Abstract
Social and civic participation are important tenets for both the age-friendly city and active aging frameworks promoted by the World Health Organization. Yet older adults are often under-represented in civic affairs. This study examines the effects of using photo-voice as a method in facilitating older adults’ civic participation. Specifically, an empowerment-based participatory photo-voice training model was implemented among older adults with limited formal education in Hong Kong. We conducted three focus groups comprising 12 older adults and one in-depth interview with a social worker. Findings revealed that photo-voice is an effective tool in capturing older adults’ views that would have otherwise been difficult to articulate in words or in writing, and in enhancing older adults’ ability and willingness to participate in community and civic affairs. These findings underscore the importance of using novel techniques to build a more inclusive society that incorporates the views of older adults.
Introduction
In light of population aging, the contribution of older adults to society has received growing attention worldwide (Van Groenou & Deeg, 2010), with studies showing that active engagement—or participation—is positively linked to favorable psychosocial outcomes and quality of life among older adults (World Health Organization [WHO], 2002, 2007). As important tenets for active aging, distinctions can be made between formal and informal participation. Formal participation refers to “activities in which a person is of service to groups or individuals in the community through their involvement in political and voluntary organizations” while informal participation comprises activities primarily conducted on the individual level for personal development, such as participating in recreational, leisure, and cultural activities (Van Groenou & Deeg, 2010, p. 448). Participation in the former type has been described as a “higher level” of participation, with individuals seeking to influence the community (Aw et al., 2017; Levasseur, Richard, Gauvin, & Raymond, 2010).
In East Asia, older adults tend to be actively engaged in informal activities but less so in terms of formal participation, especially with regard to civic and community affairs (Aw et al., 2017). Some scholars contend that this may be due to cultural differentiations, with informal activities (e.g., grand-parenting) rooted in familial and personal obligations as prescribed by traditional Confucianism typically taking precedence over formal activities (e.g., community volunteering) in East Asian societies (Aw et al., 2017; Ng et al., 2011; Wu et al., 2005). Another possible explanation accounting for the relative passiveness of older adults may be their comparatively low education attainment. In Hong Kong, for example, among the older adult population aged 65 or above, 37.1% received an elementary education only while 23.3% received no formal education at all (Census and Statistics Department, 2018). Older adults with low levels of education attainment (the majority of the older adult population in Hong Kong) may have fewer resources, knowledge, civic awareness, and channels to engage in civic activities (Chan & Cao, 2015; Cheung, Kam, Chan, & Leung, 2001). Yet another conceivable explanation accounting for this passiveness is the legacy left behind by Hong Kong’s unique colonial history, where the British government purposefully suppressed direct participation of local Chinese in political and community affairs or pursued an active de-politicization strategy in fear of upsetting the status quo (Chan, 1988; Scott & Burns, 1984).
Given that formal channels requiring higher levels of cognitive ability and analytical skills may not be suitable for engaging with older adults with relatively low income and education (Chan & Cao, 2015), it is imperative to create alternative channels to ensure that older adults with fewer resources have equal and equitable opportunities to engage in civic and social participation, and to represent and communicate their views to relevant institutions (e.g., government) and the public at large. To this end, this study examined the effects of using photo-voice as an alternative method in facilitating older adults’ civic participation in Hong Kong.
An Empowerment-Based Participatory Photo-Voice Training Model: A Case in Hong Kong
Scholars have described older adults in Hong Kong as being politically disempowered (Kam, 2000; Kam, Cheung, Chan, & Leung, 1999). Representation of older adults is often absent from community or policy (or any public) debates and discussions, even when issues directly concern them. As aforementioned, this may be due to a combination of Hong Kong’s unique socioeconomic circumstances and colonial history, wherein this generation of older adults was primarily preoccupied with survival and making ends meet. Formal participation was, therefore, not the norm.
Yet we maintain that older adults have the potential to “become a social resource of unprecedented proportions” (Harvard School of Public Health & MetLife Foundation, 2004, p. 8) and contribute meaningfully to their communities. Furthermore, given the growing older adult population, failure to properly incorporate their views in community and policymaking processes may adversely affect policy design, planning, delivery, and ultimately, older adult outcomes. To this end, this study employs the photo-voice technique in an attempt to facilitate civic participation among a group of older adults. Photo-voice is a technique that combines photography, interviews, and group discussions (Catalani & Minkler, 2010). Wang and Burris (1997, p. 370) described photo-voice as having three overarching goals: (a) to enable people to record and reflect their community’s strengths and concerns, (b) to promote critical dialogue and knowledge about important issues through large and small group discussion of photographs, and (c) to reach policymakers.
