“Another Day in Paradise”

Abstract

This article provides the results of a photovoice project conducted with older adults affected by diabetes living in three rural counties in the southern region of the United States. Photovoice is a community-based participatory action methodology that puts the tools of research in the hands of participants. This project was an initial community engagement activity that promoted trust-building and formed part of a larger comprehensive community needs assessment. The process revealed themes of personal and community resilience focused on the daily living with diabetes, formal and informal supports, barriers to taking care of their diabetes, accessibility to fruits and vegetables, changes to food preparation and consumption, and exercise supports and barriers. The impact of the photovoice project on the participants and the implications for practice are discussed.

Keywords

photovoice community-based participatory action research older adult rural diabetes

Diabetes affects 25.8 million Americans and type 2 diabetes accounts for 90% of the cases (Centers for Disease Control and Prevention [CDC], 2011). The prevalence of diabetes increases with age and affects close to 27% of older adults. Medical costs for diabetes are currently estimated at US$174 billion, including direct and indirect cost (disability, work loss, premature death). Two thirds of these expenses are for patients who are 65 or older. Diabetes can cause heart disease, stroke, blindness, kidney failure, lower extremity amputations and deaths related to flu and pneumonia (CDC, 2011). The Committee on Identifying Priority Areas for Quality Improvement from the Institute of Medicine (Adams & Janet, 2003) identified diabetes as one of its priority areas. They base their decision on the extent of the burden of diabetes on patients, families, communities, and societies; the extent of the gap between current practice and evidence-based best practice; and, the likelihood that the gap can be closed and conditions improved through change. In a national survey of state and local rural health leaders, diabetes was rated as the second highest rural health concern (Bolin & Bellamy, 2011). The incidence of diagnosed diabetes in urban areas has been estimated at 7.9 cases per 1000, while for rural areas, new cases of diabetes was estimated to be 9.1 cases per 1000. Additionally, the diabetes death rate for urban areas was estimated at 68.1 deaths per 100,000, yet was 81.4 deaths per 100,000 for rural areas (Healthy People 2020). Effective management of a chronic illness, such as diabetes, requires an accessible and knowledgeable health care system as well as self-management on the part of the patient.

Within the context of health promotion theories, the focus has moved away from individuals as the only agent of change to conceptualizing a complex system of influences that ultimately shape individual health behavior (Crosby, Kegler, & DiClemente, 2002). For rural adults living with diabetes, these influences include lack of knowledge from local physicians on how to effectively guide their patients in monitoring and managing their disease, social isolation, lack of access to affordable and healthy food choices, lack of access to appropriate and safe exercise facilities, and a rural culture that promotes smoking. According to the National Rural Health Association, 20% of the American population live in rural communities but less than 10% of doctors practice in these rural communities (as cited in Dabney & Gosschalk, 2003). When rural residents with diabetes have access to a doctor, they more often see a generalist than a specialist for their disease-specific treatment (Rosenblatt et al., 2001). Additionally, rural residents report a higher number of transportation difficulties reaching health providers, driving greater distances to hospitals and doctors (Gamm et al., 2003).

Depression is common with older adults living with diabetes and especially for those in rural areas (Bell et al., 2005; Byers et al., 2012). Yet mental health services in rural areas are limited due to the need for service providers. There is also stigma attached to seeking services, a lack of knowledge regarding how to access services and a lack of routine assessment of mental health by physicians (Lawrence & McCulloch, 2001; Sanders, Fitzgerald, & Bratteli, 2008). Consequently, older adults with diabetes suffering from depression are less likely to engage in adequate self-management increasing their complication risk (Bell et al., 2005).

Arcury et al. (2012) found that rural older adults living with diabetes with high levels of social integration (e.g., social engagement and social network size) were more likely to adhere to self-management behaviors. Yet Baernholdt, Yan, Hinton, Rose, and Mattos (2012) found that older adults living in rural areas reported lower levels of social functioning than urban older adults suggesting greater social isolation. With the potential of a smaller social network, families play an important part in the support of self-management behaviors, such as eating a healthy diet. Denham and others have suggested that inclusion of families in self-management programs is crucial since diet is not only influenced by family members but also that diabetes tends to be a family diagnosis (Denham, Manoogian, & Schuster, 2007; Manoogian, Harter, & Denham, 2010; O’Brien & Denham, 2008).

