Introduction
A collaborative community-based partnership was formed between Fairfield University and Caroline House to promote wellness, community-engaged learning, and community-based participatory research (CBPR). Caroline House is a language and literacy program for recent immigrants located in Bridgeport, Connecticut. Caroline House’s mission is, “to enable women and children to reach the fullness of their potential through education in English language and life skills” (Caroline House, Inc., 2023). Undergraduate students in health studies from Fairfield University participate in a monthly Wellness Workshop series with Caroline House each semester with the goal of fostering mutually beneficial, multi-directional learning and health, grounded in cultural humility.
Bridgeport is a vibrant and diverse city bordering the town of Fairfield, where Fairfield University is located. Half of the residents in Bridgeport speak a language other than English at home (U.S. Census Bureau, 2019) and 40% of Latinx residents experience linguistic isolation (Seaberry et al., 2023). In terms of environmental exposures, Bridgeport residents have higher comparative risk than most of the county in terms of exposure to carcinogenic air toxins, lead paint, hazardous waste, and wastewater discharge (Seaberry et al., 2023).
After a two-year wellness series with Caroline House, a Photovoice project was undertaken to better understand factors and determinants of health that were most impactful for those living, working, and learning in Bridgeport and the surrounding community. The purpose of the collaborative study was to examine social determinants of health in the Bridgeport community by collecting photographic data from community members. Through this collaborative work, we aimed to identify the community-prioritized issues to guide topics discussed in the monthly Wellness Workshops and design collective advocacy efforts.
Photovoice Methodology
Photovoice is an evidence-based, valid qualitative approach that has been used in other research contexts to identify community-prioritized determinants of health and highlight challenges of the built environment (Colón-Ramos et al., 2018). Photovoice is designed to be a participatory qualitative method that has been used specifically to elevate the community voice, especially in the areas of maternal/family and child health (Wang & Pies, 2004). Derived from multiple approaches, including feminist theory and documentary photography (Coemans et al., 2019) as well as Freire’s (1972) pedagogical and theoretical work removing pervasive constructions of oppression, Photovoice helps foster mutual respect and collaboration with students, faculty, and community members (Wang & Burris, 1997). Researchers have adopted this research approach for a variety of health-related projects that often involve advocacy, community change, policy-making, and multiple community stakeholders, guided by the powerful use of photographic documentation, evidence, and support (Wang & Pies, 2004). The findings are not meant to be widely generalizable but to highlight relevant thematic items of local importance identified by community members (Wang & Pies, 2004). Likewise, researchers who have used this Photovoice approach also highlight the inherent iterative benefits that allow for continuous collaboration, participation, and inclusion of the community perspective through multiple rounds of dialogue and analysis of key themes, which often facilitates action (Colón-Ramos et al., 2018).
Photovoice centers community as part of the CBPR approach, guides collaboration, and transcends language and/or cultural differences (Nykiforuk et al., 2011). Photovoice has specifically been utilized in Latinx contexts to understand social-ecological barriers and facilitators to community health and well-being in a way that is culturally responsive and community-centered (Winter et al., 2016). As part of the process, “citizen scientists” contribute, share, and disseminate data that help drive research priorities and outcomes (Winter et al., 2016). Key qualities of the Photovoice method include exploratory utilization of photos, coupled with facilitative discussion to enhance an understanding of relevant community issues (Nykiforuk et al., 2011). Together, this rich qualitative data prioritizes community insight and is especially useful for informing policy-directed change (Nykiforuk et al., 2011).
Photovoice As a Tool for CBPR and Community-Engaged Learning
A CBPR project utilizing the Photovoice methodology (as described by Wang, 1999, and Wang & Burris, 1997) was launched through a collaborative partnership. The project was conceptualized by the first and second author, representing insight from both the academic and community context. To highlight our positionality related to the project, the first author is a faculty member at the University and the second author is a leader at the community site (Executive Director of Caroline House). Both authors live in communities adjacent to Caroline House, but are active (working and participating in community activities) in Bridgeport. The second author is bilingual and was born and raised in Guatemala before relocating to the U.S. The first author was born and raised in the U.S. but is the daughter of an immigrant and has strong ties to her cultural roots with dual citizenship (non-Hispanic, not bilingual). The third author is a nursing student from the U.S. who identifies as non-Hispanic, not bilingual and resides near campus during the school year but is not originally from the community/region involved in this partnership.
