My Community, My Voice: Rural Older Adults Speak Through Photography

Introduction

Increases in life expectancy, the graying of the baby boomer generation, and aging in-place trends are contributing factors to the unparalleled growth of the elder population in rural America (Rogers, 2002; U.S. Census, 2003). As a result, local communities are faced with unique challenges to support the health and wellness of this population of elders. The Cooperative Extension Service is one organization poised to play an important role in meeting the challenges and opportunities through educational outreach and community infrastructure development to support the health needs of rural elders (Gerrior & Crocoll, 2008).

The health of the nation's elders is, in part, dependent upon their ability to participate in regular physical activity (Merck Institute of Aging and Health, 2007). However, the United States Surgeon General reports that by age 75, one-third of men and one-half of women do not participate in physical activity (National Center for Chronic Disease Prevention and Health Promotion, 2004). At the same time, the incidence of chronic disease, such as diabetes and heart disease is soaring, due in large part to an increasing rate of physical inactivity, especially in rural America's elder population (Centers for Disease Control, 2008; Merck Institute of Aging and Health, 2007). These trends occur despite evidence that involvement in regular physical exercise can reduce risk of cardiovascular disease, and obesity. (Merck Institute of Aging and Health, 2007). The challenge for combating the issue is twofold: to promote desire and to provide the opportunity for rural elders to be physically active. The desire to walk or exercise, for example, is often hindered by the lack of sidewalks, steep terrain, and no indoor facilities in rural areas (Gatz, Rowles, & Tyas, 2004).

As a result of these characteristics of rural culture, a community-based participatory approach is necessary to promote dialog and collective support of opportunities and policies to increase levels of physical activity to effect positive health change (Schulz, Israel, Parker, Lockett, Hill, & Wills, 2003). The process of civic engagement through a participatory research process can enhance the ability of a community to encourage physically active lifestyles within the aging context.

Foundational to Extension philosophy is the notion that, as people in the community become involved with the process of identifying and addressing a need, their ownership of a successful solution can increase (Lachapelle, Austin, & Clark, 2010). With such ownership, support of community health-related interventions and, ultimately, policy changes can be initiated (Themba & Minkler, 2003). It is essential to include rural elders in discussions to gain their perspective on issues that are of importance to them and, subsequently, to garner their adoption of solutions to identified problems. The aim of the project reported here was to engage rural elders in a community-based participatory research (CBPR) process to evaluate local environmental supports and barriers for physically active lifestyles.

Methodology

The study was designed as an exploration, through qualitative descriptive methods, of rural Kentucky elders' perspectives on maintaining physically active lifestyles. The purpose of the study was to conduct an in-depth investigation, through individual photography and group reflective discussion, of elders' views of the supports and challenges for physical activity while aging in place.

Participants were recruited who were age 55 and older, were residents of a rural community, and demonstrated interest in maintaining a physically fit lifestyle through volunteering for the described study. Eight older adults in one rural Kentucky county were recruited to participate through Extension newsletters, word of mouth within community senior citizens' circles, and flyers posted in local businesses. The local Family and Consumer Sciences Extension agent provided logistical support for participant recruitment, and group sessions. She attended each group session, listened to participants' comments, and kept a journal of her perceptions of the process.

Photovoice Group Process

To engage the participants in assessment and documentation of their findings, the CBPR project used photovoice, a qualitative approach in which participants use photography to research and ultimately give voice to their perspective on an issue (Wang, 1999). From November 2006 to May 2007, older adult participants met in four group sessions to follow the photovoice protocol involving a three-step process: familiarization, critical appraisals, and recommendations (Wang, 1999). Participants shared their photographs with each other to discuss and analyze issues that arose (Wang, 1999) using the empirically tested SHOWeD technique to stimulate discussion. SHOWeD is an anagram for questions used in the dialog process (Wang, Morrel-Samuels, Hutchison, Bell, & Pestronk, 2004) that guides discussion around the photos. Individual pictures are evaluated collectively to delve into themes, issues, and concerns that emerge from the photo array. This technique encourages participants to capture their ideas and findings visually with the goal of collective group discussion and analysis. The process, as outlined by Wang et al. (2004, p. 912), includes:

