Perceptions of Youth on Health, Nutrition, and Well-Being in their Local Community: The Somersworth Photovoice Project
Perceptions of Youth on Health, Nutrition, and Well-Being in their Local Community: The Somersworth Photovoice Project
When I was young, I knew I wanted a career that allowed me to help people on a large scale through community-wide interventions and policy change. As I got older, I developed a respect for high quality research. I understood that writing policy and implementing interventions is about more than just having an idea or an opinion. By uncovering the factors and evidence related to a problem, we equip ourselves with the facts necessary to build a credible platform for change. Put simply, research gives power to ideas.
With obesity on the rise in the United States, nutrition and public health professionals are eager to understand why. As I worked on my bachelor’s degree, I read dozens of published papers that outlined the many factors related to the 35% of adults and 17% of children in the United States who are obese (Center for Disease Control and Prevention, 2015). Eager to conduct my own research, I teamed up with my faculty mentor, Dr. Semra Aytur, and we set out to explore the impacts of the community environment on health. The objective of the study was to develop a better understanding of the relationship between the environment and nutritional health status in low-income youth by exploring the man-made elements of the environment, known as the built-environment.
The author in the "Plant for Growth" garden with youth from the Safe Haven.
Dr. Aytur introduced me to the perfect methodology for the project: Photovoice. Photovoice is an extremely accessible method of qualitative data collection that involves the use of photographs, taken by participants, to answer a research question (Wang & Burns, 1997). Because virtually anyone can learn to use a camera, Photovoice is often used to illustrate the concerns of underserved populations including those of lower-socioeconomic status, racial and ethnic minorities, and youth.
Luckily, I already had the perfect location for my project: I had been working at the Somersworth Youth Safe Haven for three years prior to the start of my project. An after-school program and summer camp that runs virtually all-year round, the Safe Haven was a safety net for at-risk youth between the ages of five and eighteen. My work at the Safe Haven began when the community leadership program at the Thompson School of Applied Science (TSAS) at the University of New Hampshire (UNH) established a large community garden in the center of the Somersworth housing authority, where the youth at the Safe Haven and I would spend our next three summers.
Building a Career: from Student to "Garden Lady" to Researcher
My education began at the Thompson School in the Culinary Arts and Nutrition program where I focused my energy on dietetic technology. The dietetic technology concentration prepares students for careers as Registered Dietetic Technicians (DTR). The program includes a ninety hour internship working in the community teaching culinary arts and nutrition to youth, serving healthy ideas to food pantry clients, working in community and school gardens, and analyzing the nutritional content of recipes. I spent many of my ninety hours (and then many more after the semester ended) at the Safe Haven. I enjoyed the hands-on teaching style at the Thompson School and appreciated the opportunity to be actively engaged in my learning. I spent more of my class time cooking in the Cole Hall kitchen and teaching nutrition basics to community members than in a lecture hall.
While my work at the Safe Haven began with the “Plant for Growth” youth gardening initiative, my role at the Safe Haven quickly expanded. In addition to being the “garden lady,” as the children fondly called me, I was also a homework helper, a health teacher, a basketball coach, and a role model. I prepared snacks, played, challenged them in the gym, and inspired the kids to create with new art projects.
After graduating from the TSAS with my associate of applied science, I stayed at UNH and continued toward my bachelor’s degree. I also stayed at the Safe Haven. Alongside the children, I planted the garden every spring, maintained it through the summer, and harvested the fresh vegetables. We used the vegetables and herbs from the garden to talk about food and nutrition.
At UNH, I pursued a degree in dietetics, but I knew eventually I wanted to find a graduate program in public health or social policy. In many ways, I knew that my degree in dietetics would serve as a unique complement to a graduate program where I would be studying health-related policy. In the classroom, I was reading excessive amounts of peer-reviewed journal articles and learning to read them critically. I challenged myself to question the information and dig deeper for answers. I practiced and relied on these new skills when writing research papers, policy proposals, and grants as part of my coursework. As a result, I grew stronger as a critical thinker and as a writer.
Still, I wanted to see beyond the published piece. Despite my confidence in the classroom, I admittedly didn’t have a clue how to conduct research. I was interested in many topics and easily compiled a list of research questions regarding health disparities, food insecurity, and food-related policy. I made room in my schedule for a four-credit Undergraduate Student Research Experience (INCO 590), and began searching for a mentor. I was looking for a mentor who was willing to teach, not just supervise.
Dr. Aytur and I shared many interests, including the health disparities related to income and culture, particularly the impacts of the built-environment. There are many ways in which the built-environment contributes to health. For example, one study showed that the number of convenience stores, fast food restaurants, snack stores, and liquor stores within 400 meters of a school increased as the proportion of Hispanic and non-Hispanic Black students increased and proportion of Caucasian students decreased (Sturm, 2008). This study also suggested that the number of convenience stores, limited-service restaurants, snack stores, and liquor stores within 400 meters of a school increased as the proportion of students eligible for free or reduced lunch increased.
