This frame for this project is derived from three research traditions: 1) the epidemiology of neighborhood characteristics that influence health—an area of resurgent interest in the field of epidemiology; 2) lay or popular epidemiology; and 3) photovoice and photo elicitation methods. In addition, the project is influenced by the history of documentary photography as a stimulus for social change, epitomized by the work of the Farm Security Administration photographers, headed by Roy Stryker.
Epidemiology of Neighborhood Characteristics That Influence Health
The proposed project will contribute to a growing literature on neighborhood characteristics that influence health by enlisting local residents in a critical evaluation of the healthfulness of their city. In the epidemiological literature, modest-to-moderate associations (with relative risks generally under 2.0) have been observed between the neighborhood conditions of poverty and deprivation and individual-level outcomes including cigarette smoking, elevated body mass index, depressive symptoms, poor self-rated health, and heightened mortality risk (Kawachi and Berkman, 2003). However, most epidemiological studies of neighborhood health effects have relied upon secondary data sources, like the census, which include a limited number of variables to characterize neighborhoods (e.g., household income, home ownership, and race—variables used to construct measures of deprivation and segregation). These characterizing variables offer circumscribed insights into community assets and liabilities that may influence health—perhaps accounting, in part, for their thus far modest explanatory power in epidemiological studies.
This project is intended to reveal local residents' insights into the causes of poor and good health in their communities, with an ultimate goal of expanding the range of neighborhood characteristics probed in traditional epidemiological studies as underlying causes of poor and good health.
The Role of Popular Epidemiology or Lay Epidemiology
The term popular epidemiology was introduced by the sociologist Phil Brown (1987, 1992), who examined the role of the public in understanding toxic environmental exposures and their potential links to cancer clusters in Woburn, MA and Love Canal. Popular epidemiology is defined as "the process by which lay persons gather data and direct and marshal the knowledge and resources of experts in order to understand the epidemiology of disease, treat existing and prevent future disease, and remove the responsible environmental contaminants." In Brown's formulation, community members are active participants in the process of unraveling the causes of illness; this is accomplished by joining forces with scientists and influential stakeholders.
Davison et al (1991) offered the concept of lay epidemiology to describe the potential value (to etiologic research) of community residents' intimate knowledge of the physical and social conditions of their lives. The frameworks of popular and lay epidemiology are rooted in a trend since the 1980s in the social sciences (including sociology) that has emphasized lay understandings of complex causal relationships. Early work by Blaxter (1983), in which she interviewed low-income, middle-aged women to understand their theories of disease causation, exemplifies this method of probing lay explanatory models of illness. Blaxter and others have emphasized the potential for such lay explanatory models to inform and improve the effectiveness of health care and health education interventions. Recently, Lawlor and colleagues (2003) have invoked the principles of lay epidemiology to argue that smoking cessation programs may be particularly ineffective in low-income communities, where more salient and immediate (real and/or perceived) threats may include substandard housing and occupational or environmental hazards.
In the tradition of popular/lay epidemiology, HOPPP documents community perspectives that may enhance future epidemiological studies and also provide context for health care/health education interventions.
Photo-elicitation and Photovoice Methods
In his manuscript "Talking about pictures: a case for photo elicitation," Harper (2002) explains that photo elicitation is "based on the simple idea of inserting a photograph into a research interview." He describes the first naming of photo-elicitation in a 1957 study by Collier and colleagues that examined mental health in changing Canadian communities, with an emphasis on the environmental basis of psychological stress. In evaluating his own photo elicitation interviews versus standard control interviews, Collier stated that "The material obtained with photographs was precise and at times even encyclopedic; the control interviews were less structured, [more] rambling, and freer in association. Statements in the photo-interviews were in direct response to the graphic probes and different in character as the content of pictures differed" while the control interviews seemed to be influenced by the mood of the respondent.
Harper (2002) asserts that photo elicitation offers a bridge between researcher and subject, noting that "In-depth interviewing in all its forms faces the challenge of establishing communication between two people who rarely share taken-for-granted cultural backgrounds...Photo elicitation may overcome the difficulties posed by in-depth interviews because it is anchored in an image that is understood, at least in part, by both parties."
Photo elicitation studies may employ any visual images, including archival photos or those generated by the researcher or participant expressly for the purpose of a particular project. In contrast, photovoice methodology, developed by Wang and colleagues at the University of Michigan's School of Public Health (Wang and Burris, 1997) is a form of participatory action research that engages the participant as a photographer who captures the photos that best illustrate his or her perspective.
This project will employ elements of photovoice methodology. Photovoice involves provision of cameras to people in the community in order to "1) record and reflect their community's assets and concerns, 2) discuss issues of importance to the community...to promote critical dialogue and produce shared knowledge, and 3) reach policy makers" (Wang and Redwood-Jones, 2001). Photovoice, as such, is a tool for recording and disseminating local knowledge, in this case related to residents' perceptions of Philadelphia's healthfulness, as well as residents' health priorities and needs.
In the realm of health, photo-elicitation and photovoice methods have been employed to study a range of populations, including vulnerable populations. Examples include studies of drug addicts (Smith and Woodward, 1999), mothers of infants with congestive heart failure (Higgins and Highley, 1986), abused women (Frohmann, 2005), homeless people (Wang, 1998), and residents of Flint, MI (Wang, 2004), which has one of the highest rates of violent crime of any city in the United States. Results of photo-elicitation and photovoice studies, including participant-generated photos, have been published in academic journals and newspapers and have been presented at community exhibitions (e.g., Killion and Wang, 2000; Frohmann, 2005). Photovoice projects are underway at the University of Michigan (Dr. CC Wang), City University of New York (The New York State Scholar Practitioner Team, Dr. L. Mullings, director), the Johns Hopkins School of Public Health (Dr. R. Strack), and other institutions.
