1. Photovoice: Understanding the perspectives of HIV+ lower income women through participatory action research Pamela Valera, PhD, MSW Grand Rounds 25 June 2009 HIV Center for Clinical and Behavioral Studies

2. Outline of Presentation
What is Photovoice?
A Study Example with HIV+ Women
Photovoice Study Results into Action
Issues and Concerns of Photovoice
Community Empowerment
Ideas for Future Work

3. What is PhotoVoice?
An applied approach based on the principles of critical consciousness1 and feminist2 theory, and used in the first stage of participatory action research
The use of photographs as a vehicle for participants to identify pressing issues and determine solutions for collective action
1Freire, 1970; 2Wang & Burris, 1997

4. Rationale of Photovoice
Health disparities and social problems are complex
Increasing interest in engaging consumers and community participants
Increasing demands to hear from marginalized and indigenous populations
Increasing funder interest in building capacity and community-driven responses

5. Photovoice Approach
Participants participate in focus group discussions
Examine issues/social problems
Determine research question to study,
Reflect on meaning behind photos, and
Create an action plan.
Involves long term commitment to social change

6. Three Focus Group Discussions
1st meeting – discuss social problem, develop research question, address ethical issues, distribute disposable cameras
2nd meeting – discuss process and reflect on meaning behind the photographs
3rd meeting – discuss how to disseminate findings, determine collective action activities
Make clear how FGD relate to the approach presented on previous two slides

7. Focus Group Protocol (2nd meeting)
Objective of taking pictures: “What did you observe?”
Reflective questions were asked to enable the group to discuss how they felt about their photos.
“How did you feel when you took that picture?”
“What was the most challenging part of taking pictures about access to healthy foods?” and “How did you decide to take this picture?”
Interpretive questions were asked to enable the group to describe the meaning of their photographs.
“What would you say about this picture to someone who is not from your neighborhood?”
Decisional questions were asked to enable the group to respond to the problems of food insecurity and limited access to healthy foods and fresh fruits and vegetables.
“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?”

8. A Photovoice study example with HIV+ women in Central Harlem

9. Agency Partner: Sisterlink
A Community Action for Prenatal Care (CAPC) program funded by the New York State Department of Health AIDS Institute.
Designed to reduce adverse birth outcomes such as mother-to-child HIV transmission and low birth weight.

10. Participants
9 HIV+ women (3 Afro-Caribbean, 4 African American, 1 Asian, 1 Caucasian)
Mothers (20-45 years old)
Residents of Central Harlem
Family shelters and lower income apartments

11. Community Health Concerns
Unavailable men (ie., incarcerated)
Community violence
Illicit drugs
Access to healthy food
Women decided after a lengthy discussion
to focus on access to healthy food

12. Health Effects: Limited Access to Healthy Food
3 times more likely to be obese and four times as likely to have diabetes compared to Upper East Side Residents
After I met with the women, I decided to conduct further research about health diseases in Central Harlem and the issues of obesity and diabetes experience by the women and their community is alarming.
NYCDOHMH, May 2007

13. Social Environment of Harlem: Limited Access to Healthy Food
Bodegas/corner stores are more common in Harlem compared to the Upper East Side
Supermarkets are much more common on the Upper East Side than Harlem
Bodegas/corner stores are not likely to carry low-fat dairy products and are less likely to carry common fruits and vegetables compared to the Upper East Side
One in six restaurants (16%) in East and Central Harlem is a fast-food restaurant compared to 4% on the Upper East Side.
NYCDOHMH, May 2007

14. Photovoice Study
Objective #1:To document the experiences of HIV+ women’s access to healthy food in Harlem
Objective #2: To bring public awareness on access to healthy food by HIV+ women
Research Question: Can we afford to eat healthy in New York City?

15. STUDY FINDINGS

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

17. “Diabetes on Sale”
I was taking pictures of some of the things that were healthy and some of the things that I’ve noticed that they were [practically] giving away. When you go to the supermarket and when you see a can of soda for 25 cents and a bottle of water for $2, sometimes your income will force you to buy the unhealthy food. (African American woman with two children) “
Rashida

18. “Sky High Prices! For What?”
Bad. Angry sometimes? This stuff. I have to cook with it, just to get the nutrients stuff that
I 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)
Shelly

19. “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 scary
turkey 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)
Patricia

20. Photovoice Study Results into Action
Report reviewed by State Legislators (2008)
Women presented paper at Columbia University Teachers College 2nd Annual Health Disparities Conference, 2008
Paper is in press, Affilia (2009)
Community Mobilization – agency is currently applying for funding to work with bodegas (2009)

21. Issues and Concerns of Photovoice
Ethical considerations (taking photographs of people)
Discuss safety issues
Understanding women’s realities with HIV and other health problems

22. Community Empowerment
Community members are involved in the stages of research
Foster collaboration and strong partnership
Shared data and shared authorship

23. Future Work with Photovoice
Develop Photovoice study with early released inmates
Develop Photovoice methods/guidelines for working with early released inmates
Examine space/place, HIV risk and chronic health diseases (diabetes and cancer)

24. Thank You!
Partners in this study - Joyce Moon Howard, Sister Link and Participants
Mentors – Rogério M. Pinto, Nabila El Bassel, and Theo Sandfort
Others – Anke Ehrhardt Fellows ( ), Patrick Wilson, Miguel Muñoz-Laboy, Bob Fullilove, Susie Hoffman, Alex Carballo-Dieguez, Patricia Warne, Heino Meyer-Bahlburg, Bob Remien, Milton Wainberg, Joyce Hunter, Adrienne Braithwaite, Jimmy Liranzo, Shari Dworkin, and Nicholas Freudenberg