Photovoice: Understanding the Photovoice: Understanding the perspectives of HIV+ lower perspectives of HIV+ lower

income women through income women through participatory action researchparticipatory action research

Pamela Valera, PhD, MSWPamela Valera, PhD, MSW

Grand Rounds Grand Rounds 25 June 200925 June 2009

HIV Center for Clinical and Behavioral StudiesHIV Center for Clinical and Behavioral Studies

Outline of Presentation Outline of Presentation

What is Photovoice?What is Photovoice?

A Study Example with HIV+ WomenA Study Example with HIV+ Women

Photovoice Study Results into ActionPhotovoice Study Results into Action

Issues and Concerns of PhotovoiceIssues and Concerns of Photovoice

Community EmpowermentCommunity Empowerment

Ideas for Future WorkIdeas for Future Work

What is PhotoVoice?What is PhotoVoice?

An applied approach based on the An applied approach based on the principles of critical consciousnessprinciples of critical consciousness11 and and feministfeminist22 theory, and used in the first theory, and used in the first stage of participatory action researchstage of participatory action research

The use of photographs as a vehicle for The use of photographs as a vehicle for participants to identify pressing issues participants to identify pressing issues and determine solutions for and determine solutions for collective collective actionaction

1Freire, 1970; 2Wang & Burris, 1997

Rationale of PhotovoiceRationale of Photovoice

Health disparities and social problems are Health disparities and social problems are complexcomplex

Increasing interest in engaging Increasing interest in engaging consumers and community participantsconsumers and community participants

Increasing demands to hear from Increasing demands to hear from marginalized and indigenous populationsmarginalized and indigenous populations

Increasing funder interest in building Increasing funder interest in building capacity and community-driven responses capacity and community-driven responses

Photovoice ApproachPhotovoice Approach

Participants participate in focus group Participants participate in focus group discussionsdiscussions Examine issues/social problemsExamine issues/social problems Determine research question to study,Determine research question to study, Reflect on meaning behind photos, and Reflect on meaning behind photos, and Create an action plan.Create an action plan.

Involves long term commitment to social Involves long term commitment to social changechange

Three Focus Group Discussions Three Focus Group Discussions

11stst meeting – discuss social problem, meeting – discuss social problem, develop research question, address develop research question, address ethical issues, distribute disposable ethical issues, distribute disposable camerascameras

22ndnd meeting – discuss process and reflect meeting – discuss process and reflect on meaning behind the photographson meaning behind the photographs

33rdrd meeting – discuss how to disseminate meeting – discuss how to disseminate findings, determine collective action findings, determine collective action activities activities

Focus Group Protocol Focus Group Protocol (2(2ndnd meeting) meeting)

ObjectiveObjective of taking pictures: “What did you observe?” of taking pictures: “What did you observe?”

Reflective Reflective questions were asked to enable the group to discuss how questions were asked to enable the group to discuss how they felt about their photos. they felt about their photos.

““How did you feel when you took that picture?” How did you feel when you took that picture?” ““What was the most challenging part of taking pictures about access to healthy What was the most challenging part of taking pictures about access to healthy

foods?” and “How did you decide to take this picture?”foods?” and “How did you decide to take this picture?”

InterpretiveInterpretive questions were asked to enable the group to describe questions were asked to enable the group to describe the meaning of their photographs. the meaning of their photographs.

““What would you say about this picture to someone who is not from your What would you say about this picture to someone who is not from your neighborhood?”neighborhood?”

Decisional Decisional questions were asked to enable the group to respond to questions were asked to enable the group to respond to the problems of food insecurity and limited access to healthy foods the problems of food insecurity and limited access to healthy foods and fresh fruits and vegetables. and fresh fruits and vegetables.

““What ideas of possible solutions do you have to address food insecurity?” What ideas of possible solutions do you have to address food insecurity?” “ “What needs to be changed?” and “Who should be involved in changing policy?”What needs to be changed?” and “Who should be involved in changing policy?”

A PHOTOVOICE STUDY A PHOTOVOICE STUDY EXAMPLE WITH HIV+ WOMEN EXAMPLE WITH HIV+ WOMEN

IN CENTRAL HARLEM IN CENTRAL HARLEM

Agency Partner: SisterlinkAgency Partner: Sisterlink

A Community Action for Prenatal Care A Community Action for Prenatal Care (CAPC) program funded by the New York (CAPC) program funded by the New York State Department of Health AIDS State Department of Health AIDS Institute.Institute.

Designed to reduce adverse birth Designed to reduce adverse birth outcomes such as mother-to-child HIV outcomes such as mother-to-child HIV transmission and low birth weight.transmission and low birth weight.

ParticipantsParticipants

9 HIV+ women (3 Afro-Caribbean, 4 African 9 HIV+ women (3 Afro-Caribbean, 4 African American, 1 Asian, 1 Caucasian)American, 1 Asian, 1 Caucasian)

Mothers (20-45 years old)Mothers (20-45 years old)

Residents of Central HarlemResidents of Central Harlem

Family shelters and lower income apartmentsFamily shelters and lower income apartments

Community Health Concerns Community Health Concerns

Unavailable men (ie., incarcerated) Unavailable men (ie., incarcerated) Community violenceCommunity violence Illicit drugs Illicit drugs Access to healthy foodAccess to healthy food

Women decided after a lengthy discussionWomen decided after a lengthy discussion

to focus on access to healthy food to focus on access to healthy food

NYCDOHMH, May 2007NYCDOHMH, May 2007

Health Effects: Limited Access Health Effects: Limited Access to Healthy Food to Healthy Food

3 times more likely to be obese and four times as likely to have diabetes compared to Upper East Side Residents