In this context, photographs were utilized to discover and address social determinants of health in the Bridgeport community identified by community members. The project was approved by the Fairfield University IRB under an expedited review process in December 2022. The IRB utilized Spanish-language expertise to ensure the content of the consent form and research process were communicated clearly and consistently in both languages.
The research and Photovoice process was explained by one University researcher and two Fairfield University nursing students (one who was bilingual and explained the project and read the consent form in Spanish) to members of Caroline House in small groups divided by language level; any questions were answered in person. Subsequently, those who were interested and over the age of 18 were offered the opportunity to participate in the project and had the choice of signing the consent form in English or Spanish. A total of 23 women consented to participating, which is consistent in response size with other Photovoice projects done in similar populations (Winter et al., 2016). Each participant was offered a disposable camera or the option to use their phone camera to take pictures of places, spaces, and objects that most impact their health throughout the community. Participants were asked not to take any pictures that included other people for privacy purposes. About six total participants opted to use the disposable camera and the remainder preferred to use their phone camera. Due to COVID-19 protections, no cameras were shared and photos were either submitted digitally to a study specific e-mail address or the camera was left in a drop box location at Caroline House. Each participant received a $10 gift card for the submission of any number of photos (1+). Plastic gift cards were distributed to those who returned disposable cameras and digital gift cards to those who submitted via email. Email addresses were utilized to provide gift cards and physical gift cards distributed by study staff, but otherwise the photos were anonymous and names were not recorded.
Photos were taken and submitted in December 2022 and January 2023. After receiving and printing all the digital and disposable camera photos, a workshop was scheduled in February 2023 to discuss the images and bring to the forefront major themes. Students in a 2000 level undergraduate public health course were briefed on the Photovoice process and collaborative project and worked on displaying the photos on posterboard based on similar features for the workshop. While photos were displayed and presented in groupings, key themes were generated by the community during the workshop. In order to ensure the students were approaching the conversation in a way that challenged institutional power dynamics, students spent a month learning, reflecting, and practicing cultural humility and anti-racist pedagogy, enhanced by guided readings (Donahue & Plaxton-Moore, 2018; Villarosa, 2022), videos (Chavez, 2013; Kendi, 2020), discussions, and writing activities. On the first day of class, students contributed to a set of community guidelines to enhance community engaged-learning (CEL) and respect with open-mindedness, vulnerability, and active listening adapted from Bell and Love’s (Adams et al., 2016; Bell et al., 1997) and Singleton’s (2006, 2016) guidelines. Students were asked to challenge assumptions, explore, and reflect to identify any implicit or explicit bias that would bring harm to the community conversation and to be prepared to listen in a way that opposed traditional power-based speaking orders. This was reinforced with several in-class exercises and reflective entries.
The first community dialogue session was scheduled for February 2023. A total of 35 photos were collected and displayed on poster boards around the Caroline House main classroom and several duplicate photos were passed around for closer inspection. Caroline House students were asked what they thought and for any initial reactions to seeing the collective photographic display. After the initial round of feedback, further dialogue clarified if any responses were more common or if any themes emerged in the images displayed. University students and researchers were quiet and took notes/utilized active listening to allow for sharing from the Caroline House participants who took the photographs. It was at this time that community members began providing stories behind the photos, which often changed the perceived meaning of the photo. For example, one photo of a street corner with a sunset was originally perceived as positive, but a participant shared that this corner became dangerous at nightfall because people drank alcohol there and littered cans and bottles. Thus, the image was intended to portray the lack of safety for children and families. Another photo of traffic was explained to highlight congestion, air pollution, and lack of pedestrian safety as two-way traffic did not allow for safe passing on this neighborhood street. A picture of garbage in the street (Figure 1F) was highlighted as blocking a sewer which prevented rainwater drainage and led to standing water, pests, and lack of cleanliness.
Community members had the opportunity to discuss the photos, aided by a translator, across several months/visits to Caroline House. These dialogues highlighted the most prevalent issues and themes that emerged from the photos (see Table 1 for timeline and process). Community members and students generated a list of the most impactful factors and determinants of health in the community over the course of several visits in early 2023. After the first meeting, Caroline House students took the lead and presented advocacy ideas and steps related to their findings to the group in a combination of English and Spanish.
