Research Feature

“Join us in connecting to the community researchers engaged in rural health projects across the province! Learn more about rural health research taking place and personal experiences in conducting research. If you (or someone you know) have a rural health research project you would like to share, contact us for more information on how to be featured!

June 2019


Understanding Mental Health Experiences of Adults 50 Years and Older Living in the Similkameen

A Qualitative Study Using Photovoice.

Lauren Airth is a Registered Nurse who recently completed her Master of Science in Nursing. She began working in the mental health field as a care aide in 2009 and has focused her entire nursing career in this area. Presently, Lauren works in three different mental health acute care areas at Kelowna General Hospital and is a campus health specialist with the Voice and a clinical assistant with the School of Nursing at UBC Okanagan. For her thesis, Lauren conducted a photovoice study exploring the experiences of older adults with mental health concerns living in a rural area. This research was conducted in the southern interior of BC.

 

 

"Photovoice allowed me to explore creative, unspoken elements of participants’ lives and analyze them in a meaningful way. This method of data collection also emphasized the experience of the participant, a key part of patient-oriented research."

 

Tell us more about your project! Who was the focus of it and why is the topic important to explore?

This photovoice project was conducted as part of my thesis work in the Master of Science in Nursing program at UBC Okanagan. My research explored the experiences of adults aged 50 and over living with a mental health concern in a rural community in British Columbia. This topic is important for many reasons. Mental health concerns are currently the leading cause of disability internationally (World Health Organization, 2014). This statistic aligns with the present mental health landscape in Canada. As the country’s population ages, adults aged 50 and over are expected to have the most mental health concerns of all age groups in Canada in the coming years (Smetanin et al., 2011). The population of older adults is also increasing in size in rural areas (Moazzami, 2015). Despite this growth, there is a paucity of literature regarding the experiences of older adults with mental health concerns in rural communities.

 

What is photovoice?

Photovoice was developed by Wang and Burris in 1997. It is a qualitative data collection method which aims to help participants “identify, represent and enhance their community” (Wang, 1999, p. 185). This involves providing participants with a camera and having them take photos of what represents the topic being explored – in this case, participants took photos of what represented their life as an older adult with a mental health concern in their rural community. Participants took as many photos as they desired (we recommended no more than 100). They then narrowed it down to about 10 of their most significant photos to explore in individual interviews with myself. Interviews followed a semi-structured interview guide based on the SHOWeD method (Wang& Redwood-Jones, 2001). These interviews were recorded and transcribed verbatim, then analyzed alongside the selected photos to identify common themes. Themes were finalized in discussion with participants in a member-checking meeting.

 

What made you decide to use photovoice for this project?

When I first heard about photovoice, it seemed like the perfect combination of science and art. Photovoice allowed me to explore creative, unspoken elements of participants’ lives and analyze them in a meaningful way. This method of data collection also emphasized the experience of the participant, a key part of patient-oriented research. My research used critical social theory and interpretive description, and photovoice aligned well with this methodological structure. It was important to me that the findings would be true to participants’ experiences, and that the process, as much as possible, would be controlled by participants, which photovoice supported. Using photovoice also provided a unique way of presenting results, which helped involve the community and drew in a different audience than typical research journals might.

 

Photo Title: Pick Me Up, I Still Have Value. Photographer: Anonymous.

 

Photo Title: Love and Company. Photographer: Herb.

 

What are some of the insights (key themes) that emerged from this project? Is there any new knowledge gain from this project that may serve to inform policy and/or practice?

Five key themes arose from the data. For the first theme, mental wellbeing, participants unveiled eight facets of wellbeing: personal qualities, hope, spirituality and gratitude, nature, routine and productivity, medication, substance use, family, and isolation. For the second theme, losses, participants described how they were affected by the loss of abilities, friends, family, lifestyles, and thoughts regarding death. The third theme, stigma, was experienced internally and publicly. The fourth theme was services and supports. Participants identified barriers to support, as well as negative and positive experiences when they accessed services, and the importance of informal supports. Finally, participants’ mental health was influenced by their environment (home, finances, community).