Sharkey, Johnson, and Dean (2010) found that increased distance from grocery stores selling a variety of fresh and processed fruit and vegetables was associated with decreased daily consumption of fruit and vegetables among rural seniors. In a review of the impact of the built-in environment on adults living in rural areas, Frost et al. (2010) found that light traffic, safety from traffic (e.g., perceived presence of sidewalks and shoulders), and the presence of recreational facilities, trails, or parks were correlated with physical activity in adults living in rural areas. These studies suggest the need for local governmental officials to consider greater accessibility to fruits and vegetables as well as traffic lights, stop signs, crosswalks, and sidewalks to reduce secondary complications for older adult residents of rural counties.

Older adults living in rural areas have significant obstacles that can impede adequate access to the necessary health care and management of their diabetes. Hartley (2004) promotes three key elements that need to be addressed to reduce rural health disparities, namely, working with individuals and motivating them to take control of their chronic health conditions, preparing health practitioners working in rural areas to better care for their patients by following nationally recommended guidelines for care, and developing community resources that will promote healthy living for rural residents.

In late 2009, the Kentuckiana Regional Planning and Development Agency (KIPDA) Rural Diabetes Coalition (KRDC) was funded by the Centers for Disease Control and Prevention (CDC) to eliminate health disparities for rural older individuals of low income living with diabetes. Three rural counties in the north central region of Kentucky were selected to be the focus of this initiative due to their high rate of diabetes that ranges from 10.9 % to 11.4% (CDC, 2009). The project utilized a comprehensive needs assessment guided by the socioecological model (Bronfenbrenner, 1977, 1979) to direct intervention on the individual, interpersonal, organizational, community, and public policy levels. A research methodology was needed that intervened on multiple levels and also provided trust building between the agency-academic team guiding the grant and the community. Photovoice was chosen as a methodology to not only address the individual, interpersonal, and community levels but also as an initial grant activity because of its proven ability to link needs assessment to community participation (Wang & Burris, 1997).

Photovoice is used to promote critical dialogue and knowledge about important issues through photographs and small group discussions and then subsequent reaching out to policy makers to advocate for change (Wang & Burris, 1997). This method provides participants, who traditionally have little voice in community policy decisions, with training in photography, critical dialog, photo captioning, and policy advocacy (Kramer, Schwartz, Cheadle, & Rauzon, 2012). As part of this process, participants are given cameras and asked to take photographs to document their management of a personal struggle. They are then asked to write individual narratives to complement their photographs, create visual summaries of their most relevant photos, and collaborate with a group of similarly afflicted individuals by identifying group similarity across participant photos.

A couple of studies have used photovoice with older adults; one studied chronic pain (Baker & Wang, 2006) and one explored the barriers and supports of physical exercise (Chaudhury, Mahmood, Michael, Campo, & Hay, 2012). Baker and Wang used this methodology because they wanted to gain a more personal understanding of older adults’ experiences with chronic pain beyond what could be achieved with standardized chronic pain assessment instruments. Chaudhury et al. (2012) used photovoice as part of a larger effort to document the physical and social influences on the physical exercise of older adults. Minkler (2005) underscores the importance of this type of participatory action research with older adults because the findings have local relevance, interpretation of the findings is inevitably more valid, and can help translate the findings into culturally appropriate policies and programs.

Method

The Inquiry

In this photovoice project, rural older adults living with diabetes documented their personal and community-specific environmental challenges to a healthy lifestyle by taking photographs with a disposable camera and discussing their findings in a subsequent focus group. The research was guided by two questions posed to the participants: (a) What are your day-to-day experiences living with diabetes? and (b) What is the impact of your personal environment and community on your ability to care for your diabetes?

Participant Characteristics

Purposive convenience sampling was used to secure participants. Inclusion criteria for participants were that they were at least 50 years old, lived in one of three counties, had the capacity to be mobile, alone or with assistance, and had type 2 diabetes. Participants were recruited by grant-retained Bullitt, Henry, and Shelby County Community Organizers using flyers that were distributed in each community. Twenty-three rural, older adults living with diabetes participated in the photovoice project. They ranged from 60 to 78 years of age with a mean of 68.08 years (SD = 4.38). Six were African American and 18 were female. Four participants had a physical or mobility impairment including being blind, wheelchair bound, or cane assisted. Thirteen reported having two to three health problems in addition to their diabetes. Another nine reported having four to six additional health concerns, while one person reported having nine health concerns. Twelve were high school graduates, another 5 had some college, and 3 had graduated from college.