Although not widely practiced, photo-voice has been used among older adult populations to elicit their views on various issues, and in relationship to gerontological research. For example, Adekeye, Kimbrough, obafemi, and Strack (2014) used photo-voice methodology to examine African immigrant older adults’ perceptions on health, and access and barriers to health resources in the United States, while Mahmood et al. (2012) explored how older adults perceive their physical and social environments in relation to their physical activities in North America via photo-voice. Alternatively, Rush, Murphy, and Kozak (2012) used photo-voice to explore how older adults conceptualize risks, while Novek and Menec (2014) examined older adults’ perceptions of age-friendly communities (AFCs) in Canada.
While photo-voice has been used as a technique to elicit the views and opinions of older adults in various domains in both Western and East Asian contexts (Chan, Chan, Chan, Cheung, & Lee, 2016; John & Gunter, 2016; van Hees, Horstman, Jansen, & Ruwaard, 2017), relatively few studies have analyzed the photo-voice participation process itself rather than the actual content of photos. These few exceptions have shown that photo-voice is an effective tool in eliciting older adults’ perceptions and in giving voice to their concerns (Novek, Morris-Oswald, & Menec, 2012; Ronzi, Pope, Orton, & Bruce, 2016; van Hees et al., 2017).
In this study, we aimed to explore how the process of participating in a photo-voice project facilitated participants’ civic participation, and propose an empowerment-based participatory photo-voice training model. Derived from community psychology literature, “empowerment” considers individuals’ strengths and competencies as inherent qualities while problems and poor functioning are the result of inadequate social structures and a lack of resources that impede existing competencies to operate (Zimmerman, 1995). Scholars, thus, argue that to optimize individual strengths, existing structures including the family, neighborhood, and voluntary organizations must be realigned to enable individuals to gain control over decisions that affect their lives (Rappaport, 1981, 1987; Zimmerman, 1995).
Drawing reference to the empowerment literature (Rappaport, 1981, 1987; Zimmerman, 1995), we chose photo-voice as a means to engage older adults because it does not require participants to possess high levels of cognitive or analytical abilities, yet provides participants with an alternative means to express themselves. The photo-voice project was part of a larger citywide initiative that aims to empower older adults and to promote age-friendliness in Hong Kong. Specifically, our research team conducted five photo-voice training sessions with older adult participants at a district elderly community center (DECC), followed by a weeklong exhibition. These training sessions were grounded in the following principles, which were derived from existing literature on empowerment (Rappaport, 1987; Zimmerman, 1995), and from recognizing the need to mitigate social exclusion of older adults (Kam, 2000; Kam et al., 1999). Furthermore, these principles were also a consolidation of key lessons learned from our extensive project implementation experience that involved older adult populations.
Principle 1: Older Adults Are Co-Creators of Well-Being
Our empowerment-based participatory photo-voice training model marks a distinct shift from traditional modes of service provision for older adults, which typically see older adults as service recipients of community-based organizations or social service providers (Cheng, Lum, Lam, & Fung, 2013; Lum, 2012). This worker–client, provider–recipient model, while valid in many cases, is not necessarily effective in empowering older adults living in the community. Instead of conceptualizing these older adults as service users, we see them as co-creators of well-being, as advocates in their own right who are capable of effecting real changes in the community by themselves for themselves.
Principle 2: Older Adults Are Experts in Their Own Lives
Being immersed and embedded in their own communities, we see their knowledge of the local community as a key asset and a resource that can be mobilized to promote age-friendliness. Hence, while we provide participants with skills of photo-voice (e.g., photo-taking), older adults reciprocate by providing us with local knowledge resulting from their daily experiences. Rather than directly providing older adult participants with what we, as researchers, thought was “age-friendly,” older adults were instead asked to provide us with local examples of what they thought was “age-friendly” and what was not.
Principle 3: Older Adults Are to Glean a Sense of Ownership
With the objective of enabling older adults to glean a sense of ownership of the entire photo-voice project, strong emphasis was put on co-creation during the training sessions. Rather than simply assigning a theme for photo-taking to older adult participants, democratic processes such as having older adults vote on an AFC topic most relevant to them were implemented to foster such sense of ownership. It is based on these three principles that we implemented the photo-voice training session. The following gives a brief description of the process.