These themes existed in tension with one another. While participants had ways of caring for their wellbeing, these strategies were inhibited by stigma. Stigma was the underlying factor for many of the complexities uncovered. Isolation, poverty, and access to services were all related to stigmatizing experiences. The topic of isolation revealed some interesting dynamics – participants valued intentional solitude but struggled with feelings of loneliness. This relates to the challenges our participants faced when trying to maintain social relationships. Although participants felt they had some negative relationships in their life, they chose to maintain them out of the need for social interaction. There is little literature on this dynamic of older adults’ friendships. Additionally, participants’ personal histories often influenced their coping strategies, and their ability to reflect on their mental health needs.

Themes informed recommendations made for policy development, education, health services delivery, and future research. Specifically, there is a need for more specialized care providers in rural areas to address older adults’ mental health. This need could be addressed by incorporating education on this topic into the curricula of various health and social development programs. It would also be beneficial to see health care workers support the development of peer support groups in rural areas. These groups could incorporate elements of mental wellbeing discussed in this study.

 

Photo Title: Think Before You Do Anything. Photographer: Nola.

 

Photo Title: Antique Furniture. Photographer: Anonymous.

 

What are some of the outputs of this project (e.g., community exhibition, media release, book publication)?

This project resulted in two major knowledge translation activities, which were decided upon in collaboration with participants. One activity was a gallery event in the community where the research was conducted. Photos from the study were showcased at the community center for a month. Each photo was accompanied by a write-up explaining the themes. The second activity was the creation of postcards. These postcards used photos from the study and featured paraphrased topics from interviews. Postcards also featured a link to a blog where people could see more photos and read more about the study. Some postcards listed local mental health resources for older adults. Throughout my time in graduate school, I presented on this research at three different events (two conferences, one webinar). For the future, I am hoping to publish articles related to my thesis work, to host a photo installation in Kelowna, and I am working on collaborating with the School of Nursing at UBC Okanagan to incorporate aspects of this research into the curriculum. 

What did the process look like for engaging community members in the research process?

This photovoice project was made possible through the work of the research team. This team consisted of a patient population representative, a local nurse, a retired registered psychiatric nurse running outreach programs in the area, and my two supervisors. Additionally, this study was funded by Mitacs and the South Okanagan and Similkameen Mental Wellness Centre, and my work was assisted by a scholarship I received from the Canadian Nurses Foundation. We began the study with a photovoice education session, which led into the photo-taking period, and this was followed by individual interviews and the member checking meetings. The initial meeting helped to build rapport, introduce participants to the study, and gave them the opportunity to practice using the cameras we supplied them with. It was important to provide information on the study in multiple ways – visuals, discussion, and typed pamphlets – and be available for questions participants had during the photo taking process.

It was challenging to engage community members due to the sensitive topic our research focused on. Many people feared having their mental health diagnosis exposed, because of stigma. This resulted in two cohorts of four participants. It was important for me to maintain relationship with participants, especially with the length of time between cohorts (one started in July 2018, the other in October 2018) and their different meetings. Relationships were maintained through regular phone calls and allowing myself to become more invested in participants’ lives than I was used to as an RN in acute care.

What was the community response to the Photovoice project? Was there reception to participation?

The community was supportive of our work – the local grocery store contributed food and beverages for the opening day of our gallery event, and the community space was provided to us at a very low cost. Local groups who used the community center also came through to view and discuss the photo exhibit. Many community members who came to see the exhibit commented on the importance of the topic, and how engaging they found the photos. The opening event did not draw in as many community members as we expected, but the people who visited the photo installation appeared very invested. The photo exhibit was available for the public to view for approximately one month.

 

Photo Title: Togetherness. Photographer: Anonymous.

 

What are some of the challenges you faced with conducting this photovoice project? What is needed to be successful in conducting a photovoice project?

The biggest challenge was recruitment. In rural communities, people feel much more visible, and participants feared their mental health concerns would be exposed. Successful recruitment was largely thanks to the positive rapport workers in the community had with their clients. Another challenge was the type of cameras we used (we provided participants with point and shoot digital cameras); the cameras were difficult to use with certain physical concerns (ex. tremors, arthritis). Given the nature of the study, participants also found their mental health prevented them from being able to take all the pictures they hoped to. It is important to create a safe space for participants to express their concerns and feel heard, and to leave as much control as possible in the participants’ hands. I believe patient-oriented research is the key to a successful research project and creating findings that will be of benefit (e.g., raise awareness, reduce stigma, and provide input for health services delivery change).