Narrative Storytelling
Narrative storytelling has been utilized in a variety of public health contexts to both explore and better understand factors impacting health (McCall et al., 2021). Throughout the workshops, several participants engaged in narrative storytelling to give voice to the photographs in a way that informed their impact, relevance, and meaning. For example, one participant shared that broken glass littered a park where she brought her daughter to play. Another, in reply to an image of a grocery store aisle and check-out area, highlighted that broken items in the grocery store are not cleaned up promptly. This discussion of the community impact of litter, trash, and disrespect led to a robust discussion about neighborhood cleanliness, including clean water, air, and environments for children. While many women shared stories of community spaces that needed repair, clean-up or general attention, several also shared stories about personal homes, neighborhoods, and enforcement of policies by landlords. For example, one Caroline House participant shared someone was smoking and throwing trash on her property even after he was asked to stop. These poignant stories gave deeper meaning to the images and started to tell a narrative that made themes of the pictures emerge around related issues of environmental justice: trash, hygiene and pollution, neighborhood cleanliness and safety, littering and air pollution from smoking (see Figure 1 for select photos from these themes). This first dialogue on the photos only began to skim the surface of the broader community issues that emerged, but already, synergies and areas of common concern were identified and reinforced by multiple Caroline House members.
Action-Oriented Follow-Up
At the end of the first workshop (which was about 1.5 hours long), there was already a call for several action-oriented follow-up steps. There was interest in reaching out to the Mayor’s Office/Town Hall to report some of these unsafe/unclean areas and advocate for improved community cleanliness. Several community members suggested signage around Caroline House to alert neighbors not to litter, curb their dogs, and recycle. Students also suggested changes within Caroline House related to recycling, gardening, and setting an example for their neighbors. A few questions came up related to laws and policies about smoking near schools, marijuana usage in apartment buildings, and who was ultimately responsible for the cleanliness of shared/community spaces. Caroline House and Fairfield University members both committed to exploring these action items further and thinking about how to collectively advocate for the identified environmental justice issues over the next month.
Ongoing Advocacy as a Result of the Photovoice Project
The Caroline House Executive Director and the University faculty debriefed between the workshops to communicate that community members were engaged and committed to working on several of these environmental justice projects, but would appreciate support in contacting city officials and creating signage on littering and cleanliness. In response to this feedback, Fairfield University students created a list of local officials’ contact information, including the Mayor’s Office, Department of Environmental Health, Department of Health and Social Services, Water Pollution Control Authority, and Department of Parks and Recreation along with sample tips/scripts of what to include on these calls (verbal interpretation was available to walk community members through this list). A sample letter to city officials was written in both English and Spanish, including some photographs and a call to action. Fairfield University students created sample signs about pollution and littering as examples and looked up laws related to smoking/marijuana in the city and around schools and parks. When the March workshop occurred, students shared these materials as a starting point. Community members and students agreed to reach out to city officials as a collective show of support around these issues. The draft letter was edited and updated with feedback from Caroline House members and recirculated in both languages post-workshop for distribution/further individualized editing.
Key laws were reviewed to clarify where signage would be appropriate and how to advocate to landlords and local park authorities based on applicable laws. Using the example signs, posters and markers were distributed so Caroline House students could design their own signage. Caroline House students then presented with large easels and note pads their ideas to the group in English and Spanish, starting with their identification of the problem of trash/garbage in the neighborhood, on the streets, and in parks. Next, community members highlighted that the solution begins with Caroline House and offered suggestions on how to maintain the trash/recycle area, make signs, plant flowers, clean up the exterior yard, and encourage the involvement of neighbors and local city officials. Community members called the project “Caroline House Cares” and from this point forward, Fairfield University researchers/students moved into a supportive role to ensure the community members could lead the efforts that they identified and prioritized. By way of support Fairfield University was asked to provide more information about composting/gardening and recycling and to draft some social media posts to encourage greater participation for these action steps to coincide with Earth Day.
