Studying Food Environments Through Photovoice

Manuel Franco MD, PhD
Associate Professor
School of Medicine, University of Alcala, Spain
Adjunct Associate Professor
Department of Epidemiology
Johns Hopkins Bloomberg School of Public Health
A Participatory Action Research project to
study and improve the food environment
in Madrid
PHOTOVOICE VILLAVERDE PROJECT

http://hhhproject.eu
Food environment research
Food environment and residents dietary patterns
• PhD project MESA study 2005 (AJPM, AJCN)
• Baltimore City Health Department meeting 2007
Baltimore Food Policy Timeline. JAFSCD 2014

Social and Physical Urban
Environment and CV Health:
The Much Needed
Population Approach
PI: Manuel Franco MD, PhD

To study the impact of the
social and physical environment in terms of
tobacco, alcohol, food and physical activity
on residents cardiovascular health
Heart Healthy Hoods
Overall Objectives

Food environment in Madrid, Heart Healthy Hoods
• Structural changes to improve population´s diet (JECH 2014)
• Madrid-Baltimore study on Healthy Food Stores (PM 2016)
• The HHH exploratory study in Madrid (BMC Methods 2016)
Understanding food environment in whole cities
• Baltimore City Food Environment 2010, 2015
• Philadelphia?

• Understanding food environment and residents diet
• Need for participatory research in order to obtain “real” data
of use and meaning of food environment
• Necessary information to design culturally appropriate and
effective interventions
Participatory Project in Madrid

Manuel Franco MD, PhD
in Madrid
PHOTOVOICE VILLAVERDE PROJECT

What is Photovoice?
• Photovoice is a participatory-action research method. Caroline
C. Wang and Mary Ann Burris (1994, 2000)
• Enables people to identify, capture, and reflect their
community´s strengths and concerns through photography
• Informs policy makers to promote health related public policies

Main objective
To conduct a photovoice project with
residents of a low-income Madrid area to
understand the local food environment and
its influence on individuals’ diets

Specific Objectives
1. To describe photovoice participants’ main themes
relating local food environment to residents’ diets
2. To translate phtovoice findings into urban food policy
recommendations
3. To communicate and disseminate Photovoice results

Methods: Study setting
• Two administrative
low-income
neighborhoods
(Los Rosales and
San Cristobal)
• Collaboration with
Villaverde Health
Promotion Centre

Methods: Participants
• We used a purposive sampling
strategy to engage participants.
• Participants completed informed
consents and image release forms.
• Villaverde Health Promotion Center
facilitated participants’ recruitment
and retention.
• 24 residents enrolled in the project.

Methods: Photovoice procedure
• Four Photovoice groups by gender/neighborhood
• During five group discussion sessions, participants:
• attended a Photography workshop
• critically discussed their photographs
• analyzed their photographs

• Participants took 163 photographs, and identified 30
categories emerging from the photographs and
discussions
• Final categories were then organized around five themes
of the food environment related to dietary behaviors :
1. Eating in moderation
2. Cultural diversity
3. Food stores
4. Social relationships
5. Economic crisis and poverty
Methods: Participatory data analysis
Diez. J. Under Review, Health and Place

Theme 5: Economic crisis and poverty

Translation into food policy
recommendations: Methods

Participants and co-facilitators met twice to translate
photovoice results into policy recommendations

1. We conducted a “problems and objectives” analysis using an
adapted logical framework approach.
2. We identified root and causes of both:
a) positive environment features to be encouraged
b) negative environment characteristics to be addressed/changed
Problem:
Roots:
Shortage of food retailers
Insufficient access to variety of food
with suitable quality and price
Low competition between
businesses higher prices
Low quality food supply

3. Participants turned identified problems into policy recommendations
Promoting small food retailers
Insufficient access to variety of
food with suitable quality and
price
4. Recommendations were prioritized
according to:
a) Time (score: 1-5)
b) Impact (score: 1-5)
c) Feasibility (score: 1-5)
d) Cost (score: 1-5)

Food policy recommendations (ranked)
1. Offering local leisure time activities to avoid unhealthy behaviors
(e.g. snacking, alcohol, sodas)
2. Improving food banks management
3. Reactivating traditional markets and small retailers
4. Improving food hygiene conditions
5. Promoting the availability of organic foods and for patients
(e.g. diabetes and celiac disease)
6. Reducing food waste
7. Improving nutrition labeling
8. Offering healthier alternatives to workplace vending machines
9. Teaching food education at schools
10. Promoting healthy social networks for older people
11. Giving street vendors legal status

Dissemination and communication
Photovoice results
• Residents participated in dissemination and communication
strategies to promote social action:
• Photobook
• Exhibition
• Video
• Citizen Science meetings
• Interactive Cartography
• Media collaboration

Photovoice results
• Free- downloadable Photobook: hhhproject.eu/photovoice

Photovoice results
• Photography exhibition in three different venues in Madrid
• 6 months at the third most visited cultural center un Madrid

Photovoice results
• Two citizen science meetings. Participants presented
results and policy recommendations to local policymakers

Photovoice results
• Interactive cartographical application:
http://www.geogra.uah.es/PHHHotovoiceMap/photovoice.html

Ongoing and future research
The mismatch between observational measures and residents’
conceptualization of food access: a mixed methods study

Photovoice and empowerment?
Kirsten Budig, MPH Erasmus
Empowerment dimensions: Knowledge gain, Self-perception
change and Access to local resources.
Methods: 10 semi-structured interviews
Results: Participants acquired new knowledge and developed a
critical awareness of their food environment.
The social recognition they received transformed their self-
perception.
Participation expanded their social networks in the area.
Photovoice empowered participants to take different actions.

Ongoing and future research
Pedro Gullón MD, MPH, PhD Candidate
Studying the urban environment and its
influence on physical activity using
Photovoice in two different SES
neighborhoods in Madrid

Successful method to engage residents in a participatory
action research project collecting, analyzing, and
communicating
Participants identified five themes relating their local food
environment to residents’ diets
Results were translated into community generation food
policy recommendations may inform policies improving
population diet
Project communication included a photobook, a public
exhibit, a video and an interactive cartography
Photovoice conclusions

Video
https://www.youtube.com/watch?v=VIiFggKzVas

Acknowledgements

http://hhhproject.eu/research/photovoice/

• Collaboration Madrid Public Health Institute Hall and
• Funding:
• European Research Council
• Fundación Mapfre
• Ayuntamiento de Madrid
• Drexel University Urban Health Collaborative
Acknowledgements

in Madrid
¡ GRACIAS !

Studying Food Environments Through Photovoice

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