Procedures

The method described here relied heavily on The Innovation Center’s Collective Leadership Works photovoice method procedural manual (The Innovation Center, 2008), Gustafson and Al-Sumait’s (2009) manual and Wang and Burris’s (1997) methods. After receiving Institutional Review Board approval, participants attended a training session where they were taught about the photovoice method, provided an example from another photovoice project with older adults (Chaudhury et al., 2012), and taught how to take meaningful photos depicting the impact of their everyday personal environment and community on their diabetes. The training session lasted approximately 3 hours and took place in a county extension office known for older adult programming. They received a disposable camera, tips on how to take the best photo, safety protocols, and ethical photo-taking practices. After the training they spent 2 weeks taking up to 27 photos of their everyday personal environment and community with the disposable camera and writing narratives about the photos on index cards provided to them. At the end of the 2 weeks, they delivered the camera to their county community organizer for photo development. All cameras were processed, doubles of each photo were made, one set for the participants and one set was kept at KIPDA for later use at the focus group. Then they met their community organizer to receive their developed pictures and directions for the next step. In the directions, they were asked to select six photos and narratives that they were willing to share. The six photos and accompanying narratives were to represent their most significant and meaningful messages that described how their personal environment and community made it easy or hard for them to take care of their diabetes. They delivered their index cards identifying the six selected photos with their narratives of the photos to their community organizer. They were then invited to a half-day focus group session where they created individual posters and several communal posters with their photos and narratives noting the overarching themes. At the conclusion of the focus group, they also discussed the best ways to use their communal posters to create change in their community. They were asked to participate in at least one 2-hour community event to showcase their posters. Participants were compensated for each required activity including their attendance at the ½ day of training, the photo-taking and meetings with their community organizer, ½ day focus group, and their participation in a 2-hr community event, totaling US$225 per participant.

Analysis

Data analysis was directed by the participants and coding of the themes was modeled after Miles and Huberman (1994). Initially, each participant chose six photos and narratives with the greatest personal meaning without assistance from the academic team or community organizers prior to attending the focus group. Next, each participant attended a focus group and individually created a poster of their photos and narratives and presented their poster to their fellow county photovoice participants who had been asked to gather around their poster. As each photovoice participant presented, an academic team member documented the messages as stated on a white board or flip chart. After the presentations of the individual posters and documentation of the core messages on the white board or flip charts, the participants clustered together in close proximity to the visual display to review each core message, identifying similarities and differences among the core messages by using colored markers to denote similarity and diversity of the items, and to identify a thematic label for each similarly colored group of messages. Then the participants explored ways to cluster the themes in a more general sense. Following the categorization, they created communal posters placing the overarching themes with their corresponding photos and narratives onto several large trifold poster boards using an extra set of photos and narratives saved for this purpose. This allowed for the preservation of the participants’ individual posters.

After each set of focus groups, the academic team members debriefed about the themes presented and also documented similarities and differences, specifically in the labeling of the overarching themes. The final categorization across the counties is presented.

Results

The photos and captions were categorized into the following overarching themes: daily life as a person with diabetes, formal and informal supports, barriers to taking care of their diabetes, accessibility to fruits and vegetables, changes to food preparation and consumption, and exercise supports and barriers.

Daily Life as a Person With Diabetes

A common theme among the photos and corresponding narratives was that taking care of one’s diabetes is all consuming. Attending to glucose levels, medication regiments, and eating schedules was of paramount importance to this group of participants and required an army of medical devices. One photovoice participant noted that the necessary daily equipment to care for her diabetes was “as much a part of her life as a toothbrush.” Another photovoice participant offered the following:

Some of the things that a person with diabetes has to get used to using every morning . . . include: pills, blood glucose meter, lancing device, lancets, test strips, blood pressure tester. If you are going away for the day, you must take your blood glucose test kit. It’s hard to remember, but you need to take it with you. You have to check your blood sugar level after doing certain things. Examples: exercising, eating out, long trips (stress level) etc. If you don’t check your sugar level and correct it, it could make your day and trip miserable.

See Figure 1. These narratives and photos offer a glimpse into the persistent vigilance required by individuals affected by diabetes and note the consequences that will occur if they are neglectful of their bodily demands, both in the short and long term. One participant stated,

Without these [tools to help control my diabetes] there would be no life after a while. Your body would start shutting down, you could go blind, your kidneys would shut down. High sugar causes your memory to start shutting down.

Figure 1.

Every morning routine, 70-year-old adult with diabetes.

