Braiding the Healing Gifts of Photovoice for Social Change: The Means Are Ends in the Making.

Photovoice is an important participatory action method for motivating social change. The potential for this change within the processes of the method remains under-explored. We present the voice and perspectives of three health promotion practitioners who have important connections to photovoice: a grandmother and co-founder of the method, a nurse from Wales, and an early adopter seeking change. Through braided storytelling, the voices describe their history with photovoice and how their relationship to the method has changed over time, arguing ultimately that in photovoice the means are as important as the ends for advancing relations with others, understanding and working with power, and realizing the gifts the processes bring.

Multilevel Factors Influencing Interruptions in PrEP Use Among Young Women in Siaya County, Kenya.

Young women in sub-Saharan Africa continue to be disproportionately at risk for HIV. Oral pre-exposure prophylaxis (PrEP) can reduce women's HIV risk when taken daily throughout their "seasons of risk". We used photovoice to describe community views on factors influencing interruptions in PrEP use among young cisgender women in Siaya County, Kenya. Through group discussions, young women taking PrEP and their social network members (female peers, male peers/partners, family, and community members) shared photographs and identified broad social-ecological causes of PrEP interruptions, including: (1) widespread misinformation about PrEP, (2) social pressures from religious communities, (3) health care staff recommendations to interrupt PrEP use, (4) partner rejection of PrEP, (5) changes in women's risk awareness, and (6) a personal desire to occasionally pause daily use. Collectively, participants identified strategies to address these challenges. These findings can inform future programs targeting the broader social-ecological influences on young women's persistent use of PrEP.

The path to good health: Shifting the dialogue and promoting social ecological thinking.

The purpose of our research was to assess whether an intervention could produce changes in critical consciousness (CC) relative to participants' understanding of social influences on health and individual health behaviors. The intervention was a 4-min animation, entitled The Path to Good Health , that described how factors in our social environment influence individuals in a variety of ways and thereby our health. We used the same sampling and intervention strategies with two discrete cohorts of participants (Initial study: June 2018, n = 249; Retest study: October 2019, n = 315), who were recruited and incentivized through Amazon's Mechanical Turk platform. We measured direction and extent of change from pre-to post-intervention in four key constructs of CC (Passive Adaptation, Emotional Engagement, Cognitive Awakening, and Intentions to Act) using the 4-Factor Critical Consciousness Scale (4-FCCS), and we investigated differential effects of the intervention related to demographics of participants, including political typology. We also assessed concurrent and predictive validity of the (4-FCCS). Changes of CC subscale scores from pretest to posttest moved in the expected direction in both the Initial and Retest studies; Cohen's d effect sizes were medium to very large in both studies. Overall, findings suggest the video intervention was effective at improving CC among participants drawn from the general population. We demonstrated that it is possible to influence people's cognitive-emotional interpretations in as little as 4 min, regardless of one's political ideology, and that the (4-FCCS) is sufficiently sensitive to measure changes in CC. This study provides preliminary evidence that a brief intervention can broaden cognitive-emotional interpretations from an over-emphasis on personal responsibility for individual health to an appreciation of the impact of social ecological factors on population health.

Episodic Use of Pre-Exposure Prophylaxis Among Young Cisgender Women in Siaya County, Kenya.

The concept "seasons of risk" promotes use of pre-exposure prophylaxis (PrEP) only during periods of HIV risk. PrEP guidelines are aligned on daily use in women having vaginal sex during a risk period, and daily use for 28 days after the last potential exposure is recommended. However, when starting a "season of risk," guidelines vary on "time to protection," and unknowns remain in pharmacological research on PrEP protection in this population. During our iterative research on PrEP persistence using photovoice and in-depth interviews, we identified an ineffective pattern of PrEP use based on current guidelines-that is, routine, episodic use-among young cisgender women (YCW) in Siaya County, Kenya. Through same-group (n = 33 participants) and mixed-group (n = 31 participants) photovoice activities with YCW taking PrEP and female peers, participants explained that YCW associate their HIV risk with the sexual behaviors of their male partners who frequently travel from home. PrEP is considered unnecessary when partners are away because of no perceived risk. YCW re-start PrEP on or around the day of their partners' return because of heightened risk perceptions. Among the YCW interviewed (n = 18), nearly all of their partners traveled for about 1 week to 1 month at a time; about one-third of these women reported stopping PrEP during their partners' absence and re-starting it soon before or immediately upon their partners' arrival home. Additional research is critically needed to better inform PrEP guidelines and the decisions adolescent girls and young women make on how to use PrEP based on their risk context. In the interim, counseling on current dosing guidance when stopping and re-starting PrEP within a "season of risk" is needed.

