community participation in health promotion takes many forms. It may require health workers to host community events and organize focus groups, to collect community perspectives and input as they develop health promotion materials and programs, or to build a supportive online community for those struggling with their health. No matter the forum, the goal is to encourage communities to assume an active role in achieving health outcomes, and to give communities a sense of ownership over the initiatives created to address their specific needs.

Strategies oriented around community participation, specifically the Planned Approach to Community Health (PATCH), Mobilizing for Action through Planning and Partnerships (MAPP), or Community-based Participatory Research (CBPR), have been developed by public health professionals to help guide academics, researchers, and community participants as they work in partnership to identify and address health concerns and create effective community-oriented campaigns.

Planned Approach to Community Health (PATCH)
The Centers for Disease Control and Prevention (CDC) created PATCH in the early 1980s “to increase the capacity of communities to plan, implement, and evaluate comprehensive, community-based​health promotion programs”​¹⁹ . This goal is accomplished through the establishment of a health promotion team responsible for collecting and analyzing local data, selecting health priorities, developing program objectives, serving on working groups, and helping with program implementation and evaluation​²². The team is composed of the PATCH advocate, community organizations and agencies, government officials, “program champions” (prominent, credible members of the community), and local participants that are representative of the community itself. Most importantly, the team should reflect the entire community ​ united in a shared vision of health promotion​².

PATCH cites the following elements as critical to its success: (1) Community members participate in the process; (2) Data guide the development of programs; (3) Participants develop a comprehensive health promotion strategy; (4) Evaluation emphasizes feedback and program improvement; (5) The community capacity for health promotion is increased²²​.

Mobilizing for Action through Planning and Partnerships (MAPP)
The CDC and the National Association of County & City Health Officials (NACCHO) developed  MAPP in the 1980s and 1990s to provide a framework for strategic planning in health promotion¹²​​. Strategic Planning is defined as a disciplined effort to produce fundamental decisions and actions that shape and guide what an organization (or other entity) is, what it does, and why it does it. Strategic planning requires broad-scale information gathering, an exploration of alternatives, and an emphasis on the future implications of present decisions. It can facilitate communication and participation, accommodate divergent interests and values, and foster orderly decision-making and successful implementation​7. The MAPP process for strategic planning places substantial emphasis on organization and collaboration; recommends continuous assessment according to community perspectives, input from the public health system, data analysis, and evaluation of the external forces that may impact the public’s health; identification of strategic issues; and formulation of goals and strategies¹⁴​.

Community-Based Participatory Research (CBPR)
CBPR requires a collaborative approach to research that involves community members, organizational representatives, and researchers sharing knowledge, skills, experiences, and resources to enhance understanding of a given phenomenon and the social and cultural dynamics of the community, and to integrate the knowledge gained with action to improve the health and well-being of community members​9​. Central to this collaborative approach are the partnerships between the community and researchers. In a review citing two decades of CBPR studies, Brush et al.​⁴ outlines the characteristics of a successful partnership as having “strong, shared, and trustworthy leadership; flexibility and adaptability in research activities, internal operations; and effective communication strategies.”

Involving community participants in all aspects of research, from identifying health priorities to implementation and dissemination, bridges the gap and quells distrust between researchers and the communities that have traditionally been treated only as “subjects”²¹.  Strengthening this relationship between researchers and communities increases the likelihood that efforts in health promotion will be received and embraced by the community they are intended to help.

Online Strategies for Encouraging Community-Participation
The availability of health information online has increased accessibility of health information and made individuals more aware of their health and the health status of their community​5​. eHealth interventions have proven to be an effective means of improving health behaviors, and online networks provide a valuable outlet for vulnerable or isolated youths to receive social support and solicit health and ​ identity-related information​3. With improved means of reaching out to communities, particularly through social media and other online networks, health advocates have a promising new platform to expand their outreach and encourage broader participation in health promotion.

Community participation in health promotion — whether it’s building the capacity of the community, strategic planning for the community’s future, or community-based participatory research — is largely agreed upon as an effective practice in public health¹⁵​. While modes of community-oriented health promotion, like MAPP, CBPR, and PATCH, may seem outdated, their foundational principles are still applicable and their goals more achievable than ever due to the emergence of online networks capable of connecting individuals and organizations¹⁰​.

CURRENT INITIATIVES IN ALASKA PUBLIC HEALTH
Alaska has no shortage of community-oriented public health programs. Current initiatives include: the Play Every Day Campaign, which promotes active youth and families through community sporting events¹⁶​ ; Alaska’s Tobacco Quit Line for those seeking support as they quit smoking​²⁰; and Lead On! For Peace and Equality trains youth to return to their rural communities as health advocates​¹¹. The Alaska Division of Public Health has “collaboration and engagement with communities” listed as a top priority​ on the summary of their Strategic Plan for 2016-2020¹⁷​, and their public health projects align with the framework laid out for community participation in health promotion.

Unfortunately, access to many of these programs is limited by the rurality of towns in Southeast Alaska. The Department of Health and Social Services’ (DHSS) Play Every Day Campaign hosts regular youth sporting events, but the events almost exclusively take place in Anchorage and Fairbanks. Without incurring the expense of travel, families in Southeast Alaska are unable to participate in these events.

Local resources for Southeast Alaskans are also limited. The 2014 Health Care in Alaska update from the Alaska Health Care Commission revealed a shortage of primary care providers and behavioral health providers, and only six facilities committed to public health education and development activities⁶ exist in the entire region​⁶ . It’s not impractical to conclude that the community health centers that do exist are overloaded with patients as is, and do not have the time, staff, nor the resources to lead community efforts to conduct regular community needs assessments or to develop and maintain prevention programs.

Despite the shortage of providers and limited public health facilities, locals of Southeast Alaska have established certain community-led groups that exemplify the strategies of community-oriented health initiatives and show their efficacy for encouraging community-participation in a rural setting. The Southeast Alaska LGBTQ+ Alliance (SEAGLA)¹⁸​ is one such group that effectively promotes well-being through community-participation in strategic planning, local events, online networks, and other forums.

SEAGLA’s outreach is characterized by an active online presence that incorporates the use of networking platforms like Facebook and Twitter. These social media networks allow SEAGLA to easily connect with the community and to disseminate information about upcoming events and campaigns, and to collect perspectives and data from the community with minimal hassle. They’ve also formed partnerships with community stakeholders, including elected officials and the faith community, through online promotion. This online network of community members and stakeholders has created a platform for LGBTQ+ members throughout Southeast Alaska to find inclusive activity groups, or form their own, and receive community support.

COMMUNITY-ORIENTED ONLINE HEALTH PROMOTION
SEAGLA’s success in fulfilling their goal to “provide a supportive social network for gay, lesbian, bisexual, transgender, and queer people in Southeast Alaska” recommends the use of online platforms for increasing community participation in the pursuit of population-wide objectives. If we were to evaluate SEAGLA in terms of PATCH, MAPP, and CBPR, we’d find that their PATCH promotion team consists of the SEAGLA organizers, drag queens (which could be considered “program champions”), and community stakeholders that sponsor their events. These advocates for SEAGLA help to increase community awareness and connectedness by working in partnership to create community campaigns, fundraisers, and events.

SEAGLA also initiated its own strategic planning process, similar to MAPP, that emphasizes community participation. Social media gives them a convenient platform for collecting input and data from a much larger audience than they would have access to otherwise. Below is an infographic taken from their Facebook page promoting community feedback for their strategic planning process: