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Running head: HEALTH THROUGH YOUNG EYES 1

Health through Young Eyes: A Photovoice Project

Judith A. Graziano, PhD, RN, Joyce Bredesen, DNP, RN, and

Theresa O’Hanlon-Nichols, PhD, RN

Metropolitan State University

HEALTH THROUGH YOUNG EYES 2

Abstract

Photovoice, a participatory action research method was used to capture images of the day to day

lives in a health context of children living in poverty. Twelve children living in poverty

participated. Three themes emerged (a) where we live, meaning that the environment in which

we live has an impact on health; (b) what we do, which suggested that individuals have

responsibility for their health; and (c) who we are, meaning our genetics, values and beliefs

influence our health. These findings give voice to youth living in poverty and inform those who

make decisions regarding health issues of families living in poverty.


Poverty defined as living in a family of four earning below $22,050, affects 14% of

Minnesota’s children and 21% of children nationally (National Center for Children in Poverty,

2009). Much is known about the relationship between poverty and health in youth. According

to Currie and Stabile (2002), “The relationship between socioeconomic status and health is one

of the most robust and well documented findings in the social science” (p. 1). Children living in

poverty experience more health problems and their overall health status is worse than that of

children from families of greater financial means (Klerman, 1991).

Examples of poorer health include worse physical health outcomes such as lower birth

weight and higher infant mortality, more deaths (ages 0-14), more stunting, more number of days

spent in bed and number of short stay hospitalizations when children living in poverty are

compared to children not living in poverty. Cognitive problems include more developmental

delay and learning disabilities in children living in poverty compared to children not living in

poverty; more behavioral and emotional problems are also reported. Children living in poverty

experience lower school achievement including greater grade repetition and a greater incidence

of being suspended or expelled. Youth growing up in poverty experience more out of wedlock

births, unemployment, hunger, abuse, neglect, violent crime, and fear (Brooks-Gunn & Duncan,

1997).

Many policy recommendations have been made to address countless poverty related

issues such as hunger, lead poisoning, exposure to second hand smoke, asthma, obesity and

overweight, low birth weight, behavioral and emotional problems and learning disabilities (Seith

& Kalof, 2011). Some initiatives resulting from these recommendations involve efforts to

increase participation of eligible families in the Supplemental Nutrition Assistance Program,

(SNAP) and grants that provide funding to clean up lead paint in existing housing and to provide


lead-free affordable housing. Other initiatives are health care based such as home health visits

from nurses that have been found effective in reducing parental smoking, which is associated

with low birth weight, premature birth, and childhood asthma. Many initiatives are incumbent

upon providing youth with access to health insurance coverage, which enables access to medical

and dental care to prevent and treat health problems.

Although many policy recommendations and initiatives are made on behalf of children

living in poverty, rarely do families and children living in poverty have direct access to the

individuals who make policy recommendations regarding their own health. The intent of this

project was to use photographic images to examine the perceptions of day to day lives in a health

context of children living in poverty. The broader aim of this study was to facilitate dialogue

between families in poverty, the community in which families in poverty live, and policy makers

regarding health concerns of youth within the community.

Methods

This qualitative study used photovoice, a participatory action research method that uses

cameras to give voice to individuals who don’t have access to people making decisions about

their lives. Built on the foundation of documentary photography, which views the world through

an outsider’s lens, photovoice tries to capture an insider’s perspective (Strack, Magill &

McDonagh, 2004). Photovoice incorporates feminist theory, which purports that the people

within a group are best suited to study the issues related to that group and that sharing of

experiences facilitates understanding of the issues (Strack, et al., 2004). Research supports

photovoice as a tool that helps create partnerships that bridge the gap between researchers and

communities and that uses the knowledge and personal lived experiences of community

members to assist in creating change (Catalani & Minkler, 2009; Hergenrather, Rhodes, Cowan,


Bardhoshi, & Pula 2009; Hwang, Tolomiczenko, Kouyoumdjian, & Garner, 2005; Wang &

Burris, 1997; Wang, Morrel-Samuels, Hutchison, Bell & Pestronk, 2004).

In this study photovoice was used as a strategy intended to empower underserved youth

to reflect upon and critically analyze what they consider health means within the context of their

community and to communicate this to the larger community. Empowerment was done by

giving cameras to children between the ages of 12 and 17 and asking them to take photographs

of their everyday experiences as they related to their health. Using visual imagery through

photographs to tell their stories it was hoped that the children would be able to share thoughts

related to heath within the context of their community.

Setting

An ethnically diverse government subsidized housing community in the Midwestern

United States was chosen for this study. This community houses 314 units, 244 townhouses and

70 apartments with approximately 963 residents; seventy-five percent of the residents are living

100% below the poverty level. The demographics of this community are outlined in Table 1.

This community was chosen because of the challenges children and adolescents face living in an

urban predominantly low-income neighborhood. All meetings throughout the study were held in

the community center, a common area where residents of the community gather for classes,

meetings, and group activities. Children and adolescents often spend time at the community

center after school. The study was approved by a Human Subjects Institutional Review Board at

a local university. Two co-investigators (investigators) who were professors at the local

university conducted the study.


Recruitment

Entrance to the community was facilitated by a social and her assistant who invited

English-speaking youth between the ages of 12 and 17 along with their guardians to an

informational session with the investigators. The social worker has worked with the community

for over six years and has well-established relationships with the families and youth living there.

The assistant, a native Hmong speaker, assisted with the language barrier when discussing the

project with the Hmong-speaking guardians of Hmong children. At the information session, the

investigators explained the study to approximately 25 attendees and answered questions.

Because all potential study participants were minors, both they and their guardians were asked to

read and sign the consent document after all of their questions were answered. No English-

speaking youth between the ages of 12 and 17 who wanted to join the study were denied.

Participants with signed consent documents were offered $25.00 gift cards to Target; these were

distributed after participants retuned the cameras and attended two additional meetings with the

investigators.

Data Collection

A variety of data collection methods were used including investigator observation, tape

recording of focus group interviews, and collecting photographs taken by participants. The

participants met with investigators for a second time one week after the initial information

session. Each participant was given one single use 35 mm disposable camera with 27 exposure

film and a built in flash. They were instructed on the operation of the cameras. The cameras

were labeled with a code that was assigned to a corresponding participant so that pictures could

be linked to the youth. The participants were asked to take photographs of objects or people in

their day to day environment that affected their health or that were representative of health.


They were instructed to avoid photographing faces so that anonymity of photographed people

could be maintained. Directions regarding what to photograph were purposefully open-ended

and non-specific to encourage the youth to define what represents health in their lived

environment and to avoid investigator bias. Participants were given two weeks to take the

photographs and were asked to drop the cameras off at the community center on a designated day

after the two week period.

The participants met with the investigators again after the photographs were developed.

Each participant was given his or her photographs to review, and was asked to select five images

that were most representative of health. Participants then shared their five photographs within a

focus group interview setting with the other youth in the study. Each investigator moderated one

45 minute focus group of seven or eight participants. The focus group interviews were

structured around the following question: How does each photograph represent health?

Participants took turns describing one photograph and how it was related to health until all of the

selected photographs were shared. This meeting was audio tape recorded and written notes were

taken by the investigators.

Analysis

Qualitative data analysis used in this study followed a general inductive approach

described by Thomas (2003). This approach allows “frequent, dominant or significant themes”

(Thomas, 2003, p. 2) to emerge from the data. Statements referring to selected photographs

from audio recordings of the focus groups were transcribed using a personal computer and

Microsoft Word 2010. Each investigator carefully read the transcripts independently multiple

times to become familiar with the data and to begin understanding themes embedded in the data.

The investigators viewed the photographs in which the participants were referring to in the


transcripts and reviewed their individual field notes taken at the time of the focus group

interviews concurrently while reading the transcripts.

The investigators then came together to continue the analysis; the quotes were placed into

categories that were created from phrases directly from the text of the transcripts. These

categories, supported through clusters of words and phrases, were used to analyze the topics

mentioned most frequently by the participants and that were most directly related to specific

photographs.

Results

Fifteen youth were recruited and participated in the photovoice project. Six boys and six

girls between the ages of 12 and 15 years completed the study, which included eight African

American, one Hmong, one Caucasian and two Latino youth. This sample reflected the diversity

of the community in which they were living. Three themes emerged: (a) where we live, meaning

that the environment in which we live has an impact on health (b) what we do, which suggested

that individuals have responsibility for their health, and (c) who we are, meaning our genetics,

values and beliefs influence our health. Examples of photographs and important words and

phrases related to each theme are described below.

Where We Live

This theme emerged primarily from viewing photographs of the neighborhood

surrounding the community. Several participants showed photographs of trash and litter; one

participant showed a photograph of a knife lying on the ground (Figure 1) stating, “This is a

picture of a dirty knife I found on the ground and if you got stabbed with it, it could kill you.”