NYCDOHMH, May 2007NYCDOHMH, May 2007

Social Environment of Harlem: Social Environment of Harlem: Limited Access to Healthy FoodLimited Access to Healthy Food

Bodegas/corner stores are more common in Harlem Bodegas/corner stores are more common in Harlem compared to the Upper East Side compared to the Upper East Side

Supermarkets are much more common on the Upper Supermarkets are much more common on the Upper East Side than HarlemEast Side than Harlem

Bodegas/corner stores are not likely to carry low-fat Bodegas/corner stores are not likely to carry low-fat dairy products and are less likely to carry common fruits dairy products and are less likely to carry common fruits and vegetables compared to the Upper East Sideand vegetables compared to the Upper East Side

One in six restaurants (16%) in East and Central One in six restaurants (16%) in East and Central Harlem is a fast-food restaurant compared to 4% on the Harlem is a fast-food restaurant compared to 4% on the Upper East Side. Upper East Side.

Photovoice Study Photovoice Study

Objective #1:To document the experiences Objective #1:To document the experiences of HIV+ women’s access to healthy food in of HIV+ women’s access to healthy food in Harlem Harlem

Objective #2: To bring public awareness on Objective #2: To bring public awareness on access to healthy food by HIV+ womenaccess to healthy food by HIV+ women

Research Question: Research Question: Can we afford to eat Can we afford to eat healthy in New York City? healthy in New York City?

STUDY FINDINGSSTUDY FINDINGS

Our Options to Eat: “24 Hours to Our Options to Eat: “24 Hours to Eat Fat”Eat Fat”

RashidaRashida

“ “Diabetes on Sale”Diabetes on Sale”

““I was taking pictures of some ofI was taking pictures of some of

the things that were healthy and the things that were healthy and

some of the things that I’ve some of the things that I’ve

noticed that they were [practically] noticed that they were [practically]

giving away. When you go to the giving away. When you go to the

supermarket and when you see asupermarket and when you see a

can of soda for 25 cents and a can of soda for 25 cents and a

bottle of water for $2, sometimes bottle of water for $2, sometimes

your income will force you to buy your income will force you to buy

the unhealthy food. (African American woman with two the unhealthy food. (African American woman with two children)children)

ShellyShelly

““Sky High Prices! For What?”Sky High Prices! For What?”

Bad. Angry sometimes? This stuff. I have to cook with it, just to get the nutrients stuff thatI need to better me. But, oh man! That’s a lot of money. I just look at [it] and leave it alone.I need them, but I can’t buy them. (Afro-Caribbean woman with one child)

PatriciaPatricia

““Beat Up Torkey”Beat Up Torkey”

People buy this stuff? (all) Yeah, they can’t afford not to. No, that’s not the local store, that’s between Broadway and Amsterdam. You see how beat up the turkey is; that’s why it’s so cheap, but people buy it. So many scaryturkey parts. . . . Scary, but it looks like food, and you don’t feel hungry [afterward], but for fruits, you know, you pay like $10 and still make you feel hungry. (Asian woman with one child)

Photovoice Study Results into Photovoice Study Results into Action Action

Report reviewed by State Legislators (2008) Report reviewed by State Legislators (2008)

Women presented paper at Columbia University Women presented paper at Columbia University Teachers College 2Teachers College 2ndnd Annual Health Disparities Annual Health Disparities Conference, 2008Conference, 2008

Paper is in press, Paper is in press, AffiliaAffilia (2009) (2009)

Community Mobilization – agency is currently Community Mobilization – agency is currently applying for funding to work with bodegas applying for funding to work with bodegas (2009) (2009)

Issues and Concerns of Issues and Concerns of Photovoice Photovoice

Ethical considerations (taking photographs of Ethical considerations (taking photographs of people)people)

Discuss safety issuesDiscuss safety issues

Understanding women’s realities with HIV and Understanding women’s realities with HIV and other health problems other health problems

Community Empowerment Community Empowerment

Community members are involved in the stages Community members are involved in the stages of research of research

Foster collaboration and strong partnershipFoster collaboration and strong partnership

Shared data and shared authorshipShared data and shared authorship

Future Work with Photovoice Future Work with Photovoice

Develop Photovoice study with early Develop Photovoice study with early released inmates released inmates

Develop Photovoice methods/guidelines Develop Photovoice methods/guidelines for working with early released inmates for working with early released inmates

Examine space/place, HIV risk and Examine space/place, HIV risk and chronic health diseases (diabetes and chronic health diseases (diabetes and cancer)cancer)

Thank You!Thank You!

Partners in this study - Joyce Moon Howard, Sister Link Partners in this study - Joyce Moon Howard, Sister Link and Participantsand Participants

Mentors – Rogério M. Pinto, Nabila El Bassel, and Theo Mentors – Rogério M. Pinto, Nabila El Bassel, and Theo Sandfort Sandfort

Others – Anke Ehrhardt Fellows (2006-2009), Patrick Others – Anke Ehrhardt Fellows (2006-2009), Patrick Wilson, Miguel Muñoz-Laboy, Bob Fullilove, Susie Wilson, Miguel Muñoz-Laboy, Bob Fullilove, Susie Hoffman, Alex Carballo-Dieguez, Patricia Warne, Heino Hoffman, Alex Carballo-Dieguez, Patricia Warne, Heino Meyer-Bahlburg, Bob Remien, Milton Wainberg, Joyce Meyer-Bahlburg, Bob Remien, Milton Wainberg, Joyce Hunter, Adrienne Braithwaite, Jimmy Liranzo, Shari Hunter, Adrienne Braithwaite, Jimmy Liranzo, Shari Dworkin, and Nicholas FreudenbergDworkin, and Nicholas Freudenberg