Dr. Aytur and I developed a research question that was reasonable and achievable: how does the built-environment within a community impact the health of low-income youth? More specifically, we were interested in how the children felt the built-environment impacted their health. Large-scale problems, like the obesity epidemic in the United States, are icebergs: often professionals are able to easily see what is above the surface and that the only way to truly understand the extent of an issue is to have a conversation with those who live beneath the water. While I spent a great deal of time at the Safe Haven, the young participants lived in this community. Luckily, Dr. Aytur had done a similar Photovoice project with youth in Manchester, New Hampshire, which I was able to use as a guide (Aytur et al., 2013).
The Research Process vs. the Research Question
“This garden belongs to my class at school. Gardens encourage students to eat more vegetables, but it is easier to start small. For example, right now I am working on liking onions. All schools should have gardens. It is nice to be outside during the school day.”
“This is my bike rack at home. I am not allowed to bike places yet, but I will be when I am older. I have always wanted to bike to school. Biking is good exercise. I guess it is easier to bike places if there are bike racks, so all places should have bike racks. Also, all kids should have bikes.”
“Oranges are healthy. Having these in your house is better than having a bowl of ice cream. Oranges taste good and they are good for you. These have a positive effect on younger and older kids.”
“This is a healthy food. It is all natural. Exposure helps kids eat healthier: we eat what we are given after school, so if it is healthy then we eat healthy food. Some of it also tastes great, like apples!”
“My parents smoke and it isn’t healthy. I am probably going to die of second hand smoke. We should make more signs saying ‘don’t smoke’ instead of ‘smoking is fun or cool’.”
“I titled this picture ‘scum of society’ because this disgusting pool of filth is located right next to our school.”
“Soda and microwave popcorn are bad. There is too much sugar in this picture. We need more nutrition education classes for kids everywhere, like the ones we have here (at our after school program).”
“The pizza at school is an example of bad, unhealthy food. Mostly, we eat what we are given, so being given good food means we are more likely to eat good food. I probably wouldn’t eat as healthy if I didn’t have an after school program to go to."
While I was eager to answer the research question that Dr. Aytur and I had developed, my primary objective was to learn how to conduct research. There were more behind-the-scenes steps than I imagined, many of which addressed the legal and ethical components of using humans as research subjects. This included a human research subject training and the long process of seeking approval from the Institutional Review Board (IRB) at UNH. Before the research could begin, I needed IRB approval on every aspect of my research project, including promotional materials and consent/assent forms. After submission, it is common for the IRB to return applications for revision, so I wasn’t discouraged when the IRB responded to my application with a list of revisions. The process of receiving IRB approval took longer than I anticipated, but once I received IRB approval, I was able to dive in.
Forms in hand, I waltzed into the Safe Haven and gathered around a table with the ten oldest kids. I explained the project to them and gave them an opportunity to ask questions and share ideas. One teenage boy opted not to participate and I told him that was OK. On the other end of the spectrum, some of the kids seemed thrilled to participate. One young girl ran home to ask her dad to sign her consent form on the spot. Over the next two weeks, as the participants turned in the forms, I began to hand out cameras.
Due to my experience working at the Safe Haven, I knew that being flexible would allow me to avoid excess frustration. Of the nine kids who expressed interest, one participant was excluded due to a missing parental consent form, two participants were excluded for not returning their cameras, and results from another two participants were excluded because the participants were unable to participate in the sharing session and did not write captions for their photos. Therefore, my results include photographs and captions from four participants. The four participants who completed the study ranged in age from ten to eighteen years old.
As I distributed cameras, I instructed each participant to take photographs of elements of their neighborhood, homes, and schools that they believe influence whether they make healthy or unhealthy choices. I asked the participants to pay special attention to determinants of food choices. Once the photographs were developed, we gathered as a group to discuss the results and problem solve. I steered the discussion using the SHOWED method (Wang & Burns, 1997): What do you see here? What is really happening here? How does this relate to our lives? Why does this problem, condition, or strength exist? What can you do to educate others about this problem, condition or strength? What can we do about it? Next, I asked the participants to select one to five of their favorite photos and write captions for them based on what was said during the discussion.
What I Learned from a Group of Smart Kids
Even before distributing the cameras, the participants enthusiastically began to detail the photographs they planned on taking. One student mentioned the visible grease on the school lunch pizza at her middle school. Another participant commented that she wished she had the camera when the sidewalks were covered in snow, making the walk to school more dangerous. The participants unanimously agreed upon pictures of cigarettes or ashtrays.
There were many common themes in the results. Participants took many pictures of healthy and unhealthy foods, cigarettes and ashtrays, as well as community and school gardens. Most participants agreed that being involved in an after school program had led to healthier after school snacks and overall healthier diets than if they went directly home after school. Many of the results were ones I expected, such as the photographs of the school garden. Others surprised me, demonstrating that community members (even the youth) often have insight that professionals and outsiders lack. I was most surprised by the image of the polluted pond near the high school. By choosing to capture this image, the young participant seemed to acknowledge that how well we care for our community influences how well they care for themselves. Dr. Aytur commented that youth who participated in the Manchester Photovoice project made very similar observations about how the environment can symbolize caring.