Several of the participants underscored the need to be cognizant of foot care. One stated, “Care of the feet is very important for the person with diabetes. Regular trips to your podiatrist are needed, especially if you are experiencing numbness in your limbs, toes, feet and legs.” Often people with diabetes cannot feel injury to their feet because of the numbing impact of the excessive glucose in the bloodstream, which if not attended to can lead to infection, gangrene, and possible amputation of the limb. These participants were aware of their need to care for their feet with one stating, “These feet were made for walking, it’s important to keep moving.”

Given the chronic nature of this disease, several narratives spoke of the frustration experienced as well as the patience required for their diabetes care. One photovoice participant wrote the caption “Just Another Day in Paradise,” sharing that “Every morning it is the same thing! I get up and I stick my finger and put my blood on a strip. It tells me how bad or good my day is going to be.” A wheelchair-bound person with diabetes wrote,

Snarly and popeyed is how I sometimes feel. Between trying to keep sugar levels right and not being able to go to the grocery to buy the right food . . . Frustration is a HUGE part of someone’s life with diabetes.

Another disabled person’s caption read, “Being a person with diabetes will cause one to easily become depressed. During my depression I cried a lot, stayed in bed all day, and secluded myself from others.” See Figure 2.

Figure 2.

Depression, 60-year-old adult with diabetes.

Formal and Informal Supports

Some of the participants took photos of their health care providers, highlighting both the quantity of providers as well as the quality of care and education received. One photovoice participant stated that “Diabetes affects a lot of different parts of your body. Eyes, kidneys, feet, heart, to list a few. I see a kidney specialist, an eye doctor, an urologist, a cardiologist, and my primary care physician for diabetes-related problems.” Others reported being thankful for support groups or classes but lamented either the loss of the class due to the retirement of a nurse in the county or the distance required to travel to participate in a group located in the city. One photovoice participant explained her experience with the support group:

I started attending and now don’t want to miss a meeting. It seems like at every meeting someone brings up a problem that I have had. How they handle their problem has helped me. Our county needs such a group and more education on how to handle being a person with diabetes.

Another participant discussed the benefits of a class and loss felt by its termination:

When she retired 2 or 3 years ago, the classes never started back. I had been going there once a month and met other people with diabetes. We all shared our ideas and we learned a lot from this person. She demonstrated healthy recipes and we all got to eat them. She gave us recipes, tips on meal planning and healthy eating. Not replacing her at the time was hard not only for me but others in the community.

Others discussed the benefits of the occasional, local community health-focused events including information about exercise programs as well as education program offerings by nonprofit and government agencies that could support the health and social service needs of the older adult living with diabetes in the community. Another reported not having access to the Internet but she sought education from borrowing books from her county library. Lastly, informal supports were also mentioned by one photovoice participant who created a caption that read, “Thank God for Help!” and her narrative stated,

I am on a lot of medication. I have to have family members come and set my pills up and fill my syringes with my insulin for the week. Also, I use eye drops to lower the pressure in my eyes. I drink large amounts of water to control my high blood sugar along with a sliding scale shot. I take Sucral for my stomach and Gabapentin for nerve deterioration in my legs. Again, I am thankful to God for having people in my life that help me out.

Similarly, many participants reported their motivation to taking care of their diabetes was their grandchildren who reminded them to take their medication and of their upcoming milestones. One participant titled her narrative Someone to live for and she wrote the words of her granddaughter “Mamaw I want you to be at my graduation. Mamaw I want you to be at my wedding. Mamaw did you take your medicine?”

Barriers to Taking Care of Their Diabetes

Barriers to taking charge of their diabetes care included comorbid conditions and concerns over how to handle payment for their medical needs (e.g., strips, medicines) when recurring bills unexpectedly increase such as the cost of the gas required to heat one’s home. Transportation issues were also noted as stated by one photovoice participant, “We have an excellent class on the 3rd Thursday at 10:00 a.m. and it ends at 11:00 a.m. I would benefit from these classes ‘IF I ONLY HAD A WAY!’”

Accessibility to Fruits and Vegetables

The participants highlighted both noncommercial and commercial accessibility to fresh fruits and vegetables. Most of the participants acknowledged the benefit of eating fresh fruits and vegetables, as exemplified by the following statement: “People with diabetes need five vegetables and fruits daily to balance their diet. Colorful ones are good with a mix of lower carb veggies for a good carb count.” Many of them had backyard gardens and identified health benefits, as stated by one of the participants:

My husband is in our backyard garden gathering zucchini, yellow squash, and tomatoes. Being able to walk out your back door and gather fresh vegetables this summer has certainly helped in planning good meals low in calories and carbs. This summer we have also enjoyed leaf lettuce, onions, green beans, green peppers and cantaloupes.