In the first session, participants were introduced to the concept of AFC as espoused by the WHO, and the photo-voice method, its pros and cons, as well as ethical issues of photo-taking. The second session focused on interpretation skills. Participants were split into several small groups and were asked to identify themes among a series of photos that were taken by fellow participants. Participants were encouraged to share, debate, and discuss potential themes that arose from each photo from different perspectives and angles. The third session equipped participants with classification and presentation skills. Participants were once again divided into small groups and presented with photos. Participants discussed with other group members, then classified photos according to an agreed category developed by themselves. They then presented these categories (or “themes”) to the rest of the class. In the fourth session, participants learned additional ways to present their photos, such as combining different photos into one, fashioning 3D photos, and adding captions to a photo.
In preparation for the final exhibition, a participatory approach was taken in deciding the theme of this. Insofar as it is related to the AFC agenda, participants were asked to first suggest a certain theme as a focal point for the final exhibition. Suggested themes included “transportation,” “outdoor space and buildings,” and “my favorite places or facilities in the district.” At the end, transportation had the highest number of votes. Thus, as take-home assignments, participants were asked to take photos of events, objects, the environment, or anything they felt relevant to transportation in their own district. They were encouraged to ponder the following questions: “What is it you are trying to capture in this photo?” “What are you trying to express?” “What is your personal experience in relation to the thing you took in the photo?” “Why is this photo important or relevant to you?” “Who do you want to see this photo?” “What do you want to see change in the community?” The final session was to consolidate the materials and content from previous sessions and to make final preparations for the public exhibition.
Shortly following the last photo-voice training session, a public exhibition comprising the photos and artwork of participants was held at a local university for a 1-week period. There was also an opening ceremony that local district councilors, students, professors, and social workers were invited to attend. Approximately 150 people attended the event. The exhibition boards were then displayed for a week-long period for the public to peruse. At the time of the research, follow-up actions regarding transportation in the Southern district were being discussed among study participants.
Method
We used purposeful sampling to recruit participants. Older adults who previously took part in the photo-voice training were invited back to participate in the focus groups. Focus group interviews were selected as the appropriate methodology in this study because the research team wanted to leverage group dynamics to generate qualitative data, and to see whether participants derived (dis)similar opinions and feelings from the photo-voice training experience (Kitzinger, 1995). Twelve out of a total of 17 older adult photo-voice training participants returned for focus group interviews. Three focus groups comprising 12 older adults aged 65 or above were conducted at the same DECC, which is located in the Southern district of Hong Kong. During focus groups, participants were asked about their feelings and opinions toward the photo-voice training workshop in relation to their personal lives (e.g., “How did you find the photo-voice project?” “How has the photo-voice training affected your personal lives, if at all?” “What aspects did you like or dislike about the photo-voice process?”), as well as their civic participation (e.g., “How has the photo-voice training affected your participation in the community, if at all?”). In addition, we also conducted one in-depth interview with the social worker who was part of the photo-voice project. Table 1 presents the demographic details of study participants. As illustrated in Table 1, the majority of participants received limited formal education, and lived in public rental housing. All interviews were conducted in Cantonese, audio-taped, and transcribed verbatim.
Demographic Details of Study Participants.
Data Analysis
Transcripts were analyzed using thematic analysis (Braun & Clarke, 2006), which consisted of several analytical steps. First, we familiarized ourselves with the data by reading the transcripts repeatedly. We then generated an initial list of codes that were relevant to our research question. Quotes relevant to participants’ feelings and opinions toward the photo-voice participation process, and toward their civic engagement in the community were highlighted. This was followed by a categorization of the initial codes into themes. These themes were subsequently reviewed and refined. To ensure data reliability, two researchers coded the transcripts independently. Where there were discrepancies pertinent to the coding and the interpretation of themes, the research team met and discussed critically until consensus was reached. The emergent themes are presented in the following.
Results
Supported by illustrative quotes, six key themes relating to the photo-voice process emerged from our analysis. These themes reflect the outcomes gleaned from participating in the photo-voice process, as identified by study participants.