To illustrate positive influences on health, participants took pictures of a vegetable garden at school, a bike and bike rack at home, as well as food items: 100% apple juice, fresh apples, peanuts, and a bowl of oranges. To illustrate negative influences on health, participants took pictures of ashtrays and cigarettes, a polluted pond near their school, and unhealthy food items such as soda, microwave popcorn, and greasy pizza.
I am curious about how the results may have been swayed by the Safe Haven’s emphasis on health. The program encouraged healthy habits through nutrition lessons, daily gym time, activities related to smoking cessation, and of course, the “Plant for Growth” youth gardening initiative. The participants expressed to me that the environment of their after school program influenced their behaviors. For example, one participant wrote in a caption: “I probably wouldn’t eat as healthy if I didn’t have an after school program to go to. If I went home after school I would still eat apples because they are good, but I would eat more bad foods, too.” It would be interesting to compare these results with those from adolescents who do not have an after school program available to them, or those whose after school program did not promote healthy habits.
Sadly, the Somersworth Photovoice Project was implemented in the Safe Haven’s final weeks. Due to her declining health, the program director had submitted her resignation, prompting the Somersworth housing authority to close the Safe Haven doors after fifteen years, due to inadequate funding and support. I am grateful to have been involved with the program during its final years.
This project gave a voice to a population that is eager to be heard, especially as they watched their second home close. I genuinely enjoyed the experience of hearing what these bright middle and high schoolers had to say. Their thoughts reinforced how important the Safe Haven was to all of us. Each participant expressed gratitude that they had somewhere safe to go after school. Every day as the kids stepped off the school bus, they were greeted with fun activities, homework help, and simple snacks of apples and granola bars or, in the bitter-cold New Hampshire winter, hearty meals of chicken soup or chili. The Safe Haven was nearly always full of volunteers and interns from UNH to whom the children looked as role models.
Watching the Safe Haven close was difficult for all involved. The forty children who jumped into my arms every day after school are underdogs who I will always be rooting for. As the kids tearfully chanted “Safe Haven Strong” on the program’s final day, I vowed to use my education to advocate for the health of these vulnerable children and their families, starting with this project. I will keep this promise and these children in mind as I begin working toward my masters in public policy at the Carsey School at UNH this fall. The youth who participated in this study were given one last opportunity to voice how important the Safe Haven was to them in a productive, powerful way. As I continue on in graduate school and in my career, my hope is that I will be able to give power to more voices like theirs.
This project wouldn’t have been possible without the support and encouragement of Dr. Semra Aytur who was as happy to teach as I was to learn. I also owe a very special thank you to the Somersworth Youth Safe Haven - to the youth who participated in this research project for your enthusiasm and to Betty and Roger Eaton, the Safe Haven’s fearless leaders, for welcoming me with open arms. Additional thanks to the Hamel Center for Undergraduate Research at the University of New Hampshire for the support necessary to complete my research project through INCO 590: Student Research Experience.
Aytur, S., Schifferdecker, K., Butcher, R., & Zavatone-Veth, H. (2013, February 27). Creating safe neighborhoods for active living: A case study of cross-sectoral collaboration [Oral presentation at The Robert Wood Johnson Foundation/ Active Living Research Annual Meeting, San Diego, CA].
Centers for Disease Control and Prevention. (2013, September 3). Childhood obesity facts. Centers for Disease Control and Prevention Retrieved from http://www.cdc.gov/obesity/data/childhood.html
Sturm. R. (2008). Disparities in the food environment surrounding US middle and high schools. Public Health, 122(7), 681-690. doi: 10.1016/j.puhe.2007.09.004.
Wang, C., Burns, M.A. (1997). Photovoice: concept, methodology, and use for participatory needs assessment. Health Education & Behavior, 24(3), 369-387.doi: 10.1177/109019819702400309
Author and Mentor Bios
If there's a word that captures the essence of Sarah Garstka, it's gumption. A recent alumnus, Sarah graduated in December of 2015 with a bachelor’s of science in nutrition/dietetics. She pursued the research project she wrote about for Inquiry to gain experience in research, and felt that the process taught her nearly as much as the project itself. Searching widely for a mentor who would "teach, not just supervise," mostly by doggedly asking professors and working connections, she found an ideal match in Dr. Aytur. Sarah believes strongly in the value of social research to create new knowledge and perspectives. "One participant submitted a photograph of a polluted pond near the school. It didn’t occur to me before that the way we take care of our environment may influence the way we take care of ourselves," she explains. In fall 2016, Sarah will enter the master’s program in public policy at UNH’s Carsey Institute.
Dr. Semra A. Aytur is an associate professor in the department of health management and policy, and has been with the University of New Hampshire for seven years. Dr. Aytur specializes in public health and epidemiology. Working with Sarah on this project, Dr. Aytur was pleased with Sarah's abilities as a community liaison, noting Sarah's strength in building trust for her Photovoice project, as well as her perseverance in pursuing Institutional Review Board (IRB) approval for projects with human subjects under tight time restrictions. A well-suited pair, Dr. Aytur noted that, "Working with youth to improve community resilience is a very important research area for me, so it was terrific to have a student like Sarah who was so passionate about the project and the community members."
Copyright 2016, Sarah Garstka