Another participant noted additional cost-saving benefits to her backyard garden,

Staying active and working in my garden helps keep my sugar down. Eating fresh vegetables does too! Having a garden saves you money with gas being so high . . . With the economy so bad, it helps to have some fresh vegetables.

See Figure 3. Another spoke of the benefit of canning fruits and vegetables for the winter. Another was appreciative of the assistance she received by a neighbor in plowing her garden and planting the seeds. In addition to backyard gardens, many of participants started shopping at the farmer’s markets. One participant wrote, “I had never really considered shopping at a farmers market before until I was diagnosed with diabetes. There are a variety of fresh, naturally grown vegetables, fruit and other items to choose from.” Several of the participants commented on their county farmers selling their homegrown produce in front of their farms. Others commented on the expense of eating fresh fruits and vegetables noting that their grocery stores, “. . . have a large selection of produce. That is good! But, the prices have gotten so high it makes it difficult to buy and that is BAD!”

Figure 3.

Vegetables, 71-year-old person with diabetes.

Changes to Food Preparation and Consumption

One participant discussed how much she loved to eat everything fried and that the hardest part of controlling her diabetes was changing her diet and method of cooking. One participant who discussed visiting McDonald’s often commented that “Bad food is cheap to buy” highlighting the impact of being on a fixed budget. Another participant realized the benefit of changing her cooking methods “I used to cook and fry foods. I now steam a lot, a lot of vitamins were lost when I boiled vegetables.” A couple of the participants talked about the struggle to make meals fast and need to follow the “my plate” specifications (U.S. Department of Agriculture [USDA], 2011). One participant’s caption read,

I don’t think about portion control, I think fast and easy. I usually end up with a lot of things that is not good for me. Usually vegetables and fruits are not included in my fast and easy, just junk food. I have been to two nutrition classes that have really helped. I know now what I should eat, but I don’t. I need more ideas of fixing good quality fast and easy meals. I know you should divide your plate like the food chart—vegetable, fruit, carbs and protein. You should learn to use a smaller plate instead of a bigger one piled full. I am still working on my portion control.

See Figure 4. Several photovoice participants were glad to have sugar-free options to help their daily sweet cravings. A few participants voiced needing help with educating family members on the dietary needs of an individual with diabetes noting the abundance of cookies and cakes at family outings that were so tempting. Another was grateful to a friend during her girlfriends’ “Bunco game nite” stating “Thank goodness for friends who take your diabetes into consideration when planning their menu. This friend’s husband has type 2 diabetes and she prepares desserts for him all the time. We share recipes when we find a good one.”

Figure 4.

Portion control, 70-year-old person with diabetes.

Exercise Supports and Barriers

Many photovoice participants spoke of the importance of exercise acknowledging that to maintain good weight, exercise was crucial. Various forms of exercise were mentioned including walking outside and on treadmills, stationary bikes, swimming, and golf. One participant in an effort to reduce her gas consumption to drive to a walking trail in her county mapped out a walking path on her road and driveway wishing that her driveway was blacktopped instead of gravel and rocks. Several noted the benefit of having a walking partner to help motivate and reduce the sense of isolation but on the other hand many identified the difficulty of walking around their homes because of the busy, long winding nature of their rural roads. A couple of participants identified community strengths noting recently funded walking trails that were frequently used; yet many discussed concern over the cost of gas to and from the trail. Some mentioned their support for their county’s plan to fund the development of a new indoor swimming facility and another mentioned one of the few exercise facilities or Body Recall, a fitness and flexibility training program for older adults and special needs populations, offered by a county extension office, as an option for exercise. Another mentioned the value in having public jungle gyms noting it helped her bond with her grandchildren while providing physical activity.

Since the photovoice project took place in late August in Kentucky, several commented on the heat and humidity as playing a significant role in their lack of daily exercise. As noted by one participant,

Temperature was 102° F at the Henry County High School and it wasn’t the hottest part of the day. Being a person with diabetes, you must exercise. At this temperature, it’s not safe to be outside. So instead of being outside walking or doing other things, I hug the air conditioner and stay inside. It’s too hot to do anything.