Prior to the third and final spring workshop, Fairfield University students were invited to Caroline House to participate in a community/yard clean-up. Caroline House led and organized this well-attended community clean-up to beautify their grounds as a model for the community. Subsequently, Caroline House organized a door-to-door campaign with materials they created to educate and motivate neighbors to participate in these efforts related to Earth Day. Again, community members invited Fairfield University students along to support and translate as needed. The result was a robust community campaign to encourage the neighbors to advocate for a cleaner community and promote environmental justice. The excitement from these events was shared at the April workshop, but there was still an overall frustration at the lack of timely reply from city officials. A plan was devised for further outreach to city officials and in the meantime, seeds were distributed for potting/planting. In the meantime, students and community members collectively engaged in a composting activity using recycled materials to enhance the possibility of on-site composting.
Sustainability of the Photovoice-Related Action
In May, the first author received an email reply from a city official asking for a list of streets, parks, and community areas that needed to be cleaned up in response to an influx of letters and calls from students and community members. Caroline House community members compiled a list of key streets and parks that needed attention, and the City of Bridgeport committed to sending staff to those sites to inspect, clean up, and remediate as needed. To date, we continue to follow up with city officials on the status of this clean-up. Over the summer months when the University and Caroline House are not in routine session, communication continued about how to foster the continuation of this work. Several ideas were considered, including supporting community-health worker paid training, seeking community-focused grants, and participating in community gardens through a local non-profit. The collaborative work continues to engage students and community members on this area of collective interest.
Feedback on Process
Students and community members routinely reflected and debriefed throughout the process. A feedback survey was also distributed to community members after the third workshop to elicit suggestions on how to improve the collaboration, what was most valuable, and suggestions for the future. Community members shared that they liked the partnership and felt the awareness of the issues and the related actions were important. This collaborative work is ongoing to create and promote sustainable change, health promotion, and environmental justice.
Strengths/Limitations
There are many inherent strengths to a Photovoice methodology, particularly in this collaborative, community-based approach. In particular, the photos came across very clearly as thematically aligned on environmental justice issues while simultaneously fostering robust discussion and innovative, community-driven solutions. However, the ability to forward change through advocacy and enhance environmental justice as a result of this work is not immediate. The collaborative project will require sustained efforts to ensure the impact is measurable. While both Caroline House and Fairfield University are committed to the community relationship and ongoing work in this area, changes that occur beyond the scope of an academic term/year need to be formalized. Grant mechanisms to support the tremendous community health work organized by Caroline House are needed to support community members’ continued involvement. Finally, prolonged advocacy efforts are needed to actually create policy-level and environmental change.
Other limitations to the approach include that images were static (not video) and taken alone, not in groups, teams, or with University members. Additionally, the photographs alone were often only part of the story, supplemented by the robust dialogues of the images and the power of narrative storytelling. There was an emphasis on keeping the photographs anonymous to protect the identity of the photographer, but if there had been a way for participants to caption their photos, that might have provided additional depth to the images. While titles and captions are often a part of the Photovoice process, it was not included here in order to transcend language differences. However, this can also the limit the scope of the work. In the future, translated titles or bilingual captioning should be considered.
Further, students did display and organize the photos to exhibit, which could have been done more collectively with the community prior to thematic generation. The current process provided independence and autonomy for the community members (not influenced in any way by the University partners in taking the photographs) while also allowing for triangulation of images and photographic data through subsequent discussions. In other contexts, “go-along” approaches to Photovoice have been utilized to encourage a more dynamic and collaborative team-based approach between research and community partners to talk through, and document with photo or video the issues concurrently (Carpiano, 2009). This is a possible avenue for future work in this area, especially given the invitation for continued collaboration that occurred through the community clean-up and outreach efforts.
Conclusions
Several key determinants related to environmental justice and health inequity emerged. Disparities across town/city lines — including access to clean air, sanitary streets, and well-maintained parks — that have immediate and long-term impacts on the health of residents are unjust. Additional anti-racism work is necessary to advocate for equitable policies, environmental standards, and community determinants of health. The Photovoice methodology is an evidence-based and community-centered approach that overcame linguistic differences to create solidarity. The resulting collective advocacy efforts enhanced necessary health promotion work and actively engaged both University and community partners to learn from one another, collectively work to dismantle health inequities within the community, and advocate for access to healthy environments for all.
Acknowledgements
Thank you to the Caroline House community for partnering with us to collaboratively advocate for environmental justice and health equity. Thank you to the Lawrence Family Fund for supporting the student research of the third author, which included the cameras, photo printing, and research incentives. Finally, special thanks to the students in PUBH 2201: Public Health Disease and Injury who supported these efforts.