CARDIOVASCULAR DISEASE (CVD) is one of the leading causes of morbidity and mortality in the United States, and does not discriminate by ethnicity.1 In fact, the health of many US ethnic minorities, especially immigrants, is known to be poorer than their Caucasian counterparts living at similar socio-economic levels and geographic regions.2–5 Issues related to poverty, heath care access, and quality of care greatly impact rates of disease once immigrants arrive in this country.6,7 Efforts to develop health promotion programs to decrease risk factors for CVD are complex because of language and cultural issues that must be addressed for efforts to succeed. It is important to “see” what a targeted group sees, to understand how they view specific topics if one intends messages to relate to them.
We asked older Asian immigrants to show us how they viewed cardiovascular health using Photovoice, a qualitative method in which people identify their perspectives on a topic by taking pictures that are significant for them.8 We recruited 23 Chinese, Vietnamese, and Korean immigrants with limited English-speaking proficiency, mean age 72 years, to participate in 2 sessions held in their respective language. In the first session we received informed consent, explained our goals, and provided participants with cameras to depict (1) those aspects of their lives that promoted cardiovascular health, and (2) barriers they perceived that prevented a “healthy heart.” We asked each participant to select 2 of the photos and reflect on why they took it as well as what it represented to them. At a second session, each participant shared their pictures and thoughts, providing researchers with unique perceptions of cardiovascular risk factors.
While the photographs represented common themes related to diet, exercise, and stress, each group provided a cultural context of their understanding of CVD. For example, a Chinese woman expressed her beliefs on the health benefits of drinking tea (Image 1), while another Chinese man reminded us that affordability is crucial to making healthy purchasing decisions (Image 2). The loneliness that is often felt when leaving one's homeland was an issue for one Korean man who had recently immigrated to the United States (Image 6), while a grandmother described how a picture drawn by her granddaughter kept her spirits up (Image 7). A Vietnamese woman emphasized the importance of family in caring for and keeping older adults healthy (Image 9). We present here some of the photographs that were taken in these Photovoice sessions with the reflections of the participants who took them. We found this method to be an insightful and fun way to initiate discussion in community members whose views might be more difficult to “see” in any other way.
Image 1.
Drinking Tea Keeps You Away From Illness. “I believe drinking tea regularly is important to your health. It does not matter what kind of tea…no matter if it is green tea or other kinds. Chinese like tea and we cannot live without tea. I believe certain kinds of tea can treat disease.” (Chinese woman aged 66 years and living in the United States 1 year).
Image 2.
Look for Healthy Food That Is Affordable and Available. “I love tomatoes and they are good for your digestion. You can get them anywhere. It is cheap but has good nutritional values. I have them twice a week—I think it is good to keep me healthy.” (Chinese man aged 65 years and living in the United States 35 years).
Image 6.
Lonely Seagull. “I moved to the US from Guam so my children would have a good education. But I feel much loneliness for my home. This is not good for my heart” (Korean man aged 50 years and living in the United States 3 years).
Image 7.
Laughter. “This is a drawing by my 6-year-old grand-daughter. I have it by my bed so when I wake up in the morning I can see it and it makes me smile. Laughter is good medicine for your health” (Korean woman aged 65 years and living in the United States 37 years).
Image 9.
Old but Healthy. “Here is an old woman who is 97 years old. Her daughter takes care of her. Her life is very healthy––her diabetes is under control, so her heart is very healthy and her blood pressure is good. This picture also represents how the people around you can make a difference in your health. This woman's good health depends on her daughter” (Vietnamese woman aged 66 years and living in the United States 19 years).
Image 3.
Working on Your Feet to Keep a Healthy Heart. “Every day I step on stones and walk back and forth for about 15 minutes. In that way, my feet get massage and I get exercise. This is a kind of exercise for elderly. Exercise can improve your heart health and massaging feet with stone is important to prevent death!” (Chinese man aged 80 years and living in the United States 30 years).
Image 4.
Seafood is Blest by the Creator. “There are references to fish throughout the Bible. When we eat fish, we don't feel full. It is healthier” (Korean man aged 67 years and living in the United States 35 years).
Image 5.
Speeding Cars. “We all go places too fast. When we drive we become stressed. This puts a huge burden on our heart” (Korean man aged 50 years and living in the United States 3 years).
Image 8.
Unnourished Heart and Arteries. “This picture is a symbol of undernutrition, lacking of healthy arteries such that the heart can no longer live. If the heart and arteries cannot live, then everything will die” (Vietnamese woman aged 66 years and living in the United States 19 years).
Acknowledgments
This study was supported by a cooperative agreement from the Centers for Disease Control and Prevention's Prevention Research Centers Program (PRC) Special Interest Project (SIP) (9-05, U48 DP00050). The PRC Cardiovascular Health Intervention Research and Translational Network is supported by the Centers for Disease Control and Prevention's Heart Disease and Stroke Prevention Program.
We also wish to thank the participants in our Photovoice sessions who contributed the photographs presented here.
Human Participant Protection
Institutional review board approval for this project was received from the University of Washington Division of Human Subjects.
References
- 1.Lloyd-Jones D, Adams R, Carnethon M, et al. , for the American Heart Association Statistics Committee and the Stroke Statistics Subcommittee Heart disease and stroke statistics 2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2009;119:e21–e181 [DOI] [PubMed] [Google Scholar]
- 2.Liao Y, Tucker P, Okora CA, et al. REACH 2010 surveillance for health status in minority communities––United States, 2001–2002. MMWR Surveill Summ 2004;53:1–36 [PubMed] [Google Scholar]
- 3.Williams DR. The health of US racial and ethnic populations. J Gerontol B Psychol Sci Soc Sci 2005; 60:Spec No 2:53–62 [DOI] [PubMed] [Google Scholar]
- 4.Singh GK, Hiatt RA. Trends and disparities in socioeconomic and behavioural characteristics, life expectancy, and cause-specific mortality of native-born and foreign-born populations in the United States, 1979–2003. Int J Epidemiol 2006;35:903–919 [DOI] [PubMed] [Google Scholar]
- 5.Ku L, Matani S. Left out: immigrants access to health care and insurance. Health Aff (Millwood) 2001;20:247–256 [DOI] [PubMed] [Google Scholar]
- 6.Lasser KE, Himmelstein DU, Woolhandler S. Access to care, health status, and health disparities in the United States and Canada: results of a cross-national population-based survey. Am J Public Health 2006;96:1300–1307 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Huang ZJ, Yu SM, Ledsky R. Health status and health service access and use among children in US immigration families. Am J Public Health 2006;96:634–640 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Wang C, Burris M, Xiang Y. Chinese village women as visual anthropologists: a participatory approach to reaching policymakers. Soc Sci Med 1996;42:1391–1400 [DOI] [PubMed] [Google Scholar]