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. 2013 Feb 11;6(1):72–77. doi: 10.1111/cts.12028

Visual Voices: A Participatory Method for Engaging Adolescents in Research and Knowledge Transfer

Michael A Yonas 1,2,✉, Jessica G Burke 2, Elizabeth Miller 3
PMCID: PMC3575688  NIHMSID: NIHMS430685  PMID: 23399093

Abstract

Integrating the expertise and perspectives of adolescents in the process of generating and translating research knowledge into practice is often missed, yet is essential for designing and implementing programs to promote adolescent health. This paper describes the use of the arts‐based participatory Visual Voices method in translational research. Visual Voices involves systematic creative writing, drawing, and painting activities to yield culturally relevant information which is generated by and examined with adolescents. Qualitative data products include the created artistic products and transcripts from group discussions of the content developed and presented. Data are analyzed and compared across traditional (e.g., transcripts) and nontraditional (e.g., drawings and paintings) media. Findings are reviewed and interpreted with participants and shared publicly to stimulate community discussions and local policy and practice changes. Visual Voices is a novel method for involving adolescents in translational research though Integrated Knowledge Transfer (IKT), a process for bringing researchers and stakeholders together from the stage of idea generation to implementing evidence‐based initiatives. Clin Trans Sci 2013; Volume 6: 72–77

Keywords: youth engagement, adolescent health, community based, knowledge transfer, participatory research methods

Introduction

The growing attention given to the science of translation1, 2 and increasing emphasis on the need to implement interventions that will save lives and resources3, 4 creates an ideal opportunity for identification of appropriate methods for engaging adolescents in research to influence decisions about programs and policies aimed at promoting adolescent health and well‐being. Participatory research approaches that integrate diverse expertise throughout the research process are particularly salient for connecting with adolescent expertise and experience. A small, but growing, body of literature on the impact of participatory action research has underscored how involving adolescents in the research process can increase community involvement, ensure that research reflects the lived experience and priorities of adolescents and that research is implemented in a culturally relevant and ethical manner.5, 6, 7, 8

While traditional and translational research has generally failed to incorporate input from adolescents,9 select participatory action research studies have engaged youth to address topics such as safety and violence, obesity and diabetes, school environment, sexual health, mental health, and substance use.6, 10, 11, 12 Integrating the “voice” of adolescents into the continuum of the research process, from idea identification to dissemination of research findings, provides researchers valuable opportunity to engage hard to reach populations, increase the quality and cultural relevance of findings, and disseminate and implement findings in a manner that is uniquely relevant to adolescents.6

Involving adolescents as partners in the research process can be challenging given varied cognitive and social phases of development that may influence their perceptions of health and social problems as well as limit understanding and experience with the research process itself.13, 14, 15, 16, 17 Previous research suggests that the way in which children and adolescents are approached and integrated within the research process may determine their capacity as partners to participate in research.18, 19 Essential to creating an appropriate context is the utilization of methods which strengthen trust and develop common expectations for the research.

The development of a robust translational adolescent health research agenda requires a paradigm shift toward using methods that facilitate developmentally appropriate participation of adolescents in the research process itself. Given the lack of standardized models for translating adolescent health research into programs or policies, researchers and practitioners are often left to assume that evidence will be adopted somehow by those operating programs and make policy decisions.20 Efforts to involve youth formally in the research process are increasing; some have employed creative methods using cameras and theatre productions to encourage dialogue about factors influencing their health and well‐being.6, 11, 21, 22 To encourage implementation of evidence‐based practices, adolescent health researchers require additional methods and tools to facilitate the transfer of knowledge about research‐tested interventions to key stakeholders.23

Exploring youth participation in integrated knowledge transfer (IKT)

The effective transfer and uptake of evidence‐based knowledge from one group to another are critical, yet distinctly different, components of the Knowledge Transfer process.24, 25, 26, 27 There are several accepted models for Knowledge Transfer. First, the producer‐push model, involves academic researchers developing knowledge and implementing strategies to “push” their research toward stakeholders to use on their own. The second is a user‐pull model in which users or stakeholders identify and “pull” the research findings on their own to use and apply guided by their own decision making needs. The third model, Integrated Knowledge Transfer (IKT), is an information exchange model which involves building relationships among researchers and those who use the knowledge to effectively allow for the equitable exchange of research information, ideas, and experiences for informing action.24, 25