See Figure 5. The most common barrier noted was the lack of sidewalks, or the poor construction and maintenance of the sidewalks that are present. See Figure 6. One participant provided the caption What Sidewalks? with the following statement:

Walking is a good form of exercise almost anyone can do. However, a lack of a sidewalk on a very busy stretch of road can severely inhibit the ability of a person with diabetes to get exercise if you don’t live in a nicer neighborhood.

Figure 5.

It’s HOT, 70-year-old person living with diabetes.

Figure 6.

Bad Sidewalks, 66-year-old person with diabetes.

Another participant discusses a walking route that was mapped out by a fellow resident and he questions the safety by noting,

The road is narrow with deep ditches on left and right side of the road, posted with low shoulder signs. Returning to his home . . . he must cross . . . a very dangerous crossing area. Traffic speed is 35 mph. Visibility very poor, plus a tremendous amount of traffic due to the mini-market.

Discussion

This photovoice project was a participatory, empowering, colearning process between the academic researchers and the community members in which capacity was built for the goal of change in programs and policies on an interpersonal, community, and public policy level. It was participatory in that each participant’s camera acted as the tool of research putting the power to decide what was important in the hands of the participants. They not only decided what would be highlighted on their own poster by selecting the six most significant and meaningful photos and narratives but also what photos and messages would be placed on their communal county poster. They also decided to whom they would present and then followed through on the presentations with city, county, and state government officials without the presence of the academic partners. The project transferred the power of knowledge generation to the participants in that they set the agenda and priorities throughout the project.

Asking the photovoice participants to document experiences in their daily life that affect their ability to manage their diabetes, including experiences in their personal environment and their community, was invaluable in gaining access to the individual, social, and community-level influences. Consistent with the literature, they documented their mental and physical health care needs, needs for education and support, need to locate affordable fruits and vegetables, needed education for their family and friends regarding dietary limitations, and the difficulty associated with accessing exercise particularly the dangers of walking on rural roads. By putting the tool of research in the participants’ hands they were able to use their visual testimonials in conversations among coalition members and county government officials, as backdrops for community gatherings, at booths at community events aimed to increase awareness of the coalition’s goals and the continued need assessment recruitment efforts for the face-to-face assessment and at a statewide advocacy event entitled Diabetes Day at the Capital. The posters created dialogue as people enjoy looking at pictures and hearing about the lives of their fellow community members. The posters helped to provide a nonthreatening way to communicate with policy makers, allowing for dialogue about the supports in place for healthy living as well as helping community members initiate problem-solving dialogue. In one county, after a presentation on their photovoice posters, they had a lively conversation with a county judge executive around issues related to transportation to public exercise facilities. Additionally, this county was able to have a sidewalk repaired as a result of the photovoice dialogue. In another county, the photovoice participants reported feeling apprehensive when presenting to government officials. Advocacy training has been offered twice to the participants as their understanding for the need for effective advocacy increased. Through their gained collective understanding, the participants have felt empowered to initiate these conversations because of their shared knowledge and sense of belonging to a group that desires personal and community-level change.

The results of the photovoice project generated ideas that have been incorporated into KRDC’s strategic plan for action by building on the individual and community strengths and filling in gaps for healthy living for people with chronic disease. Ideas for the strategic plan from the photovoice project included strategies to promote the visibility and awareness of healthier food options at fast food and locally owned restaurants and formal and informal farmer markets, efforts to increase dialogue around dietary restrictions for events in the community or at family gatherings, family-focused diabetes resource fairs, increased number of diabetes support groups and educational programs, county-specific directories listing opportunities for physical activity, and the improvement of sidewalks.

Recruiting for CBPR can be challenging. It was difficult to locate the rural, older adults living with diabetes who would be willing to participate in this project. Working with community organizations that had a history of longevity and trust with their residents and having community organizers that were well-known in their communities were two of the most successful recruitment strategies for the project. There was a certain amount of trust by association that was transferred to the academic partners. In rural areas, community members may also report concerns over confidentiality and this photovoice project required comfort with communication about personal struggles, including sensitive economic and mental health topics.

Photovoice adds value to a comprehensive need assessment beyond what is realized in traditional investigator-driven survey research. This grassroots method documents daily participant struggles in more depth and context relevant manner. The process allows the voice of participants to be heard through photos, stories, and individual and communal photo boards. Throughout the process of crafting combined messages interest in communicating collective awareness is developed and desire for health promotion is awakened.

