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Understanding Health Literacy Through the Eyes of Immigrant Youth:
A Photovoice Project
Mandy Benson, Jennifer Kimbrough, Ali Phillips
Center for Youth, Family & Community Partnerships, University of North Carolina at Greensboro
Introduction
Health Literacy:
What is it and why does it matter?
Health literacy is the ability to obtain, understand, and use
the information needed to make wise health choices (DHHS,
2000). Low health literacy can affect a patient’s ability to
read consent forms, written medical information, and
prescription labels. It can also inhibit a patient’s
understanding of oral information from health care providers
as well as compliance with medications and appointment
schedules.
Low health literacy impacts the overall health of our nation
and costs the nation’s health system as much as $58 billion
a year (DHHS 2000; Pawlak 2005). The consequences of
low health literacy can affect anyone, regardless of age,
race, education, or income. Some of the most vulnerable to
the consequences of low health literacy are immigrants; a
growing segment of the U.S. population, with approximately
26.3 million now living in the U.S. (Kimbrough, 2006).
Photovoice:
A picture is worth a thousand words
The Photovoice methodology is a unique method of
collecting qualitative data by which participants use
photography to answer research questions. Photovoice
allows participants to record and reflect local community
issues, promotes in-depth group discussions around the
photos taken, and provides a unique avenue for explaining
issues to policy makers (Wang, 2005).
Methods
Setting and Participant Recruitment
High School students from the English Speakers of Other
Languages (ESOL) classes, located in Greensboro, North
Carolina, were recruited to participate in the Photovoice
project.
Consent was obtained with parent signatures on a form
describing the Photovoice project and requesting their
child’s participation. Students over 18 years of age were
allowed to sign the consent form themselves and students
under 18 years of age completed an assent form in addition
to the parental consent form. Consent forms were available
in the family’s native language(s) when needed.
Participants and their families were fully apprised of their
rights and responsibilities as research subjects.
Data Collection
Prior to the distribution of the cameras, an instructional
session provided students with information on how to
correctly use a camera and a reminder to ask permission
before taking pictures of an individual. Participants were
specifically requested not to take pictures depicting nudity or
potentially illegal situations.
Students were further engaged in a discussion about the
different dimensions of health and how the environment,
social class, living conditions, food, and other factors
contribute to health. In addition to the researchers’
interaction with the students around aspects of health, the
classroom teacher took up health literacy as a class topic for
approximately a four week period. During this time,
students spent the majority of their class time learning about
health issues and completing a project on social
understandings of health.
Students received disposable cameras and a two-week
period of time in which they were to use photography to
answer the question, “What is it like to try to be healthy as
an immigrant?” At the end of the two-week period, the
cameras were collected and the photographs were
developed.
Four discussion groups, facilitated by the researchers, were
held to show the students their photographs and give them
the opportunity to discuss their pictures. Each discussion
was conducted in the ESOL classroom, lasted
approximately 50 minutes, and was recorded via
handwritten notes by researchers. Handwritten notes were
favored over audio or video tapes as many of the students
spoke quietly and cultural tendencies for many people to
speak at one time.
Data Analysis
The handwritten notes were typed and compiled into one
document and then distributed to the research team for
analysis and theme development. Each member of the
research team read through the notes to become familiar
with the content and then coding schemes were developed.
Results
The fourteen participants were representative of many
countries, including six from African countries, three from
Latin American countries, four from Asian countries, and one
from Israel. Five participants were female and nine were
male. The average age of participants was 16.7 years.
Although many themes emerged from the data, there were
primarily three significant themes: cultural isolation,
healthcare providers/health care, and environmental
conditions.
Cultural Isolation:
Students described their experiences as an immigrant and being
new to the school as difficult, when trying to make friends. They
were particularly attuned to racist attitudes among their classmates.
Student Quote:
“[Black kids] can make you hurt. They call you ‘African monkey’
but we have the same skin. They say ‘I know English,’ but I know
English too.”
Student Quote:
“Gym classes are so segregated; the white people are on one
side; black people on the other side. White and black people play
basketball separate. If you go to their side, then they going to
talk. I say why people being so racist. Why you guys so racist
and people say ‘shut up.’ I say, if you see the truth, just tell the
truth. I say why you guys so racist? Just be friends.”
Additional themes:
There were several other less significant themes that emerged from
the data. These included:
-Nutrition
-Education/teachers
-Personal hygiene
-Romantic relationships
-Exercise
-Spirituality
-Sunscreen use
-Nature
-Friends and family
-Substance use/abuse
Conclusions
Racism in schools against immigrant students negatively influences
the mental health of ESOL students. In working with the ESOL
students, it was obvious that they felt comfort and a sense of
belonging within the ESOL classroom and among their peers that
are also immigrants.
The idea of gangs as a place of social belonging was also
significant to the cultural isolation theme.
Student Quote:
“There’s too many gangs all over the state. [Students] want to
look cool. You have to do whatever they say to do. They look out
for you”
Navigating the healthcare system is not a simple endeavor for
immigrant students and their families for several reasons, including
language barriers, the financial burden of healthcare costs, and lack
of health insurance. When an interpreter is not available within the
healthcare setting, frustration and embarrassment are commonplace
for immigrant families. Utilization of the healthcare system seems to
occur only when there is absolutely no other alternative.
Healthcare providers/healthcare:
Students described their experiences with the healthcare system and
interactions with healthcare providers while interpreting for a family
member.
Student Quote:
“[Healthcare providers] speak very fast sometimes. When I
translate for family members at the doctor, they talk too fast and
it’s hard.”
The findings of this study have future implications for educators
and healthcare professionals alike. First and foremost, to educate
American youth on the importance of helping immigrant youth
assimilate into a new social context. Second, to increase
healthcare professionals’ awareness of health literacy and cultural
issues surrounding the immigrant communities.
Acknowledgments
Students also conveyed that a lack of insurance and costly
healthcare fees restrict their families from accessing healthcare.
Student Quote:
“My mom, she moved here, she didn’t have medical insurance.
She don’t want to pay much more. So she try to eat healthy, use
vitamins so she doesn’t have to go to the doctor. She uses
traditional medicine. She knows about medicines. The most
important thing is to eat healthy and try not to get sick. If you
really have to go just go [to the doctor] but if you don’t have
paper, insurance, then it’s too much.”
The study described was supported by the Center for Youth, Family & Community
Partnerships at UNCG.
Literature Cited
Kimbrough, J. (2006, May). Health Literacy Matters, [report]. Greensboro: Center for Youth,
Family, & Community Partnerships, University of North Carolina at Greensboro.
Pawlak, R. (2005). Economic considerations of health literacy. Nursing Economic$, 23(4),
173-180.
U.S. Department of Health and Human Services. (2000). Healthy People 2010:
Understanding and improving health. Retrieved October 15, 2006, from
http://www.healthypeople.gov/publications
Wang, C.C. (2005). Photovoice: Social change through photography. Retrieved November
11, 2006, from http://www.photovoice.com/index.html
Environmental Conditions:
Sub-standard living conditions and unclean surroundings were
mentioned and discussed by the students.
Student Quote:
“Man you can’t tell [landlord]. Like in our room there’s a hole with
water coming down. On our roof there is water dripping. The
[landlord] doesn’t listen.”
For further information
Please contact [email protected] or [email protected]