Widely recognized as the most effective model, IKT focuses on developing equitable and transparent relationships between the researcher and those who are intended to use the research knowledge.27 More specifically, IKT involves the transfer of knowledge between researchers and the target audience through a partnership approach where stakeholders inform the focus, design, interpretation, dissemination and application of new or existing research for policy and practice decisions.28 While more time and resources may be required with this model, this partnership approach to research enhances evidence‐based decision making and increases the probability that the best possible decisions and evidence are used to benefit adolescents in their communities.28

Facilitating the exchange of knowledge and information specific to adolescent health is essential for informing and sustaining meaningful and measurable programmatic and policy change. A common challenge facing researchers is HOW to actually engage and sustain relationships with adolescents as key stakeholders, experts, and research partners. This paper describes the use of the arts‐based participatory Visual Voices method in translational research. The following case example from research conducted with urban middle school age youth is used to illustrate how Visual Voices is a particularly fitting method for translational research with younger adolescents. Specific attention is paid to how Visual Voices complements an IKT model for action‐oriented translational research.

Visual Voices

Visual Voices began in 1993 as a project that provided a creative and fun opportunity for free expression, learning, and relationship development that crossed age, gender, race, and economic boundaries. Visual Voices has since evolved into a formal participatory research method for cultivating relationships between evidence producers (e.g., health researchers) and evidence users (e.g., communities). This method has been used to examine a wide range of community‐generated health priority issues including neighborhood safety and violence, adolescent bullying, healthy relationships and dating violence, and contextual influences and stressors for childhood asthma and asthma disparities (Yonas et al., unpublished data, 2011; Rak et al., unpublished data, 2011).28

A more complete description of the Visual Voice method has been published previously.28 In brief, Visual Voices is an arts‐based method that uses multiple sessions to address a focal research area, most often generated by community stakeholders. Each session includes an overview discussion, followed by an art activity (either through painting, drawing, or writing), and a group “critique” or discussion of the work generated (Figure 1).

Figure 1.

Figure 1

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Visual Voices creative group discussion sessions.

After the group discussion, the individual artist participant is invited to voluntarily share their thoughts. To extend the partnership to include younger adolescents, participants are encouraged to first co‐facilitate and then independently facilitate the different painting, writing, drawing, and discussion phases of the process. Participants are then invited to help build the final exhibit piece or mural aimed at capturing key concepts and themes identified during the research process. The final exhibit integrates the different creative products from each session and photographs of the process. The materials are layered together that allows the paintings and writings to be viewed together, as one final collaged exhibition of the participants’ work, thoughts, and feelings (Figure 2).

Figure 2.

Figure 2

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Visual Voices mural construction and final exhibit example.

Methods

Topic identification

An academic researcher (Dr. Yonas) was invited by the resident council manager of a public assisted housing community, director of an after‐school program, youth, and administration from a local community hospital to initiate a research project with youth to learn about factors influencing adolescent safety. As part of the initial information gathering phase, the researcher provided information about various qualitative and quantitative methods, including Visual Voices, for collecting data as well as an overview of traditional and participatory research approaches. With a commitment to future research and action, the interdisciplinary collaboration decided that a partnered research approach was ideal, and that Visual Voices would be a useful method for involving younger adolescents in a conversation about their perceptions regarding adolescent health, safety, and violence. Local adults, youth after‐school program coordinators and local hospital administration were concerned about the influence of high rates of violence within their community. For example, their community had substantially higher rates of juvenile arrest (community = 15.7% compared with the Pennsylvania = 3.9%), adolescents bringing a weapon to school (community = 4.8% compared with the Pennsylvania = 2.2%) and adolescents attacking someone with intent (community = 27.7% compared with the Pennsylvania = 10.5%). Community research partners and the University of Pittsburgh Institutional Review Board approved the study.

Participants

Thirteen African American youth between the ages of 8–15 who lived in a publicly subsidized housing community and attended an after‐school program participated in the project. A majority of the participants (69%) were female. Following multiple community‐based information meetings to describe the proposed project, written and verbal parental consent and youth assent were obtained for all participants prior to the initiation of any research activities.