Footnotes

Acknowledgements

We are grateful to the rural older adults who were willing to participate in this photovoice journey, and the community organizers, Elaina Burks, Jessica Craddock, and Mona Huff, and coalition members who encouraged the older adults’ participation.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors declared the receipt of the following financial support for the research, authorship, and/or publication of this article: Support for this research was provided by Cooperative Agreement 1U58DP002815-03 from the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention.

Author Biographies

Pamela A. Yankeelov, PhD, is a professor and Associate Dean of Student Services at the Kent School of Social Work, University of Louisville. Her research explores the individual and environmental facilitators and barriers of health particularly among vulnerable populations experiencing diabetes. She is also interested in implementing and evaluating the impact of various individual and contextual interventions aimed to improve access and health outcomes.

Anna C. Faul, PhD, conducts mixed method studies on older adults living with chronic conditions in the community. Her research explores creating healthy environments for older adults living in the community to facilitate lifestyle changes, improved health, and access to quality health care. She is a professor at the University of Louisville, Kentucky as well as a research fellow at the University of the Free State in South Africa.

Joseph G. D’Ambrosio, PhD, JD, LMFT, is a program manager for the KIPDA Rural Diabetes Coalition and Assistant Adjunct Professor at the Kent School of Social Work, University of Louisville. His research interests focus on community-based interventions for vulnerable populations, the promotion of compassionate love within marginalized groups and individuals, and the creation of livable aging opportunities for adults as they age.

Wanda L. Collins, PhD, is a professor and Director of the Bachelor of Social Work program in the Raymond A. Kent School of Social Work at the University of Louisville, in Louisville, Kentucky. Her research focuses on psychosocial aspects of caregiving and aging among minority elders, strengths of the African American church, and coping strategies related to cancer, diabetes, and Alzheimer’s.

Barbara Gordon, MA, is the Director for the Kentuckiana Regional Planning and Development Agency’s Area Agency on Aging and Independent Living and is the principal investigator for the Center for Disease Control and Prevention’s Vulnerable Populations grant, which supports the KIPDA Rural Diabetes Coalition. Her areas of interests include the reduction of health disparities, health promotion, and disease prevention interventions in the community for older adults and persons with disabilities.

References

Adams

Janet

M. C.

(2003). Priority areas for national action: Transforming health care quality. Washington, DC: National Academies Press.

Arcury

T. A.

Grzywacz

J. G.

E. D.

Saldana

Nguyen

H. T.

Bell

R. A.

Quandt

S. A.

(2012). Social integration and diabetes management among rural older adults. Journal of Aging Health, 24, 899-922.

Baernholdt

Yan

Hinton

Rose

Mattos

(2012). Quality of life in rural and urban adults 65 years and older: Findings from the National Health and Nutrition Examination Survey. Journal of Rural Health, 28, 339-347. doi:10.1111/j.1748-0361.2011.00403.x

Baker

T. A.

Wang

C. C.

(2006). Photovoice: Use of a participatory action research method to explore the chronic pain experience in older adults. Qualitative Health Research, 16, 1405-1413. doi:10.1177/1049732306294118

Bell

R. A.

Smith

S. L.

Aurcury

T. A.

Snively

B. M.

Golden

S. L.

Quandt

S. A.

(2005). Prevalence and correlates of depressive symptoms among rural older African Americans, Native Americans, and whites with diabetes. Diabetes Care, 28, 823-829.

Bolin

J. N.

Bellamy

(2011). Rural healthy people 2020. College Station: The Texas A&M Health Science Center, School of Rural Public Health, Southwest Rural Health Research Center.

Bronfenbrenner

(1977). Toward an experimental ecology of human development. American Psychologist, 32, 513-530.

Bronfenbrenner

(1979). The ecology of human development. Cambridge, MA: Harvard University Press.

Byers

A. L.

Vitttinghoff

Lui

L. Y.

Hoang

Blazer

D. G.

Covinsky

K. E.

Yaffe

(2012). Twenty-year depressive trajectories among older women. Archives of General Psychiatry, 69, 1073-1079.

10.

Centers for Disease Control and Prevention. (2011). National diabetes fact sheet: National estimates and general information on diabetes and prediabetes in the United States. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention.

11.

Centers for Disease Control and Prevention. (2009). National Diabetes Surveillance System. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention.

12.

Chaudhury

Mahmood

Michael

Y. L.

Campo

Hay

(2012). The influence of neighborhood residential density, physical and social environments on older adults’ physical activity: An exploratory study in two metropolitan areas. Journal of Aging Studies, 26(1), 35-43. doi:10.1016/j.jaging.2011.07.001

13.