Another participant showed a photograph of cigarette butts lying in a pile of snow and stated,

“This is a picture of cigarettes in some snow. They are bad because they can cause lung cancer.


Second hand smoke is also bad for my health.” A photograph of trash lying along a roadside

curb was depicted as, “This is a picture of people littering and throwing things out and dirty

snow and the roads are nasty and it affects our air.” Others expressed concern about air quality as

well; for example, a participant showed a photograph of a vehicle exhaust pipe (Figure 2) and

commented, “I picked this photo because of the exhaust given off from all the vehicles affects

my lungs.” Others focused on the importance of tress on improving air quality such as a

participant who showed a photograph of blue sky and tree limbs who commented, “Trees affect

my health because they give me oxygen to help me breathe not bad air.”

What We Do

This theme emerged from photographs depicting objects with descriptions of behaviors

associated with them. For example, “I took a picture of a TV because it is bad for your health.

Playing games all day and can mess up your health for school”; “This is a picture of my bike. It

affects my health, say I go out on regular bike rides around the bike paths”; “This is a picture of

a water fountain because water is healthier for you than pop and stuff”; “These are the shoes that

I use to run in and play basketball in and helps me exercise and its good for my health”; “What

our hobbies are affects us. Some of us read and some of us play sports or we do something in

between.” One photograph in this category depicted an image of a sign that reads, “Speak up,

Stop Bullying” (Figure 3); the participant stated, “This picture affects my health because I see

people getting bullied. Bullying can lead to killing.” Another participant described a photograph

(Figure 4) stating, “This is a picture of my friend sticking up his middle finger. I didn’t notice it

at the time, but it’s like who you hang out with and what your friends do can pressure you to do

things you don’t want to do.”


Who We Are

This theme emerged from pictures and descriptors ranging the physical self to the

spiritual self. A participant who took a photograph of an anatomical skeleton (Figure 5) stated,

“How our body is built, what our genetics are, and our ancestry affects who we are and our

health.” A photograph of a sign that encouraged sports fans to respect players and referees was

accompanied by the statement, “This picture affects my health because some people do not have

respect. You need to follow the rules or you won’t get anywhere in life.” An image of a

religious figure was represented as, “Your religion sometimes affects what you eat and what you

do.” A photograph of an image painted on lockers depicting people circling the globe (Figure 6)

was portrayed as, “This picture is about people around the earth and how we take care of the

earth and how we treat people. This affects what we do and how long we are able to live. Our

world and community affect who we are and what we do.”

Dissemination

The intent of this project was to use photographic images to examine the perceptions of

day to day lives in a health context of children living in poverty. The broader aim of this study

was to facilitate dialogue between families living in poverty, the larger community in which

families living in poverty reside, and policy makers regarding health concerns of youth within

the community. These constituents were invited to attend a gathering to gain an understanding

of the complexity of issues that youth perceive as impacting health.

Representative photographs labeled with the category each depicted, and a quotation

from the focus group interview data were displayed in the community center during a gathering

held after data collection and analysis were complete. Attendees included ten of the youth


participants and their parents/guardians, representatives from the city housing authority, leaders

and members from local churches, employees and students from a local university, and the

general public. The photographs and their descriptions served as a conversation starter among the

diverse constituents attending the gathering.

Limitations

The limitations of this study included its small scope. Each participant was only given

one camera in which to take photographs and the investigators had limited time to interact with

the youth. The project would be enhanced by giving the participants more than one camera and a

longer period of time in which to take the photographs. At least one participant had never used a

camera before, and many of them started to take photographs prior to leaving the first meeting

with the investigators. Having a more than one focus group interview with the participants to

explore more deeply the meaning of the photographs would provide a richer understanding of the

data. Finally, having an interactive forum with the youth and the community at large would lead

to dialog and eventual change.

Discussion

This participatory research method is “based on the concepts that images teach, pictures

can influence policy and community people ought to participate in creating and defining the

images that shape healthful public policy” (Goodhart et al., 2006; Wang, 2006; Wilson et al.,

2009, 2006 p. 148). Photovoice provides a process where individuals can record the realities of

their lives and share their images and stories with others to promote dialogue and change

(Goodhart et al., 2006; Wang, 2006; Wilson et al., 2009). Through the photovoice methodology,

youth can express their views on issues that directly affect their lives and be active participants in

the process (Goodhart et al., 2006; Wang, 2006; Wilson et al., 2009). The photovoice process


assists in advocacy and infuses the perspectives of youth within their community using their own

experiences to promote dialogue and change (Wang, 2006).

