Peter Balvanz is a graduate student in the Department of Health Behavior and Health Education (HBHE) at the Gillings School of Global Public Health.
Fellow HBHE graduate students Jeff Quinn, Leilani Ogan and I recently wrapped up a photovoice project with a small group of high school youth from Caswell County. Through the project we asked participants to explore what keeps them healthy and what gets in their way through photography and follow-up discussions that we facilitated. We were interested in both factors that directly affect health such as nutrition and physical activity, as well as more distal social determinants and contextual factors such as stress inducing scenarios and access to health promoting materials. Through four separate sessions over the course of a month participants developed the following topics with us to guide their photography:
• Healthy and unhealthy things in my life
• Healthy and unhealthy places
• Healthy and unhealthy prices
• Things I love about my community
During discussion sessions the photos deemed to be most representative of the photo topics were selected by participants, and served as a trigger for the facilitated discussion. Each discussion was recorded, transcribed, and the qualitative data was later analyzed for emerging themes and results that could guide future action to better support the health of youth in Caswell County. Our results fit within three categorical levels: interpersonal, organizational, and environmental influences on health.
Youth are highly influenced by others in their community whether it be a care giver, role model, peers, or otherwise. Behaviors of others viewed by youth and their interactions with participants were viewed to both help and hinder health. Participants reported responding well to social support provided to them by their care givers or other adults, particularly when the other was believed to truly care about them and not act merely like a baby-sitter. Such people received respect from the youth, and youth were thus more likely to follow their advice. Modeling behavior of some adults in the community had a negative influence that made youth curious about alcohol. For the photo topic “healthy and unhealthy things in my life” one participant took the following photograph and commented:
“You see the old man do it [drink alcohol], you wonder why they do it so much. You get to the point where you want to try to see what’s so good about it. So, it’s like, eager to do it.”
Peers also had both a negative and positive influence on health. Youth were more likely to be physically active if their friends participated with them. Alternatively, peer pressure within some social circles encourages youth to drink, pop pills, and engage in sexual activities.
Being constantly connected with peers via cell phone texting was reported to not only be important, but integral to participants. Youth noted that they regularly sent dozens of texts per day and the modality served as a primary pathway for information sharing. The text reportedly allows one to share information without potential embarrassment, and can both alert youth to upcoming parties or be used to invite friends to exercise. The central role texting plays in the lives of youth is apparent through the following quotes of two participants from the photo topic “healthy and unhealthy things in my life”:
“I was just sitting in the bed and I was like, ‘I got to stop texting’. There’s my covers right there. I was laying in the bed texting. I could be doing something, but I’m laying in the bed texting. “
“My cell phone is my life; I don’t know what I’d do [without it]; I’d be at school and people would ask, ‘why you got attitude? Why don’t you cool down.’ I’d be like, ‘I don’t have my cell phone.’ For real? I’d be like, yep”
Organizations that could influence the health of Caswell County youth were often mentioned in a positive light. Although participants lamented the former condition of their high school and the prevalence of fights, they report that recent changes have helped clean up the school. Participants generally agreed that high school and Piedmont Community College (PCC) had potential to be a positive influence, and they appreciated the chance to receive college credit at PCC while in high school. School events were noted as activities that brought the community together, as can be seen through this comment from a discussion on the topic “what I love about my community”:
“I like the football games…. Because, whether you dislike somebody or whatever, everybody still comes together for the football games. It’d be a packed thing.”
Similar to the results recorded in interpersonal factors, youth viewed organizations that they perceived to care about them as positively influencing health. Some of these organizations specifically mentioned included church, Caswell County Partnership for Children, and a pharmacy.
Numerous factors within the surrounding environment, or community, of youth have an influence on whether or not youth are able to lead a healthy life. Participants note various barriers within their surrounding community that hamper their ability to remain healthy. During the discussion that accompanied the photo topic “healthy and unhealthy prices” participants spent considerable time discussing the inaccessible cost of healthy foods as compared to junk foods. This, and the lack of control youth have in selecting and buying foods is summed up in the following participant quotes with accompanying photo:
“Okay. You know how they say that our kids eat too much candy; there ain’t enough vegetable stuff or whatever. Okay, that’s not fair because you all the ones that’s got the prices for the healthy foods sky high and the candy is the cheapest and then they talk about your kids are obese. It ain’t our fault.”
“They’re always talking about how they want all the people to eat healthier and they don’t want people to be obese but if you don’t want that to happen then why is healthy food so high [expensive]…I’ll tell you the truth. I don’t know what the people are, but I do know that I always turn on the TV and hear about ‘your child is obese. If you’re living an obese life, you should eat healthy.’ How am I going to eat healthy? I don’t handle money.”
Youth participating in this project also reported how the presence of dilapidated structures and lack of entertainment can lead to an unhealthy lifestyle. Youth report a lack of entertainment available to them in their towns, a perception that prompts them to seek parties where youth may be involved in unhealthy behaviors or to travel to Danville. Some structures that provide activities for youth were mentioned to be uninviting due to litter and the presence of individuals engaging in risky behaviors on site. Dilapidated or dirty structures were perceived by youth to invite crime and bad behaviors, as well as foster an ever-growing lack of appreciation for community, as is summed up in these quotes:
“Very, very unhealthy, look at that. Inside messed up, you have people on the side doing drugs, selling drugs….[This place] makes you come and want to do drugs, I mean it’s just calling you to come over there, for real. To me it says ‘let’s go have a drink’.”
“Nastiness. It could if you live around here, it could make people think wrong or different about you, just because of the stuff around you, like that.”
Considering these results and observations from the project it is clear that the participants face an internal conflict in the midst of developing their perceptions of health. These perceptions are influenced by the reciprocal relationship between their environment and cultural context including role models (right/wrong and healthy/unhealthy), and their health knowledge.
Throughout the study we collectively kept a running list of potential action steps mentioned by youth that would help them maintain a healthy lifestyle in Caswell County. Participants recognized that many things they believed would serve as a protective agent against unhealthy behaviors or facilitate a healthy life may not be immediately feasible. Actions that youth believed would help them stay healthy include:
• Create more recreation options for youth, ideas include: more accessible swimming pool, skating rink, theater, malls, clubs
• Make members of the community aware of how lack of concern for the community and the presence of run-down areas affects the town negatively and sets a pattern for future generations to care less about their community
• Clean up problem areas in town to reduce unhealthy behaviors in public and eliminate fear associated with going near these sites
• Increased law enforcement in town to curb bad behavior before it becomes problematic
• Some believe that a rehabilitation center and social support from people that genuinely care would help addicts.
• Encourage and develop stronger positive role models for youth
• Introduce public transportation to Danville, or generate carpools
• Health foods need to be more accessible, either by lowering price, increasing availability of local, inexpensive healthy options, or through starting a community garden
• Increase jobs and/or lower gas prices