Crosby

R. A.

Kegler

M. C.

DiClemente

R. J.

(2002). Understanding and applying theory in health promotion practice and research. In DiClemente

R. J.

Crosby

R. A.

Kegler

M. C.

(Ed.), Emergency theories in health promotion practice and research (pp. 1-15). San Francisco, CA: Jossey-Bass.

14.

Dabney

Gosschalk

(2003). Diabetes in Rural Areas: A Literature Review. Rural Healthy People 2010: A companion document to Health People 2010. Volume 2. College Station, TX:The Texas A&M University System Health Science Center, School of Rural Public Health, Southwest Rural Health Research Center.

15.

Denham

S. A.

Manoogian

M. M.

Schuster

(2007). Managing family support and dietary routines: type 2 diabetes in rural Appalachian families. Families, Systems, & Health, 25(1), 36-52. doi:10.1037/1091-7527.25.1.36

16.

Frost

S. S.

Goins

R. T.

Hunter

H. R.

Hooker

S. P.

Bryant

L. L.

Kruger

Pluto

(2010). Effects of the built environment on physical activity of adults living in rural settings. American Journal of Health Promotion, 24, 267-283.

17.

Gamm

L. D.

Hutchison

L. L.

Dabney

B. J.

Dorsey

A. M.

(2003). Rural healthy people 2010: A companion document to Healthy People 2012. Volume 1. College Station, Texas: The Texas A&M University System Health Science Center, School of Rural Public Health, Southwest Rural Health Research Center.

18.

Gustafson

Al-Sumait

(2009). Photo conversation about climate: Engaging teachers and policymakers through photography and narrative. Retrieved from http://www.sightline.org/research/sust_toolkit/communications-strategy/photovoicemanualpdf

19.

Hartley

(2004). Rural health disparities, population health, and rural culture. American Journal of Public Health, 94, 1675-1678.

20.

Healthy People 2020, U.S. Department of Health and Human Services. Washington, DC: Office of Disease Prevention and Health Promotion. Retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020.

21.

Kramer

Schwartz

Cheadle

Rauzon

(2012). Using photovoice as a participatory evaluation tool in Kaiser Permanente’s community health initiative. Health Promotion Practice. Advance online publication. doi:10.1177/1524839912463232

22.

Lawrence

S. A.

McCulloch

B. J.

(2001). Rural mental health and elders: Historical inequities. Journal of Applied Gerontology, 20, 144-169.

23.

Manoogian

M. M.

Harter

L. M.

Denham

S. A.

(2010). The storied nature of health legacies in the familial experience of type 2 diabetes. Journal of Family Communication, 10, 1-17.

24.

Miles

Huberman

(1994). Qualitative data analysis: An expanded sourcebook (2nd ed.).Newbury Park, CA: Sage.

25.

Minkler

(2005). Community-based research partnerships: Challenges and opportunities. Journal of Urban Health, 82(2), 3-12. doi:10.1093/jurban/jti034

26.

O’Brien

Denham

(2008). Diabetes care and education in rural regions. Diabetes Educator, 34, 334-347.

27.

Rosenblatt

R. A.

Balwin

L-M.

Chan

(2001). Improving the quality of outpatient care for older patients with diabetes: Lessons from a comparison of rural and urban communities. Journal of Family Practice, 50(8), 676-680.

28.

Sanders

G. F.

Fitzgerald

M. A.

Bratteli

(2008). Mental health services for older adults in rural areas: An ecological systems approach. Journal of Applied Gerontology, 27, 252-266.

29.

Sharkey

J. R.

Johnson

C. M.

Dean

W. R.

(2010). Food access and perceptions of the community and household food environments as correlates of fruit and vegetable intake among rural seniors. BioMed Central Geriatrics, 10(32), 1-12.

30.

The Innovation Center. (2008). Collective leadership works: Preparing youth and adults for community change. Section 7: Keeping healthy: Strategies for reflection and learning; Activity: Photovoice. Tacoma Park, MD: Author. Retrieved from www.theinnovationcenter.org/store/164

31.

Wang

Burris

M. A.

(1997). Photovoice: Concept, methodology, and use for participatory needs assessment. Health Education & Behavior, 24, 369-387.

32.

U.S. Department of Agriculture. (2011). ChooseMyPlate.gov. Retrieved from http://www.choosemyplate.gov/index.html