Youth as Change Agents for
Healthy Neighborhood
Environments: The Manchester
Photovoice Project
Semra A. Aytur, PhD, MPH
Rebecca Butcher, MS, MPH, PT
Cynthia Carlson, PhD
Karen Schifferdecker, PhD, MPH
*Richard Madol, Jenny Jing
Sara Fechner, Kamut Gabriel
APHA Annual Conference
November 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
Age-Adjusted Coronary Heart Disease
statewide rates
Mortality by Census Tract
(1995-2005)
Rates per 10,000 population
Context
Institutional Policy Changes in Manchester
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
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.
Methods
In 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
environments
2) Landlord-tenant conflicts
3) Violence in parks, schools, and
neighborhoods
4) 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 Learned
Involving 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
“Connect, Collaborate, Create”
• 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/H
ealthy_Homes_Resources.pdf
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 community
http://www.leadsafemanchester.com/MHI/docs/Healthy_Homes_Resources.pdf
Manchester Healthy Homes:
Methods
• Focus group plus educational
presentation
(summer 2013)
– Twenty-five adult heads-ofhousehold participated
– Translators present
– Notes from focus group
were reviewed and
organized into themes
Examples of Guiding Questions
1. 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 Topics
Example: 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.