Development and validation of the 4-Factor Critical Consciousness Scale.

Assessment of critical consciousness among individuals can provide a proxy measure of the readiness of communities, and individual decision-makers within, for social changes that address root causes of ill health. Critical consciousness, as conceived by Paolo Freire, emerges as a consequence of praxis. This iterative, recursive process of reflection and co-created knowledge enables community members to identify salient issues and the actions they want to take to address those issues. Public health and other social science researchers who engage in social- and population-level intervention work need a validated instrument that measures critical consciousness. Our purpose was to develop an instrument that can measure 4 key constructs of critical consciousness (passive adaptation, emotional engagement, cognitive awakening, and intentions to act) in an individual, relative to any salient community issue. We conducted two studies (Initial: June 2018; Retest: October 2019) to develop and validate this instrument. The same sampling strategy was used for both studies, but each study was conducted with a discrete cohort of participants. We used Amazon's Mechanical Turk to recruit and incentivize study participants. Data from the Initial study were used in an iterative process to evaluate construct validity and test our theoretical assumptions. Exploratory factor analyses were used to determine the best model fit that gave the greatest subscale reliability and validity. In the Retest study, confirmatory factor analysis was conducted and construct validity was verified. Our results indicated adequate construct validity as evidenced by good model fit. Additionally, the good fit of the data to the 4-factor structure confirmed our theoretical understanding of critical consciousness.

Revisiting the Roots and Aims of Photovoice.

Since its introduction, photovoice has been implemented in numerous fields with a wide array of outcomes of interest, but has the method been implemented in a way that is consistent with its initial aims in mind? From Caroline Wang and Mary Ann Burris's initial 1994 project, photovoice has demonstrated power to harness visual imagery and stories within a participatory empowerment process and established a new tool for the profession for understanding community members' lived experience and needs, raising the critical consciousness of communities, and advocating for actions leading to social change. Based in Freirean philosophy, feminist theory, and documentary photography, photovoice engages community members to identify, represent, and change their community by means of photography, dialogue, and action. Public health can benefit when researchers and practitioners more carefully conceptualize the intended aims of each photovoice effort. The purpose of this article is to consider the varied applications of photovoice and propose a classification system that encapsulates its wide-ranging aims. Close examination of foundational literature and previous applications of photovoice suggest the following categories for framing the application of the method; specifically, photovoice for (a) photovention, (b) community assessment, (c) community capacity building, and (d) advocacy for change. Full implementations of photovoice have the capacity to illuminate complex real-world issues leading to advocacy for policy, systems, and environmental change. It is our hope that the proposed framing clarifies the language used to discuss photovoice and its outcomes, distinguishes its various uses and stated aims, and maximizes its impact in future applications.

The Photovoice Decision Tree: Legal Considerations and Ethical Implications for Photographs and Captions.

This article presents a photovoice decision tree that serves as a guide for making lawful and ethical decisions during the portions of the photovoice process that involve photograph selection, caption development, and public display of photographs and captions. Lawful and ethical considerations encompass privacy of person, privacy of place, illegal acts and obscenity, defamation, representation of truth versus actual malice, and opinion versus assertion of fact, but do not address pursuing and obtaining institutional review board approval for photovoice projects and/or other important steps of photovoice projects that are beyond the scope of this article. The decision tree presumes that a comprehensive photo release process was completed with all photovoice participants and collected from any individual captured within a photograph. The decision tree has important implications for research and practice, including movement of photovoice practitioners beyond the required institutional review board approval for research projects to consider lawful and ethical issues associated with photograph selection, caption development, and public display of photographs and captions. This decision tree can serve as a meaningful tool for all photovoice practitioners and participants to guide their lawful and ethical decisions.