Data collection

During the Visual Voices painting sessions, the adolescent participants painted about topics such as their favorite place, hopes and dreams for the future as well as project specific topics of positive and negative influences on adolescent health and safety. For the participatory writing sessions, participants were asked, based on their comfort level, to write and/or draw about the same topics. At the end of the group painting sessions, a structured and facilitated discussion session was conducted by selecting paintings and holding them in front of the group for reflection, feedback, and praise (Figure 1). The group collectively reflected on the content of the painting. The exchange was facilitated by the academic researchers using a modified and enhanced approach to a standard focus group process. Participants then guided the design and construction of the final Visual Voices exhibit (Figure 2). They were asked to look at the collected works and determine which pieces they want to include and in what order. The final exhibit integrated the different creative products from each session into a collaged exhibition, creating one collective “visual voice” depicting the information gathered, shared and lessons learned.

Data analyses

All participant paintings were digitally photographed and writings and drawings were scanned and then entered into the qualitative data analysis program software, QSR NVivo, Version 8. Audio recordings of the group discussions were transcribed verbatim and similarly compiled. The majority of qualitative coding occurred as a result of the participant guided priorities as exemplified in the paintings, writings, drawings and related group discussion, such as codes related to specifics and details like “school safety” and “healthy foods and access” as unsafe or unhealthy factors. The youth participants, after‐school program staff and volunteers, parents, and other interested community members met with the academic investigators at the end of the activities to review findings, participate in interpretation, and discuss priorities for dissemination.

Results

Findings about adolescent health and safety

Adolescent participants painted, drew, and wrote freely about a variety of influences associated with their health and safety. The following is a brief summary of the type of information that emerged from the Visual Voices process. For example, some participants painted about school as a safe place (Figure 3) where “teachers [teach and] protect you.” However, during the discussion session, school was also described as being both a safe and a not safe place. “…well at our school, sometimes they just …walk through [metal scanners] beeping and you never know what they got. That’s not safe.” While participants did not talk of having experienced shootings within school, they are aware of such occurrences in their community and know they are at risk for getting caught in the cross fire.

Figure 3.

Figure 3

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Depiction of a shooting in the community.

The data from these sessions also highlighted ambiguity about the perceived benefit of local services such as school, police, and the hospital. Participants noted that at times these same institutions may pose a threat. For example, hospitals and physician offices were felt to be places that might make you sick. An account emerged of a resident of the housing community who recently contracted methicillin‐resistant Staphylococcus aureus (MRSA). It was widely believed by the group and from subsequent public dissemination of the project’s findings that this individual’s exposure to MRSA occurred at the local hospital, and that many in the community would not go to the hospital for preventive care and services for fear of getting sick. This discussion provided a valuable insight and information regarding potential reasons that residents and adolescent were not participating in health promotion programs focused on local residents, and an opportunity to discuss the risk factors and prevention practices associated with MRSA.

In a session specifically focused on positive influences on adolescent health and safety, participants shared common feelings regarding the importance of having hopes and dreams for the future and strong social networks. Participants developed pictures about having one’s own goals for the future, referring to learning from history and inspiring work of Dr. Martin Luther King, Jr. (Figure 4). In addition, family and friends were often depicted by the group as providing valuable insight and a potential untapped local resource for engaging adolescents. One participant’s feelings, documented during the writing and drawing session, were met with group support and consensus: “I [heart] my family. The reason why these are my favorite people [is] because they always love me…and they been there for me. And they never doubt me. That’s why these are my favorite people.” (Figure 4)

Figure 4.

Figure 4

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Family, friends and hopes and dreams for the future.

In the session focused upon safe and note safe influences, the group shared a perceptions regarding a variety of social and environmental factors. “Not safe” was most often associated with contextual stressors and exposures, such as drugs, guns and violence, smoking, drinking, and gambling. The images created in a piece (Figure 5) by one young female participant captured the attention of those participating and facilitated a group discussion and consensus about the unsafe factors facing young people living in their neighborhood. A description of what was in the painting included “I see a forty.… I see a bud.… I see Newport [cigarettes].… I see guns.… I see umm dice.…” The dangers related to drinking, smoking and gambling were affiliated with guns and violence. One participant said “you can have a half of that glass but people here they be like, they start to fight, then they get their guns out, then they start shooting, then the police come. Then the little kids have to run inside.” Another participant painted about the dangers of smoking, alcohol and drugs and the importance of “smoking you can die from that. You can get cancer…and eating fruits and vegetables, such as carrots…apples are good for you and your eyesight…but it’s hard [but they are hard to get].” (Figure 5)

Figure 5.