 

If you could do this type of project again, what would you do differently?

Regarding recruitment, I would speak with community leaders personally. This would include reaching out to leaders in historically marginalized populations to improve inclusiveness of the participants in the project. Recruitment may have been more successful if I could have met in person rather than over the phone with each interested individual prior to the start of the study. I would also have patient population representatives more involved in the recruitment piece, as they are more connected in the community and understand the community’s culture. I would try to shorten the meetings as well, since some participants became tired or found it difficult to commit so much time to the larger group meetings. Regarding the cameras, I would use cameras that are more accessible (ex. larger buttons, steadier focus).

 

Overall, what did you like most/least about facilitating this Photovoice project?

It was an honour being allowed into participants lives and coming to understand what it is like to be an older adult in a rural community with a mental health concern. It was an enjoyable challenge to use photography and interviews to answer a research question; photovoice uncovered elements of participants’ lives that I never would have thought to ask about, such as their time spent in nature. The most difficult part of the project was recruiting enough participants, and ensuring each participant grasped the purposes of the study. I had to establish the difference between exploring this topic as a researcher, while also being an RN who works in mental health. This also meant using previous photovoice studies to explain to participants how their photography was being used as part of a research study.

 

Photo Title: Peace. Photographer: Anonymous.

 

Photo Title: Despair. Photographer: Denise.

To follow and learn more about this project, more content will be made available throughout their website at: https://blogs.ubc.ca/ruralmentalhealthstories/

References

Moazzami, B. (2015). Strengthening rural Canada: Fewer & older: The population and demographic dilemma in rural British Columbia [pdf]. Retrieved 11/17 from http://strengtheningruralcanada.ca/file/Fewer-Older-The-Population-and-Demographic-Dilemma-in-Rural-British-Columbia1.pdf

Smetanin, P., Stiff, D., Briante, C., Adair, C.E., Ahmad, S., & Khan, M. (2011). The life and economic impact of major mental illnesses in Canada: 2011 to 2041 [pdf]. Retrieved 10/17 from http://www.mentalhealthcommission.ca/sites/default/files/MHCC_Report_Base_Case_FINAL_ENG_0_0.pdf

Wang, C.C. (1999). Photovoice: a participatory action research strategy applied to women’s health. Journal of Women’s Health, 8, 185-92. Retrieved 08/17 from https://home.liebertpub.com/publications/journal-of-womens-health/42

Wang, C., & Burris, M. A. (1997). Photovoice: Concept, methodology and use for participatory needs assessment. Health Education and Behavior, 24, 369-387. doi: 10.1177/109019819702400309

Wang, C. C., & Redwood-Jones, Y. A. (2001). Photovoice ethics: Perspectives from Flint photovoice. Health Education and Behavior, 28, 560-572. https://doi.org/10.1177/109019810102800504

World Health Organization (2014). Mental health: A state of well-being. Retrieved 11/17 from http://www.who.int/features/factfiles/mental_health/en/#


 

Bonnie Fournier PhD, MSc, BSN, RN

"My clinical practice experience has focused on community health, mental health, and global health. I am a population health researcher with an interest in the intersections of place-people-health-policy and particularly in novel approaches and interventions to improve health outcomes with a focus on integrated knowledge translation strategies. I am interested in building resilient communities in order to mitigate the effects of climate change events on mental health. Currently, I am undertaking research with youth to understand youth engagement in health system planning using arts-based methods in rural communities." - TRU (Learn more here)

 

 

Tell us more about your project!

The two-year SSHRC funded project working with youth aged 14-18 in Ashcroft and Kimberley, BC. The hope is to gain a better understanding what it is like to be youth living in a rural community through youth engagement using a community-based participatory research (CBPR) approach and arts-based methods such as photovoice. CPBR engages youth in all aspects of the research process can facilitate youth to gain greater control over their lives, take a proactive approach in their communities, and develop critical understandings of their sociopolitical environments. Understanding the challenges, barriers, and strengths of youth through art, also provides a platform for youth to find solutions and take action to strengthen their lives and improve their community.  However, youth are rarely asked to participate in decision making around services and programs that affect their lives, and often their involvement remains marginal and tokenistic. When engaged in meaningful decision-making – in schools, youth organizations, and communities there are positive development benefits for youth. We are interested in know more about what it is like to be a youth living in a rural community and how to strengthen their lives.

