Youth as Change Agents for Healthy Neighborhood Environments: The Manchester Photovoice Project

Semra A. Aytur, PhD, MPHRebecca Butcher, MS, MPH, PT

Cynthia Carlson, PhD Karen Schifferdecker, PhD, MPH

*Richard Madol, Jenny Jing Sara Fechner, Kamut Gabriel

APHA Annual ConferenceNovember 4, 2013

Background• Marginalization from decision-making

processes mirrors the health disparities observed worldwide with respect to infrastructure investments, exposure to violence and environmental hazards, and rates of chronic disease

• By enabling people to become change agents within their own communities, Participatory Action Research (PAR) methods, such as Photovoice, can facilitate the co-creation of culturally relevant strategies to address complex health issues– e.g., intersection of violence prevention

and chronic disease prevention

Context: Manchester, NH

• Largest city in New Hampshire – Population 109,830

• Refugee Resettlement Area– Over 75 languages spoken in schools

• Study area: “East Side” and “West Side” neighborhoods– Approximately 23%-36% of the

population is below the federal poverty level in West Side and East Side, respectively.

– Higher rates of chronic diseases compared to city-wide and statewide rates

Age-Adjusted Coronary Heart Disease Age-Adjusted Coronary Heart Disease

Mortality by Census TractMortality by Census Tract

(1995-2005)

Rates per 10,000 population

Manchester has implemented institutional policy changes to build cross-sector collaboration around issues of violence prevention and healthy neighborhood environments:

•Crime Prevention Through Environmental Design (CPTED)•Community Policing•Neighborhood Revitalization Projects•Safe Routes to School•Safe Havens•‘One Touch’ Healthy Homes program

ContextInstitutional Policy Changes in Manchester

Objectives

As part of a larger CBPR study, we conducted a Photovoice project in Manchester, NH to:

1) Explore youth perceptions of relationships between safety, active living, and healthy eating in the context of their daily lives 2) Understand barriers/enablers of health in their neighborhood environments

Methods:Photovoice

• Seventeen English-speaking youth (ages 13-18) were recruited (n=7 boys and n=3 girls (East Side); n=5 girls and n=2(West Side)). – Data from fourteen adolescents was used for

analysis– Twelve of the teens were from African refugee

families (from various countries, including Sudan, Somalia, Tanzania, and Rwanda); one was White and one African American.

Methods

• Youth attended Photovoice sessions once a week for six weeks during the summer or fall of 2011.– In sessions 1-5, participants were provided with

cameras and asked to take photos of their neighborhoods, focusing on health and safety issues.

– Participants also received safety training and were instructed not to place themselves at risk while taking photographs.

MethodsIn sessions 2-6, youth discussed four to eight photos per session using the “SHOWeD” method:

• What do you See here?• What’s really Happening? • How does this relate to Our lives?• Why does this problem/strength exist?• What can we Do about this?

Participants wrote captions to share with community stakeholders.

Photovoice: Guiding Questions

What things in your neighborhood make you feel healthy? Unhealthy?

What do you see when you go outside to play?

“I took this picture of cigarette signs on a gas station next to Pulaski Park. Smoking is bad for you, yet the advertising is big and eye-catching. It’s weird that these ads are so close to a place that is healthy and good.” −S.R, age 16

“This is a picture of an alleyway by Union and Central. This shows the laziness by people. We need to work together to fix this.”

–W.P., age 15

Trash in alleys where kids play- N.M. age 17

“This is a sidewalk in my neighborhood. It’s not safe, someone could cause a crash if they were riding a bike and got off to avoid a crack. It makes me feel people don’t care about our place.” − S.R., age 16

“Why can’t this vacant lot be used for a garden or a sports field?” –W.P., age 15

“I love this picture because I think it is beautiful. It shows the beauty of the West side of Manchester. It shows that some people’s thoughts about the West side are wrong. If you are

looking for the good in something, you will find it. But if you are focused on the bad, you will only see the negative.”