1. What do you SEE here?


2. What's really HAPPENING?


3. How does this relate to OUR lives?


4. WHY does this problem or strength exist?


5. What can we DO about it?

The final step of the photo inventory process involves sharing recommendations of participants with the community and its stakeholders through a public viewing of the photography (Wang, 1999). Empirically, photo inventory project participants have used newspapers (Wang, 1999), slide shows, and photographic displays (Carlson, Engebretson, & Chamberlain, 2006) to share their photo stories with community members.

Group Session I

At the first group meeting, the participants were familiarized with the use of instant cameras, the ethics and power of photography, and the use of photovoice as a research method. Also at this meeting, participants discussed aspects of the project that were potentially important to their community, particularly to the older adult residents. Through the group dialogue, the elders defined their "community" for purposes of picture taking as well as defining the focus of the project.

Collectively, the group decided to focus its photographic efforts on supports and challenges related to opportunities for the physical activity of older adults within their community. They defined the scope of their community as the county. The group planned to meet 6 weeks later to give the elders time to take their pictures and have them developed.

Group Session II

Within a month's time, the elders took their pictures and dropped off the film at the county Extension office. Double prints and a photo disc of the pictures were made prior to the meeting. At the second group meeting, the SHOWeD technique was used to stimulate discussion regarding the participants' pictures (Wang, 1999). Discussion of pictures in this session centered on questions 1 through 3 in the SHOWeD mnemonic.

As a result, participants identified themes and categories that emerged from the collective picture taking. They discussed the challenges or opportunities for physical activity that surfaced repeatedly. They also discussed images that were missing from the photo collection and made plans for next steps in the project. They determined to continue to assess their pictures individually at home and, at the next group meeting, to complete the SHOWeD mnemonic.

Each participant was given a set of pictures and asked to choose the pictures that they thought should be used in a collective grouping to share with the entire community. They were encouraged to shoot more pictures if they thought that certain images or ideas were missing or inaccurately portrayed. The elders were asked to journal about issues that seemed to be evident from the pictures. The group agreed to meet 4 weeks later to discuss their thoughts, review and analyze additional pictures shot, and make decisions about how best to share information gleaned from their efforts.

Group Session III

During the third group session, the older adults shared more pictures that they had taken and focused their discussion on questions four and five of the SHOWeD process. They decided to share their pictures via an issues booklet that would present a descriptive visual synopsis of their findings. The use of media and a photo booklet was their effort to provide a public viewing of the photography for the community and local stakeholders. The group discussed booklet contents, design, and dissemination, all with the goal of raising awareness of the issues that they found. A graphic artist from the University of Kentucky met with the group to discuss the elders' ideas, desired pictures, and timeline for printing. Based upon the older adults' findings and guidance, the graphic artist developed a 12-page full-color booklet featuring 29 pictures and participant quotes.

Group Session IV

The fourth and final group session culminated in a celebration of the conclusion of the project, distribution of the completed issues booklet, and discussion of plans for dissemination of the booklets. The elders decided to share the booklets individually with family, friends, and policymakers, and through their affiliation with local organizations.

Confirmability and Auditability

The rigor of the findings in the study reported here can be evaluated on the criteria of qualitative research literature and CBPR process. The measure of internal and external validity (Bloor & Wood, 2006) and the trustworthiness criteria that include credibility, transferability, and confirmability (Lincoln & Guba, 1985) were assessed through detailed research notes, multiple discussions among participants, comparative coding, triangulation of information, and member checks throughout the process. Member checks are defined as communication of study findings to the participants and their confirmation that the findings represent their experiences, attitudes, or ideas (Lincoln & Guba, 1985).