Photo-Voice as an Effective Means of Conveying Older Adults’ Views
Participants shared that photo-voice was an easy way to express their opinions that would have otherwise been difficult to articulate in words or in writing. Having an actual photo that older adults can use as visual presentation enables them to better express their ideas, for instance, by pointing directly at a certain aspect of a photo to illustrate his or her concern.
Sometimes when you talk to people, you may not be able to communicate effectively . . . but when you have a photo, it’s easier for me to express my thoughts . . . with a photo we can at least convey the main message across . . . so there’s a chance for people to understand. (Focus Group 1) Because [us] older adults in the Southern district . . . our education level is very poor . . . really very poor. Some people have never received any education, but now, everyone has a cellular phone that they can take photos with . . . so we tell them, if you see something inconvenient, or that you don’t like, you can take a photo of it . . . and follow up with some action. (Focus Group 2) It’s not like older adults don’t have anything to say or are unwilling to express their opinions . . . it’s just that the way they are able to communicate effectively may be limited . . . Photo-voice is an easy way for older adults to express [themselves] or to document the changes in the community . . . if you ask them to document these things in writing . . . then maybe, since most older adults have a low education level, they may not be able to articulate what they actually want to express. (Social worker)
Photo-Voice Broadens Older Adults’ Perspectives and Promotes Inclusion
Participants expressed that they were able to acquire new perspectives through sharing and discussing photos with fellow participants. Participants found these discussion sessions to be engaging, stimulating, and beneficial. They also seemed to have allowed participants to be more inclusive of others.
I like how . . . there are many angles [looking at a photo] . . . Some participants were able to provide me with more ideas building on the point I expressed [about the photo]. (Focus Group 2) There are many different angles and perspectives [through which] you can look at a photo. It fosters our thinking and imagination. I think each person sees the same photo differently. (Focus Group 3) “[The photo-voice training] was rewarding to me in many ways . . . for example, I don’t think I’ll remain so stubborn during arguments [from now on] . . . I learnt from the class that others’ point of view could be right, and mine could be wrong. We could learn from each other by sharing our thoughts . . . I learned to be more inclusive of others. So maybe if . . . I accept [their opinions] when they are right, they will also be more open to accepting my opinion as well. (Focus Group 1)
Photo-Voice Enables Knowledge Acquisition and Dissemination
Because participants were tasked to take photos of their communities relevant to transportation, some reported a heightened sense of awareness of their district. In this light, using photo-voice can be an effective way to enhance older adults’ knowledge in a particular substantive area, be that transportation or other topics. Participants also reported that photo-voice was a good method to disseminate the concept of age-friendliness in the district.
[I] became more concerned about our society . . . I mean us, the Southern district . . . the photo-voice process enables us to pay closer attention to transportation . . . or, say, the [transport] facilities. Unlike the past where we would just look past something then forget about it . . . . (Focus Group 3) [I] know more now . . . We gained a lot of knowledge through photo-taking. We had no idea [or weren’t aware] of some of these [facilities] from the past. (Focus Group 1) At least, with your help [hosting the public exhibition], our message got out. Whether or not people agree with us, at least more people will know about this topic first. (Focus Group 1) [Because the exhibition was held at a university], the fact that older adults get to share their photos with university students or professors . . . to older adults this is something novel . . . like they can share their work and voice out their concerns to an entirely new group of people. (Social worker)
Photo-Voice Enhances Older Adults’ Civic Awareness and Participation
Participants regarded photo-voice as not merely a tool for expressing their views, but an actionable means to advocate for community change. An enhanced sense of civic awareness and willingness to participate in civic affairs were also observed among participants. This is particularly poignant as older adults have been traditionally cast aside from formal community and civic participation. Hence, using photo-voice can promote a more equitable and socially inclusive society where the views of older adults can be properly represented.
[The photos] allow the [community] to understand the needs of older adults . . . and what we lack. If you don’t voice your concerns, they may never know. (Focus Group 1) At least they [the community/related parties] can hear our voice, so that something could change for us like the Queen Mary Hospital . . . it’s like a catalyst for change. (Focus Group 2) We gained more knowledge after the class, so we will be more concerned with public affairs from now on . . . . (Focus Group 3) You see, the fastest way [to effect change] is to complain to a district councilor. [Photo-voice] is the second fastest I think. Displaying our work in public is an additional platform to voice our concerns, which is more informative . . . now the district councilor has to follow up with actual actions . . . . (Focus Group 3) I think the class was helpful . . . even [after the project], [the older adult participants] still send us photos related to our community and facilities to our chat group. Some took photos of things we had advocated for in the past, or things that still needed improvement. (Social worker)
Photo-Voice Fosters a Sense of Confidence and Empowerment Among Older Adults
Participants expressed a sense of accomplishment and pride when describing their experience in seeing their work displayed in public where relevant community stakeholders, including professors, students, district councilors, social workers, and the general public, were invited to examine their works. To this end, it can be observed that using the photo-voice method empowered older adults.