T.L., age 15

“This is Pulaski Park and the basketball court. It’s a place that keeps me active. I wish there could be more parks, more ball courts, and that they’d keep them fixed up.” -N.M., age 17

“This is a torn basketball hoop at our park. We fixed it with duct tape.” -S.R., age 15

“My family built a ramp for my brother, who is handicapped, after repeated requests to our landlord and months of carrying my brother up the stairs when he wanted to go outside to play.” - RM, Manchester resident and UNH Undergraduate Researcher

“The hole in the ceiling of this rental home started out small, but after kids picking at it for a month it became this big. Residents of this household moved out to protect their health, after repeated requests to the landlord to fix the ceiling...” - RM, Manchester resident and UNH Undergraduate Researcher

“The ceiling at this household was peeling and no effort was made by the landlord to get it fixed. It was fixed the day before the home inspector arrived. .. “- RM, Manchester resident and UNH Undergraduate Researcher

Results: Photovoice Themes

1) Unhealthy indoor/outdoor home environments2) Landlord-tenant conflicts3) Violence in parks, schools, and neighborhoods4) Advertisements for beer and cigarettes in areas where youth play

*Forthcoming publication: Aytur A, Butcher R, Carlson C, Schifferdecker K. Creating Safe Neighborhoods for Obesity Prevention: Perceptions of Urban Youth. In: Brennan V, Kumanyika S, Zambrana R (eds). Obesity Interventions in Underserved US Populations: Evidence and Directions. Journal of Health Care for the Poor and Underserved, Johns Hopkins University. In Press, 2014.

Lessons LearnedInvolving youth as change agents

– Challenges• Gaining trust and long-term commitment

– Benefits• The Photovoice process generated a community

dialogue that allowed youth to voice their concerns and share their photos with community stakeholders

– Lead by example• Art exhibit• Peer learning and mentoring• Undergraduate research projects

Photovoice Art Exhibit at City Hall

Next Steps: Capacity Building and Sustainability

• Manchester – City was recently awarded a RWJF Roadmaps to

Health grant – Community School Model

• Uses public schools as safe havens• Community schools bring together many partners to

offer a range of supports, services, and opportunities to children, youth, families, and communities

– ‘One Touch’ to a Healthy Home http://www.leadsafemanchester.com/MHI/docs/Healthy_Homes_Resources.pdf

“Connect, Collaborate, Create”

Undergraduate Research - “Manchester Healthy Homes”

Richard Madol

Objectives:1) Identify perceived health risks/concerns in the

Bhutanese refugee/immigrant community related to their home environment

2) Educate and empower members of the Bhutanese community living in low-income neighborhoods in Manchester about simple ways to protect their health from risks due to home environments

3) Explore ways to enhance communication between the Manchester Health Department (especially the ‘One Touch’ program) and the Bhutanese communityhttp://www.leadsafemanchester.com/MHI/docs/Healthy_Homes_Resources.pdf

Manchester Healthy Homes:Methods

• Focus group plus educational presentation

(summer 2013) – Twenty-five adult heads-of-

household participated – Translators present– Notes from focus group

were reviewed and organized into themes

Examples of Guiding Questions1. What are some concerns you have about your home

environment?2. Are you aware of the Manchester Health Department’s “One

Touch” program?3. What are some things that you would like the Manchester

Health Department to know about regarding your home environment?

4. What kind of information or training would you like from the Manchester Health Department?

5. Has your (house/apartment) been tested for lead paint?6. Do you have any children under the age of 2?

If yes, have they had BLL testing? If yes, do you know the results?

7. Do you have any questions about the educational presentation?8. How do you think this educational presentation could be

improved?

Educational Presentation TopicsExample: Asthma Triggers

• Environmental Tobacco Smoke

• Dust Mites

• Mold

• Toxic Chemicals

• Pests & Pest Management

Aligns with Manchester Health Department’s ‘One Touch’ to a Healthy Home focus areas (Asthma, Lead Poisoning, Smoking)

Results

Themes from Focus Group Participants:

1) Overall, participants reported a lack of knowledge about health risks due to the home environment upon arrival to NH

2) Landlords’ neglect of health hazards in the homes of Bhutanese community members was an issue

3) Bhutanese community members expressed the desire for education on these topics

Conclusions & Lessons Learned• Ongoing need to develop accessible,

culturally sensitive healthy home educational programs for refugees/immigrants

• Project team is partnering with Manchester Health Department to integrate residents’ concerns into interventional activities

• The Manchester Health Department can consider addressing the cultural barrier by training refugee/immigrant youth as peer educators

Opportunities for Youth to Engage in Research for Population Health

Acknowledgements

We thank the City of Manchester for their commitment to creating healthy environments for all residents.

We are grateful to the Robert Wood Johnson Foundation's Active Living Research Program for supporting the Photovoice project.