 

What is photovoice?

Photovoice is a method that provides cameras to individuals to take pictures of their lives. In our project, youth are taking pictures of issues, concerns, or challenges they have in their lives or in their community. They bring their pictures and write a story about why they took the photo, what it means to them, how it relates to their lives and if it is an issue or concern, why it is happening and what they can do about it. An art exhibition of their photos will likely be one of the outputs of the project, providing youth with a forum to showcase photos and talk with others about their lives and how being part of the CBPR study increased their positive youth development.

 

What made you decide to use photovoice for this project?

Photovoice is a powerful way to tell stories. I have used this method many times in previous projects and have seen the strength of using a photograph to share a story about something important to that person. Youth in the project write a reflective piece for each photograph using the acronym SHOWeD :

  1. What do you See here?
  2. What is really Happening here?
  3. How does this relate to Our lives?
  4. Why does this condition Exist?
  5. What can we Do about it?

 

What are some of the insights (key themes) that emerged from this project? Is there any new knowledge gain from this project that may serve to inform policy and/or practice?

Youth want time and space to talk about what is important to them without having to be told what to talk about. Both community youth groups have formed a bond with each other, supporting and encouraging one another in their lives. Photovoice is a good method to engage youth in research. It is fun and gives them a purpose to meet and discuss their photos and stories. Youth think deeply about social issues which has led both groups to discuss climate change and the impact on their mental health.

 

What are some of the outputs of this project (e.g., community exhibition, media release,book publication)?

Photovoice is just one of the methods in this project. The youth are also using other art forms to express themselves. Some youth have sketched or painted about an issue in their community, music and theatre are also being explored for expression but also to create change in their community.

 

What was the community response to the Photovoice project?

Was there reception to participation? We are still in the middle of the project but response from both community schools has been positive. One school is providing space for the participants to meet.

 

What are some of the challenges you faced with conducting this photovoice project?

Finding digital camera’s that people are willing to donate. Using phone cameras can be an issue with confidentiality and easy access to social media where pictures can accidently be uploaded. So we are using digital cameras. However, we were only able to have a few donated to the project.

 

What is needed to be successful in conducting a photovoice project?

Training in the photovoice method and having access to good digital cameras.

 

If you could do this type of project again, what would you do differently?

Because both communities are rural, there are issues with transportation for the youth to come to meetings and for the PI’s to also access the communities due to distance. We have been using BlueJeans – an online video streaming program so that we can all connect and have also connected both groups of youth in each community with each other to share their pictures. This has been the most interesting learning for both the youth and the researchers. Youth are learning from youth in another rural community what it is like to live in their respective communities.

 

Overall, what did you like most/least about facilitating this Photovoice project?

We are still not done. We have another year to go. Its been great to see the youth become interested in their communities and wanting to change things and then watching them take action- one group is currently working on a song/video about having more green space in their community for youth and will present it to the major and council.

With permission I am sharing two photographs and their stories from the project!

Under the Bridge

I want to clean up the area. There are homeless people that go there and leave their things like blankets and litter. There is also a pub and restaurant nearby that produce a lot of litter that isn’t cleaned up. There are community groups that clean up garbage although they often don't clean up under the bridge because it isn't a common spot that people look at, so they focus more on the parks. There is some broken concrete sitting under the bridge from some sort of walkway that broke and never cleaned up. Maybe with more affordable living there would be less homeless people living there and leaving garbage. I used to go there in the summer to hang out with his friends and swim and thought it was a good spot but now the bank has widened out and become dirtier and full of garbage.  Often there are people hanging out there that make it feel unsafe.

 

 

Mental Health

This photo represents how mental health can be affected when you aren't prioritizing or taking care of your own needs. School is known for stressing out students, and I don't think mental health is always being addressed in school. Being busy isn't always a bad thing, but prioritizing only school or work rather than self care eventually takes a toll on mental health. I think if being able to balance things like school and self care were addressed more, students would have an easier time managing stress.