Rethinking flourishing: Critical insights and qualitative perspectives from the U.S. Midwest.

In recent years, human flourishing and its relationship to mental health have attracted significant attention in a wide range of fields. As an interdisciplinary, mixed-methods team with strong roots in critical medical anthropology and critical public health, we are intrigued by the possibility that a focus on flourishing may reinvigorate health research, policy, and clinical care in transformative ways. Yet current proposals to this effect, we contend, must be met with caution. In particular, we call attention to the troubling disconnect between current research on flourishing, on one hand, and the voluminous body of scholarship demonstrating the detrimental impact of structural inequities on health, on the other. We illuminate this blind spot in two ways. We begin with a critical assessment of leading conceptions to flourishing in positive psychology, which are compared to current approaches in the critical social sciences of health. In the second half of the paper, we support our argument by presenting original findings from a mixed-methods study with a diverse sample of interviewees in the Midwestern U.S. city of Cleveland, Ohio (n=167). Our interviewees' rich narrative accounts, which we analyze both quantitatively and qualitatively, highlight important ways in which everyday understandings of flourishing diverge from prevailing scholarly accounts. Given these gaps and blind spots, now is an opportune time for robust interdisciplinary discussion about the implicit values and presumptions underpinning leading approaches to flourishing and their wide-ranging implications for research, policy, and clinical care in mental health fields and beyond.

Learning to See Racism: Perspective Transformation Among Stakeholders in a Regional Health and Equity Initiative.

CONTEXT: Achieving a meaningful reduction in health inequities will require not only policy and programmatic changes but also an increased understanding of structural racism and its deleterious impact on health and well-being. One way to enhance understanding is to actively promote "perspective transformation" (PT) around race among health equity stakeholders. Experiences of PT are defined as moments or events that bring about a deepened understanding of racism and that may result in new ways of thinking and acting. OBJECTIVE: To identify catalysts and effects of PT among health equity stakeholders. DESIGN: Semistructured, in-person interviews were conducted with stakeholders (n = 50) as part of a 2-phase, mixed-methods study (n = 170). Interviews were audio-recorded, transcribed, and coded using a mixed-methods software platform. SETTING: Health Improvement Partnership-Cuyahoga (HIP-Cuyahoga), a regional health and equity initiative in Greater Cleveland, Ohio. PARTICIPANTS: A purposive sample of participants in HIP-Cuyahoga spanning 5 groups: metro-wide decision makers, public health professionals, clinicians, community leaders, and community members. RESULTS: More than two-thirds of interviewees reported at least one discrete experience that catalyzed PT, as defined earlier. Three catalysts were especially common: witnessing, learning, and personally experiencing racism. A fourth, less common catalyst involved getting uncomfortable during discussions of race and racism. Experiences of PT resulted in common effects including acquiring new terms, concepts, and frameworks; carrying the conversation forward; finding fellow travelers; and feeling energized and motivated to confront structural racism and its consequences. People of color tended to experience PT, and its catalysts and effects, differently than White interviewees. CONCLUSIONS: Many health equity stakeholders have experienced PT around racism and its impact. Experiencing PT is associated with new skills, capacities, and motivations to confront racism and its impact on health and well-being. Understanding how different groups experience PT can help advance efforts to promote health equity.

Visualizing Health Equity: Qualitative Perspectives on the Value and Limits of Equity Images.

BACKGROUND: Health educators and advocacy groups often use side-by-side visual images to communicate about equity and to distinguish it from equality. Despite the near-ubiquity of these images, little is known about how they are understood by different audiences. AIMS: To assess the effectiveness of an image commonly used to communicate about health equity. METHOD: In 167 interviews with health stakeholders in Greater Cleveland, Ohio, in 2018 to 2019, a commonly used health equity image was shown to participants, who were asked to interpret its meaning. Interviewees included 21 health professionals, 21 clinicians, 22 metro-wide decision makers, 24 community leaders, and 79 community members. RESULTS: About two thirds of our socioeconomically, racial/ethnically, educationally, and professionally diverse sample said the equity image helped clarify the distinction between "equality" and "equity." Yet less than one third offered an interpretation consistent with the image's goals of foregrounding not only injustice but also a need for systemic change. Patterns of misinterpretation were especially common among two groups: ideological conservatives and those of lower socioeconomic status. Conservatives were most likely to object to the image's message. CONCLUSIONS: Equity images are widely used by public health educators and advocates, yet they do not consistently communicate the message that achieving equity requires systemic change. In this moment of both public health crisis and urgent concern about systemic racism, new visual tools for communicating this crucial message are needed.

People and places shaping food procurement among recipients of Supplemental Nutrition Assistance Program (SNAP).

A key gap in existing food environment research is a more complex understanding of the interplay between physical and social contexts, including the influence of social networks on food habits. This mixed methods research examined the nature of social connections at food procurement places among a sample of 30 people receiving Supplemental Nutrition Assistance Program (SNAP) benefits in an urban setting. Results highlight the significance of social connections as motivators to use food places, the value of access to information and other resources at food places, and the role of weak ties with actors within food places to facilitate utilization and interaction. Social connections at the varied places individuals procure food may be leveraged to disseminate information and resources to further healthy food access.

Food Melt in Consumer Food Environments in Low-income Urban Neighborhoods.

OBJECTIVES: We systematically evaluated changes in availability, price, and quality of perishable food items from the beginning to the end of the month in lowincome, urban neighborhoods. METHODS: The sample included grocery stores or supermarkets in Cleveland, Ohio, within neighborhoods with >30% of population receiving food assistance. We collected data for 2 sequential months during the first and fourth weeks of each month. Two coders evaluated stores, collecting measures of availability, price, and quality for 50 items. We examined difference in number and proportion of items available at the beginning of the month (BOM) to items remaining available at the end of the month (EOM), as well as quality and price of those items. RESULTS: Across 48 stores, availability at EOM was lower than BOM; as store size increased, reduction in availability (ie, food melt) was significantly (p < .01) less pronounced. Overall, items became less expensive at the EOM whereas quality remained consistent; we noted no statistically significant differences by store type for price or quality. CONCLUSIONS: Food melt differentially affects individuals in neighborhoods without grocery stores. Findings reveal composition of food environments is dynamic rather than static, influencing food-purchasing choices among lowincome consumers.

The Cleveland-Cuyahoga County Food Policy Coalition: "we have evolved".

Several pieces of legislation passed in Cleveland, Ohio, from 2007 to 2011, focused on improving the city's food environment through urban agriculture initiatives. We used qualitative, case study methods, including interviews with 7 key informants, to examine the policy development process and investigate the role of the Cleveland-Cuyahoga County Food Policy Coalition in developing and implementing 4 pieces of legislation. In this article, we focus on 2 pieces of legislation: zoning designation of an urban garden and allowance of small farm animals and bees on residential property. Five key themes emerged: impetus for policy came from community needs; education and raising awareness helped mitigate barriers; a cultural shift took place among policy makers; social connections and individual champions were needed; and concerns over food access and health influenced policy decisions. Legislative actions are important tools to influence the nutrition environment, as long as they are based on local needs and context.