Figure 5

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Safe versus not safe and healthy versus not healthy reflections.

Dissemination of findings

Adolescent participants were involved in the analyses, interpretation, and summary of the multimedia and traditional qualitative findings and informed the planning of three primary dissemination sessions. The objective of the dissemination forums were to share with adults and “outsiders” that in contrast to common perception they were involved with developing and conducting positive activities in the community, highlight their safety concerns with adults in positions of power to informing future action to promote adolescent well‐being. The first priority forum selected was to share findings about youth health and safety within their community with after‐school program staff and coordinators, program volunteers, other neighborhood program staff, parents, and other community residents. The second priority was to present to a broader policy‐related group including the president of the resident council, manager of the subsidized housing community, local police chief and chief of police for the publicly subsidized housing community. And the third forum was a community presentation of the project’s process and findings to a university audience of faculty and graduate students within the university’s graduate school of public health (Figure 6). Public dissemination of the findings resulted in a number of immediate positive consequences including the recognition of the adolescents’ creative and collaborative efforts, recognition of the adolescent perspective and insight to factors influencing their health and safety, increased police presence in the community, and increased communication with local police and police chief with community residents and adolescents. An additional consequence of the Visual Voices project’s activities and dissemination forums included the identification of additional health research priority areas and new evolving research partnerships in the content areas of child and adolescent asthma and adolescent sexual health. These dissemination activities about limited community safety also had some unexpected consequences, which included the police and other adults enforcing a curfew for youth.

Figure 6.

Figure 6

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Public presentation of findings together with adolescent research partners.

In addition, several the Visual Voices murals were exhibited in a number of public neighborhood venues. Adolescent participants conducted discussions alongside these exhibits held at the local hospital and public library where the young participants, families, and friends could view the work.

Discussion

Visual Voices as a method for engaging adolescents in Integrated Knowledge Transfer

Visual Voices has great potential to serve as a specific method for Integrated Knowledge Transfer because it incorporates many of the core elements of Integrated Knowledge Transfer (See Table 1). While an Integrated Knowledge Transfer framework was not initially used to guide the research presented in this case study, it is evident that the creative and engaged research methods provide a unique process for nurturing the formative relationships necessary for Integrated Knowledge Transfer to occur.25, 29, 30

Table 1.

Key components of integrated knowledge transfer and Visual Voices (modified from ref. 25

Components of knowledge transfer Project elements/characteristics of Visual Voices for engaging adolescents in research
Who is the target audience? Who is the stakeholder group and the specific target audience for the research? • Adolescents • After‐school program staff • Resident council and housing authority management • Local and housing authority law enforcement • Local hospital administration interested in engaging youth and community residents in health promotion services • University faculty and students interested in community‐engaged research and working through research with adolescents
What is the message being delivered? The messages being developed and delivered should be clear, concise, consistent, continuous and compelling. • Messages developed in collaboration with adolescent participants/research partners • Awareness of adolescent perceptions of factors impacting the health and safety of adolescents living in public assisted housing community • Adolescents identified a variety of positive and negative community, school and family factors • Adolescents can be a strong positive force in the community • Adolescents can work together to develop, summarize, and share ideas for creating safer and healthier communities
Who is delivering the message? Messages should be delivered to an audience by a credible messenger, addressing concerns and ideas of the target audience. • Adolescents, staff, and researchers speaking together to community, university and hospital staff and administration • Researcher alone for presentation to law enforcement (as decided upon by adolescent participants to ensure safety and confidentiality)
How is the message being transferred? When selecting the appropriate knowledge transfer method, the size and nature of the audience, budget and availability of resources should be considered. • Analyses and interpretation conducted as partnership between academic researchers and adolescent participants • Public forums and presentations with discussion in the community • Formal presentation to the police and police chief, housing authority police leadership resident council • University class and seminar presentations with adolescent partners, and now every semester to graduate program masters and doctoral level students • Peer reviewed publications • Conference presentations • Public exhibition of the final project
What is the impact of the knowledge? Were there any changes in knowledge, awareness, attitude or action that has assisted decision making as a result of the work and research together? • Resident council, property manager recognition of the positive engagement with adolescents, positive ideas and constructive input from community youth • Local policy change: increased communication with police chief and officers • Curfew—unintended but did promote community sense of safety • University student interest, integration into public health and medical school courses on community‐engaged research • Youth coming to university campus to co‐present, leaving their community and working together to do so • Cultivation of strong, transparent and formative community research‐based relationships • Identification of new/emergent research priorities associated with healthy relationships/dating violence and disparities in childhood asthma • Development of a new research community‐partnered research agenda to address racial disparities in asthma
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The Visual Voices method provided an opportunity for adolescents to discuss sensitive topics such as safety, to learn about how to present ideas and encourage change in their communities, and to actively participate in the process of creating locally relevant knowledge. The specific illustrations and related discussions were informed by the youth themselves with minimal “prompting” from the research facilitators. The adolescent participants, as co‐facilitators, identified a range of issues related to community factors associated with adolescent health and community safety, and violence. Follow‐up discussions with adolescent participants indicated that this method was well received and appreciated because it was flexible, fun, involved creative activities of painting, drawing, and writing and because they had an opportunity to talk, listen, and be heard.