Rethinking Addiction.

Addiction is a complex and challenging condition with many contributing factors. Although addictive behaviors appear to be individual choices, behavior alterations cannot be addressed successfully without considering characteristics of the physical and social environments in which individuals live, work, and play. Exposure to chronic psychosocial stressors and the physiological response of individuals to their external environment activates the brain's neuroendocrine hypothalamic-pituitary-adrenal axis, with profound conditioning effects on behavior. This brief synopsis describes the social determinants of health; examines the interconnectedness of the psychosocial environment, behavior, and subsequent health outcomes; discusses the environment's critical influence on brain plasticity, adaptation and functioning; and explores additional factors that complicate adolescent addiction. Because the environment is both a determinant of behavior and an opportunity for intervention, in the context of addictions, it is important to incorporate these factors in the analysis of risk and design of early interventions for prevention and amelioration of addiction.

Disposal of prescription drugs by parents of middle and high school students.

To determine how parents dispose of unused prescription medications and correlates of disposal, we recruited 3,043 parents of adolescents to complete a survey. Multivariate and multinomial logistic regression was conducted to examine correlates of disposal of prescription medication. Only 17.8% of parents in a household prescribed a controlled medication in the past year disposed of unused medications. Of those, 36.7% used organized disposal (e.g., take-back event or drop box) and 63.3% disposed of medications at home. Organized disposal was associated with awareness of disposal opportunities. Increasing awareness of organized disposal opportunities is a promising mechanism to increase their use by parents.

Diffusion of medication drop-boxes in North Carolina from 2007 to 2016.

INTRODUCTION: A permanent drug donation box ("drop-box") is one strategy implemented in communities across the United States to reduce the availability of excess controlled medications, including prescription opioids, for diversion. The objective of this study was to examine correlates of the diffusion and implementation of drop-boxes in North Carolina. METHODS: We assessed the number and location of drop-boxes implemented in North Carolina. Cox proportional hazards models were used to examine covariates associated with drop-box implementation in NC counties (n = 100) between 2007 and 2016. RESULTS: There were 311 drop-boxes implemented in 91 (out of 100) counties. Most drop-boxes were in law enforcement agencies (78.8%) and a growing number were in pharmacies (14.5%). Counties with a higher percentage of whites, more educated residents, a substance abuse prevention coalition, higher rates of controlled medications dispensed and prescription opioid overdose, and that were Appalachian were more likely to be early adopters. Rural counties were less likely to have a drop-box. In the multivariate model, only higher rate of controlled medicines dispensed was significant. CONCLUSIONS: A growing number of drop-boxes are being implemented in law enforcement offices and pharmacies. Given that communities with higher rates of controlled medication dispensing likely have the highest need for disposal opportunities, it is promising that they are early adopters of drop-boxes. Future research should assess the effectiveness of drop-boxes as they become more widespread in a variety of locations.

US long-haul truck driver work organization and the association with cardiometabolic disease risk.

Work organization, including long working hours, irregular work schedules, and job stress, has been associated with increased cardiometabolic disease (CMD) risk for numerous working populations. The purpose of this study was to examine the associations between work hours, work schedules, job stress, and CMD risk for a sample of US long-haul truck drivers (LHTDs). A nonexperimental, descriptive, cross-sectional design was employed to collect survey and anthropometric data from 260 US LHTDs at a major truck stop. The mean BMI was 33.40 kg/m2 and mean waist circumference was 114.77 cm. Using logistic regression, researchers found longer work hours, especially greater than 11 hours daily, were associated with increased odds for an extremely high risk of CMD. Results support comprehensive and integrated approaches that address work organization, and in particular long working hours, to reduce drivers' CMD risk.