This study offered an opportunity for the underserved young participants to share their

photographs and stories and presented an avenue for dialogue. One youth participant stated

“This is a way we can make our concerns heard.” It gave voice to young people who might not

otherwise have had an opportunity to explore this issue. The concerns expressed around the

environment, personal responsibility, and values can be informative to those pondering the issue

of health policy and aid in reflecting on the meaning of health through the eyes of children living

in poverty.


References

Brooks-Gunn, J. & Duncan G. J. (1997). The effects of poverty on children. The Future of

Children: Children and Poverty 7(2), 56-71

Catalani, C., & Minkler, M. (2009). PhotoVoice: A review of the literature in health and public

health. Health Education and Behavior, Doi:10.1177/1090198109342084

Collingridge, D. S., & Gantt, E. E. (2008). The quality of qualitative research. American

Journal of Medical Quality 23, 389-395.

Currie & Stabile (2002). Socioeconomic status and health: Why is the relationship stronger for

older children? (NBER-WP-9098). Retrieved from National Bureau of Economic

Research http://www.nber.org/papers/w9098.pdf?new_window=1

Goodhart, W., Hsu, J., Baek, J. H., Coleman, A.L., Maresca, F.M., & Miller, M.B. (2006). A

view through a different lens: Photovoice as a tool for student advocacy. Journal of

American College Health (55) 53-56.

Hergenrather, K. C., Rhodes, S. D., Cowan, C. A., Bardhoshi, G., & Pula, S. (2009). Photovoice

as Community-Based participatory research: A qualitative review. American Journal of

Health Behavior, 3(6), 686-698.

Hwang, S.W., Tolomiczenko, G., Kouyoumdjian, F. G., & Garner, R. E. (2005). Interventions to

improve the health of the homeless: A systematic review. American Journal of

Preventive Medicine, 29(4), 311-319.

Klerman, L (1991). Alive and well? A research and policy review of health programs for poor

young children. (NCCP Report ISBN-0-926582-02-X).

http://www.nber.org/papers/w9098.pdf?new_window=1


National Center for Children in Poverty (2009). Minnesota demographics of poor children.

Retrieved from http://nccp.org/profiles/MN_profile_7.html

Seith, D., & Kalof, C. (2011). Who are America’s poor children: Examining health disparities

by race and ethnicity. Retrieved from

http://www.nccp.org/publications/pdf/text_1032.pdf

Strack, R. W., Magill, C., & McDonagh, K. (2004). Engaging youth through photovoice. Health

Promotion Practice, 5(1), 49-58.

Thomas D.R. (2003). A general inductive approach for qualitative data analysis. Retrieved from

http://www.fmhs.auckland.ac.nz/soph/centres/hrmas/_docs/Inductive2003.pdf

Wang, C. (2006). Youth participation in photovoice as a strategy for community change.

Journal of Community Practice, 14 (1-2), 147-161.

Wang, C. & Burris, M. (1997). Photovoice: Concept, methodology, and use for participatory

needs assessment. Health Education & Behavior, 24 (3), 369-387.

Wang, C. C., Morrel-Samuels, S., Hutchison, P. M., Bell, L., & Pestronk, R. M. (2004). Flint

PhotoVoice: Community building among youths, adults, and policymakers. American

Journal of Public Health, 94 (6), 911-913.

Wilson, N., Dasho, S., Martin, A.C., Wallerstein, N., Wang, C. C., & Minkler, M. (2007).

Engaging young adolescents in social action through photovoice: The youth empowerment

strategies (YES!) project. The Journal of Early Adolescence 27 (241) DOI:

10.1177/0272431606294834

http://www.fmhs.auckland.ac.nz/soph/centres/hrmas/_docs/Inductive2003.pdf

http://www.nccp.org/publications/pdf/text_1032.pdf

http://nccp.org/profiles/MN_profile_7.html


Table 1. Community Demographics

Characteristic NumberRace/Ethnicity

African American 333

Asian/Pacific Islander 535

Caucasian 70Latino/Chicana 17

Native American 8

GenderMale 414

Female 549Age

0-9 30710-17 17618-64 410

65-83+ 70Experiencing Poverty

Above 200% Poverty Level 47

100-200% Poverty Level 191Below Poverty

Level 725

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