The appropriateness of arts‐based methods, such as Visual Voices, for facilitating partnered research with adolescents to encourage Integrated Knowledge Transfer has been highlighted in recent literature.6 For example, Ozer et al. (2010) used photovoice with middle‐school youth in a school setting and found that adolescents provided key input into short and long‐term intervention opportunities within and outside of the school‐based setting. In another intervention conducted by Jackson et al. (2010), an interactive, theater‐based intervention was developed with adolescents to deliver health messages to low‐income, urban, African Americans with the objective of increasing adoption of a healthy lifestyle.22 However, the use of such methods has been limited. Utilizing and evaluating how arts‐based methods contribute to knowledge transfer related to adolescent health is an intriguing and potentially decisive area of continued future translational research.

Missing from this case study though is clear documentation that knowledge transfer happened at every phase of the research process, and that Visual Voices can serve as a tool for facilitating policy changes incorporating adolescents’ input. While policy change was not an initial project priority, this limitation could be addressed by simply incorporating a policy focus and additional opportunities for dialogue involving adolescents during dissemination forums using the presentations and mural exhibitions as venues for collaboratively exploring, informing and implementing policy changes. In addition, unique challenges are associated Visual Voices. For example, the process is time consuming, it requires that partners be comfortable working with the different media, facilitating discussions and working with the different types of qualitative data and data analytic techniques. Similar to other qualitative data collection techniques, the generalizability of the findings are limited. Special considerations and actions need to be taken to ensure that clear benefits are realized for all project partners and that the burden of participation is minimized.

Conclusion

The Visual Voices method provides a unique opportunity for adolescents to inform, implement, and guide the translation of adolescent health research findings into practice. It is an arts‐based participatory and developmentally appropriate research method that can be used to integrate adolescents and entire community expertise into the research process and to facilitate equitable involvement in the generation of practice and policy changes. This innovative method used within an IKT model has the potential to generate rich and valuable data about complex topics of interest and influence the lived experiences of adolescents in their communities. Utilizing an IKT model is particularly useful for accessing hard to reach populations (i.e., facilitating improved data collection); examining innovative and compelling solutions‐focused research questions (i.e., creating better suited research questions); presenting more accurate and culturally relevant findings through partnered analyses (i.e., more reliable and credible interpretations); and creating and sustaining research relationships with capacity for new and long‐term translational research (i.e., growing research agenda). Researchers interested in partnering with adolescents in research to better understand and address complex public health issues might consider utilizing this novel and creative method.

Sources of funding

  1. Clinical Translational Science Institute of the University of Pittsburgh, funded by the National Institutes of Health through Grant Numbers UL1 RR024153 and UL1TR000005.

  2. Children’s Hospital of Pittsburgh Foundation.

  3. National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number KL2TR000146.

Acknowledgments

The authors sincerely thank all of the young vibrant and creative adolescent research partners, community and academic research partners, especially Ms. Ronnica Sanders, and Ms. Vera Kelly that have made this partnered research effort possible and educational for all. We would also like to sincerely thank Patricia O’Campo, PhD, Director, Centre for Research on Inner City Health, St. Michael’s Hospital, Dalla Lana School of Public Health Sciences, University of Toronto for teaching us and sharing her expertise of knowledge transfer. In addition, without the vision and support of Steve Reis MD, Associate Vice Chancellor for Clinical Research and Director of the University of Pittsburgh Clinical and Translational Science Institute this work would not have been possible.

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