Through this research design, the study identified supports and challenges for physical activity as experienced by the older adults. As a result of the group data analysis, the findings point to factors that influenced the elders' ability to stay active while aging in the community.

Results and Discussion

As a result of the photographic analyzation process, the older adults identified two overarching themes within the group process: 1) Each person makes a personal choice to stay active and 2) the community as a whole makes resource choices to support active lifestyles throughout the lifespan. Within these two themes they used pictures to identify examples of specific categories of opportunities (Table 1) and concerns (Table 2) they experienced within their rural community.

Table 1.
Identified Opportunities for Elders' Community Physical Activity

Theme	Opportunity	Choice supporting physical activity
Personal choice	Community is in close proximity to local state and national parks for hiking and fishing	Access park system repeatedly for physical activity
Personal choice	There is a broad array of personal physical activities available in rural outdoor areas	Participate in active outdoor activities such as gardening, golfing, hiking, and other active hobbies
Personal choice	Walking trails are available on high school track and in local city park	Use walking trails regularly
Community choice	Local green spaces are designated for physical activity	Fund regular maintenance of a nine hole golf course Design and adequately maintain walking trails
Community choice	Specific physical activity programs offered by hospital, Extension office, health department, and faith based organizations	Fund continuation of aerobic classes and open church gym for walking

The older adults identified local green spaces maintained by state and national parks resources as a local oasis for physical activity options for varying abilities and interests. James, age 60, photographed a sky lift to Natural Bridge and stated, "The reason I took a picture of the sky lift ...is we have a lot of [older] people in the county that probably never think they can get out and go to Natural Bridge." Wendell, age 78, responded, "We were 76 when we made our last walk up to the top of the hill and we decided then at 76 maybe we should shut it off...now we walk on the lower trail and go fishing." Conversely, the elders identified concerns that diminished their physical activity within the community.

Table 2.
Identified Concerns for Elders' Community Physical Activity

Theme	Concern	Choice that decreases Physical Activity
Personal choice	Apathy to physical activity	Older adults choose to "sit" rather than be active
Personal choice	Fear of falling and concern about safety	Do not use community facilities because of perception of being unsafe
Community choice	The building is too small that houses the senior citizen center now. The only space for activity is a treadmill in the bathroom	Decision to convert senior citizen center to county jail for county revenue generation
Community choice	Lack of indoor facilities to walk consistently in all seasons and at night	Have not funded access or made available indoor facilities for safe walking at night or in cold and rainy weather
Community choice	Disrepair of sidewalks and walking trails	Cracks and holes of sidewalks and trails not repaired regularly.
Community choice	Roadways have narrow shoulders and no bike trails, and elders who walk on rural roads face danger from local traffic	Have not planned or funded walkable/bikeable rural roadways
Community choice	Priority given to youth physical activity opportunities rather than focusing on a lifespan approach	Funding priorities for youth activities supersedes funding for activities that encourage family and older adult physical activity, (i.e. skate park replaced local swimming pool)

Safety issues were of primary importance to the elders as they analyzed their photographs. Rural roads with small shoulders, washed out walking trails, crumbling sidewalks, and inadequate lighting were identified as major hazards for aging residents. Wendell, age 65, shared, "[My friend] Jean says that she runs on the road now because the sidewalks are rough and uneven and...over on my road there's a 90 -year-old woman that has to walk in the traffic and the curves there. Young people in that area have a tendency to drive fast... it's just [unsafe]."

Throughout the group process, the participants also identified the concern that older adults' voices are often lost because their needs receive lower priority when compared to others in the community. To address this concern and bring attention to their point of view, participants designed an issues booklet highlighting their findings through pictures and quotes. They disseminated the booklet to local policymakers and community residents to promote community awareness and action.

Elder Perspective

The project's design engaged older adults through an Extension-sponsored, CBPR approach and enabled them to identify, analyze, and share their perspective on physical activity in later years. Through the use of the photovoice technique, the older adults discovered that they each bring a different perspective to the meaning of physical activity and different expectations for community support.