The Work Organization of Long-Haul Truck Drivers and the Association With Body Mass Index.

OBJECTIVE: The aim of this study was to examine relationships between work organization features of work hours, work schedules, and job stress with body mass indexes (BMIs) of long-haul truck drivers. METHODS: Face-to-face survey data were collected first, followed by collection of anthropometric measures including height and weight (n = 260). Logistic regression (backward stepwise model) was used to identify significant predictors of BMI and to analyze odds ratios. RESULTS: Mean BMI was 33.40 kg/m(2), with 64.2% obese (BMI > 30 kg/m(2)) and 18.4% extreme/morbidly obese (BMI > 40 kg/m(2)). Working more than 11 daily hours was associated with statistically significant increased odds for being extreme obese. CONCLUSION: Findings suggest that longer work hours (>11 hours daily) have a major influence on odds for obesity among this population. The results align with recent NIOSH calls for integrated approaches to worker health.

Developing a Web-based Tool Using Information and Communication Technologies to Expand the Reach and Impact of Photovoice.

Information and communication technologies are opening up vast new arenas for conducting the work of health promotion. Technology-based health promotions expand reach, standardize information and its delivery, provide opportunities for tailoring, create engaging interactivity within content delivery, provide for privacy and autonomy, improve portability, and lower delivery costs. This commentary describes the ongoing exploration and development of a web-based tool for enhancing the reach and impact of photovoice as a community change intervention. Features of the tool use information and communication technologies that integrate the use of an online learning management system, tailored messaging, gaming technology, interactive features, and the application of social media's power to increase the capacity of communities to employ comprehensive strategies to improve the health of their communities. It will enable individuals and groups to use photos and captions to assess the physical environment, social norms and behaviors of communities; raise community awareness of the factors contributing to ill-health in their communities, mobilize stakeholders, and inform environmental strategies and policy changes. We believe it will enhance the delivery of educational content about conducting photovoice projects, provide features unavailable without the application of information and communication technologies, and will be substantive advancement over existing photovoice resources.

Health literacy from the perspective of African immigrant youth and elderly: a PhotoVoice project.

BACKGROUND: This project examines the views of African immigrants on health, access to health resources in the U.S., and perceived barriers to a healthy wellbeing faced by the elderly immigrants in the community. METHODS: PhotoVoice methodology was used to evaluate the views of African immigrant youths and elderly drawn from a convenience sample. Participants were trained on the use of cameras and guided by research questions while taking photographs. The photographs were analyzed, coded into themes and presented to community resource representatives at a photo exhibit. RESULTS: Emergent themes were: 1) nutrition, obesity and physical activity; 2) occupational regulation and educational opportunities; 3) feeling of security and public safety; 4) ethno-racial diversity and the health care system; 5) religiosity and social well-being. DISCUSSION: These results have implications for health care professionals and community agencies serving immigrant populations. A deeper look into the health issues affecting this population is essential.

Resilience of Vietnamese refugees: resources to cope with natural disasters in their resettled country.

OBJECTIVE: Study findings suggest that refugees are more vulnerable than the general population to mental disorders from disasters. This pilot study explored the nature of Vietnamese refugees' resilience to a potential natural disaster as a first step toward improving their disaster mental health. METHODS: Interviews were conducted with 20 ethnic Vietnamese and Montagnard adult refugees using a semistructured interview guide. Factors in resilience at both individual and family levels were examined. RESULTS: Our results indicated that these refugees had positive personalities and strong family cohesion. However, although a majority of the participants had experienced natural disasters, they lacked knowledge and specific strategies to cope with these events. The individual participants and their families lacked sufficient information, financial resources, emergency supplies, or social support for a natural disaster. CONCLUSIONS: Enhancing refugees' current strengths in responding to disasters, delivering them tailored emergency training, strengthening relationships between refugee service providers and refugee communities, and advocating for refugees' socioeconomic capacity building should be considered.

Using the photovoice method to advocate for change to a campus smoking policy.

