Research has shown that behavioral health conditions like mental illness and substance use disorders are closely linked with the social determinants of health — the non-medical conditions impacting health and wellbeing in the environments where people live, work and play.
But how do community members with behavioral health lived experience perceive these links?
Members of the University of Kentucky College of Public Health (CPH) Center for Innovation in Population Health Improving Public Health through Collaboration and Transformation of Systems (IMPACT) team sought to answer this question using Photovoice, a participatory method in which community members take and discuss photos to capture aspects of their environment and experiences to bring the realities of their lives home to policymakers and spur change.
The project is outlined in a recent Journal of Behavioral Health Services & Research article “Using Photovoice to Improve Engagement in Community Health Assessments Addressing Behavioral Health.”
Jennifer Gulley, the director of performance management and accreditation at the Clark County Health Department, was inspired to try Photovoice after experiencing the method to understand the opioid overdose epidemic while participating in the HEALing Communities Study (HCS) in a project led by Margaret McGladrey, Ph.D., CPH IMPACT faculty and HCS-Kentucky co-investigator.
“The power of that project that we just participated in was great,” said Gulley, who subsequently reached out to Dr. McGladrey about integrating the method into the 2022 Clark County Community Health Assessment (CHA) and Community Health Improvement Planning (CHIP) process.
“I see Photovoice as a focus group on steroids, if you will, because it takes individuals’ thoughts and perceptions and puts those in pictures,” Gulley added. “And when we went into the CHA forums, instead of just having a bulleted list from focus groups, we’ve got the power of pictures. And then the local public health system assessment is bringing together the partners to discuss how we communicate and what improvements we need to make.”
In the summer and fall of 2022, the research team recruited 23 community members throughout Clark County through listservs, civic groups, coalition meetings, pop-up events and other channels to join as co-researchers and assist in the health department's CHA, a report conducted by local public health agencies to identify key health priorities and inform CHIP.
In traditional research methods, deciding which topics to focus on is left to the principal investigator, most often an outsider looking in. By using Photovoice, the community members were empowered to generate a list of community health strengths and issues, photograph these topics to frame their own perspectives, discuss their innovative ideas or solutions, and present their data back to the community and decision-makers at two community health forums in the winter of 2022.
Analysis of the photographs and Photovoice focus group data revealed that behavioral health facilitators and barriers were perceived to be influenced by a seemingly unresponsive local government, which led to the formation of strong community organizations and partnerships but ultimately a fragmented division of responsibility between agencies and across sectors of behavioral health services.
The co-researchers cited a lack of public sector support as a major barrier to improving community behavioral health, resulting in reliance on grassroots and community-based efforts to address behavioral health issues.
As a result, co-researchers called for a re-evaluation of how behavioral health services were divided across different sectors, highlighting the need for improved multi-sector collaboration to remedy siloed agencies addressing individual behavioral health issues.
The research team acknowledged this is a complex, multidimensional problem that takes each group of stakeholders — citizens, government, nonprofits, and others — doing their part to address these challenges and bring about meaningful change.
The co-researchers emphasized that interventions to address the behavioral health crisis should not be confined to a single sector but instead employ a more interdisciplinary approach involving collaboration across sectors.
“It takes all of us working together across all sectors of our community to improve our health,” said Gulley.
The findings from the project led to the initiation of an equity coalition addressing racial disparities in education and enhanced community-government inter-communication at two community health forums. The findings also helped in educating aspiring public health professionals and sparked interest from other health departments that have similarly incorporated the Photovoice method into their CHA/CHIP activities.