The process of participating in a CBPR project increased their awareness of the concerns of other older adults in their community, as well as gave them an opportunity to voice their concerns to policymakers about the lack of opportunities to stay active as they age. They concluded that personal choice and community support for staying active are integrally related to staying physically fit in the later years. Sam, age 78, summed up his advice to other community elders this way: "Find what you enjoy and stay active doing that. Don't go home and sit on your front porch in a rocking chair. Get out there and get on with your life. " As Stella, age 63, reflected on her life as a community policymaker, she said, "All these years I worried about activities for the children, but now I realize I should have been thinking about older people too...we are all going to be there someday."

Extension Agent Perspective

The local Extension agent noted that the group process of photographic discussion enabled the older adults to be bold in their critique of their community's support for physically active lifestyles in later life. She noted:

I think that this has given them [elder participants] the opportunity to speak; a way for them to be heard that, otherwise, I don't think that they ever would have taken the initiative to do anything like that...because they would never have thought to go out and take pictures...

The CBPR approach was a catalyst to stimulate action within the small group of elder participants to take ownership of their identified issues. As the Extension agent observed:

It brought several of our seniors together as a group. It gave them a focus, a project...it's something that they are proud of...Just having listened to them, I know that some of them are already in the thought process of things they may do with this. And through this ... their hope is that this will...improve the opportunities for seniors to have real physical activity.

Implications for Extension

A CBPR process such as photovoice is a tool to enable participants to promote social change and encourage civic engagement based upon collaborative citizen perspective (Wang, 1999). As a direct result of their involvement in this process, elders' concerns and ideas emerged that pointed to the consequence of individual and community decisions to their health. The role of Extension was critical as the facilitator to bring the voices of the elders to the community via the potent personal images of photography.

The use of community-based participatory processes within a gerontological context can provide a powerful tool for elders to engage in social change in areas that directly affect their lives and those of others in their community. Elders can be involved in the evaluation, planning, and action of individual and community approaches to healthy lifestyle behaviors. Through this opportunity, they can increase their level of civic engagement and promote positive health behavior practices within their community.

Gerrior and Crocoll (2008) outlined the unique qualifications of Extension to strengthen families through programmatic focus on rural elders. Through the expertise and collaboration of the local Extension agent and state Extension faculty, the older adults can be engaged to interpret their point of view of the community to strengthen families' ability to remain healthy throughout the lifespan.

In the project reported here, Extension was viewed within the community as a catalyst to bring the voices of the elders to a public health topic that otherwise would have been silent. As a result, community dialog was encouraged, programs developed, and further discussion planned. Within the context of the project the elders individually committed to being the leaders of dance classes and aerobic programs for local senior citizens centers. Through their photographs, community stakeholders have made improvements in the local park to decrease the risk of elders falling on the walking trail. Additional progress can be encouraged by the continued involvement of elders in the community dialog surrounding health issues.

As the project demonstrates, the photovoice process is a potential tool for Extension professionals and stakeholders to gain insight into issues, behavior, activities, and diverse beliefs. The process can promote reflection and action among multiple audiences and within a broad array of issues. Downey, Ireson, and Scutchfield (2009) effectively used a high school youth photovoice project to stimulate community-wide discussion to design locally guided solutions to improve the health status of residents. Low-income women in New York voiced their food insecurity concerns through pictures and facilitated letter-writing campaigns to local policymakers highlighting their findings (Valera, Gallin, Schuk, & Davis, 2009). African-American men shared their pictorial perceptions of race and gender issues that influenced their personal health to promote dialog within their social networks (Ornelas, Amell, Tran, Royster, Armstrong-Brown, & Eng, 2009). A photovoice project gives personal voice through pictures to people who are uncomfortable speaking their concerns in public. The photo reflection process stimulates group discussion of personal perspectives and can empower participants to take action to educate stakeholders and policymakers of their findings.

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