OBJECTIVE: The authors used the photovoice method as a strategy for empowering students to advocate for change of a campus smoking policy. PARTICIPANTS: Participants included 49 college students and 160 photo-exhibit attendees during spring 2011. METHODS: Students were trained in the use of the photovoice method and a public exhibit was used to educate the campus community and advocate for change. RESULTS: The photovoice initiative resulted in an effective platform for students to successfully advocate for the relocation of ashtrays that were in violation of the policy and for the elicitation of future advocacy targets. CONCLUSIONS: The photovoice project provided a platform for students to have their views heard by campus community members and policymakers. The project served as a useful tool for grassroots student advocacy. Those interested in addressing campus health policy issues may want to consider conducting a photovoice project similar to the one described in this article.

A university system-wide qualitative investigation into student physical activity promotion conducted on college campuses.

PURPOSE: This study aimed to examine college student physical activity promotion. DESIGN: A cross-sectional approach to qualitative research was used. SETTING: Southeastern state university system. PARTICIPANTS: Fourteen of 15 (93%) universities recruited were included in this study; 22 university employees participated in a semistructured interview. METHOD: Nonprobabilistic purposive and snowball sampling strategies were used to recruit individuals who were likely to be engaged in physical activity promotion efforts on their respective campuses. Thematic analyses lead to the identification of emerging themes that were coded and analyzed using NVivo software. RESULTS: Themes informed three main areas: key personnel responsible for promoting physical activity to students, actual physical activity promotion efforts implemented, and factors that influence student physical activity promotion. Results suggest that ecological approaches to promote physical activity on college campuses are underused, the targeting of mediators of physical activity in college students is limited, and values held by university administration influence campus physical activity promotion. CONCLUSION: Findings support recommendations for future research and practice. Practitioners should attempt to implement social ecological approaches that target scientifically established mediators of physical activity in college students. Replication of this study is needed to compare these findings with other types of universities, and to investigate the relationship between promotion activities (type and exposure) and physical activity behaviors of college students.

Quantifying littered cigarette butts to measure effectiveness of smoking bans to building perimeters.

OBJECTIVE: The authors estimated the number of violations of a university policy that prohibited smoking within 25 ft of all campus buildings. PARTICIPANTS: The project was conducted by 13 student researchers from the university and a member of the local public health department. METHODS: Students quantified cigarette butts that were littered in a 30-day period inside the prohibited smoking area of 7 campus buildings (large residential hall, small residential hall, administrative building, 2 academic buildings, campus cafeteria, and student union). RESULTS: Investigators found a total of 7,861 cigarette butts (large residential hall: 1,198; small residential hall: 344; administrative building: 107; 2 academic buildings: 1,123 and 806; campus cafeteria: 2,651; and student union: 1,632). CONCLUSIONS: Findings suggest that there is low compliance with the university's smoking policy. The described project may be repeated by students at other universities as a method to advocate for policy change.

Active living in the trucking sector: environmental barriers and health promotion strategies.

BACKGROUND: As one of the most underserved segments of the U.S. labor force, truck drivers have been associated with a series of morbid conditions intimately linked to their occupational milieux, their mostly unhealthful nutritional intake and sedentary lifestyles, and their resulting excess weight-gain. METHODS: This paper reports data from a baseline assessment of 25 trucking work settings located around interstate highways I-40 and I-85 in North Carolina. It examines how the environmental attributes of these work settings influence the physical and recreational activity behaviors of truckers, compares findings with those from other occupational environments, and brings to the fore a new health promotion paradigm for trucking worksites. RESULTS: Findings support growing empirical and anecdotal evidence that trucking work settings remain not only active-living deserts, but overall unhealthful places. A scan of physical, social, and information environments within trucking worksites as well as physical environments of surrounding communities reveal only meager opportunities for physical and recreational activity for truckers. CONCLUSION: This paper places the highly underserved population of truckers firmly within the discourse of worksite health promotion, and calls for comprehensive multistakeholder wellness strategies that address a multitude of risk factors linked to the occupational context.