[I feel] a sense of accomplishment . . . like I have produced a piece of art . . . [and that] I can actually achieve such good results. And plus [we] can really convey some of our views through the photos, [which made me feel] happy and confident. (Focus Group 3) I feel very happy. At least there are others who will be able to view our work . . . In the past, even if we wanted to say something, we did not have the channel or platform to do so, but now, there’s a clear way to do so . . . a place where you can really display your work and let others understand older adults’ needs. (Focus Group 1) “[I feel] quite happy looking at my own work displayed for the public . . . yes, I feel happy when people can see my work. Of course I also hope that after seeing our work, people would participate in [similar activities] more often . . . . (Focus Group 1)
Photo-Voice Fosters Intergenerational Relationships
One unintended outcome resulting from this photo-voice project was how it enabled some participants to better communicate with younger generations. Some participants indicated that they had increased discussion with their grandchildren while others also reported that their children were proud of their engagement with the community.
Photo-voice is not only a useful tool to voice out our needs. When we showed the photos to my granddaughter, she would ask what each photo meant. This fostered our communication and reduced our generation gap . . . photos can bring us closer. (Focus Group 1) Our primary school or secondary school students may have different concerns regarding our community. Therefore, we could understand more about each other’s needs and concerns by photo-voice. For example, maybe we are more concerned about public transport but they mainly focus on playground or recreational facilities . . . . (Focus Group 3) I want our next generation to understand more about the needs of older people . . . [and] allow them to understand what, and how much, older people need. (Focus Group 1)
Discussion and Implications
In this study, we used an empowerment-based participatory photo-voice training model underpinned by the three principles: that older adults are co-creators of well-being, that older adults are experts in their own lives, and that the photo-voice training process should enable older adults to glean a sense of ownership. To this end, we explored how photo-voice can be used as a method to foster civic (formal) participation among low-income older adults in Hong Kong. Several insights can be drawn from our findings.
That older adults can continue contributing meaningfully to their community via more formal participation (e.g., civic engagement) is an important tenet for active aging, with studies showing that maintaining continuous social and civic participation is conducive to older adults’ quality of life and well-being (Adams, Leibbrandt, & Moon, 2011; Ang, 2018). Scholars have also identified a range of benefits generated through the photo-voice method (Novek et al., 2012; Ronzi et al., 2016; van Hees et al., 2017). Consistent with these studies, our study found that the photo-voice process generated multiple benefits for older adult participants. First, our findings show that photo-voice appears to be an effective method to elicit older adults’ views that could have otherwise been difficult to articulate in written or spoken words. Second, we found that photo-voice is a useful method enabling older adults to gain knowledge in a particular substantive area, be it concepts of age-friendliness or otherwise. Third, we found that by participating in the photo-voice project, participants were able to gain a heightened sense of civic awareness, especially when their works were displayed publicly and relevant government representatives were present as audiences. In this light, the presence of community stakeholders in the public exhibition lends validity to their works. Last, the skills gleaned from the photo-voice training process (e.g., photo-taking) also appeared to have facilitated positive intergenerational relationships.
Interestingly, unlike previous studies that highlight the tendency of older adults in East Asia to remain passive due to a variety of historical, cultural, and socioeconomic circumstances, at least in terms of formal participation (Aw et al., 2017; Kam, 2000), we found that older adult participants in fact had many views to express and, when given the appropriate tool and platform, were willing to participate in formal community affairs. This is consistent with the empowerment literature that argues that poor functioning is the result of inadequate social structures rather than individual-based deficiencies or shortcomings (Zimmerman, 1995). In this study, it was found that photo-voice was an effective tool to help operationalize existing competencies or knowledge among older adults.
Furthermore, while some studies have identified challenges pertaining to the photo-voice method, including recruitment, photography training, retrieving consent forms, and issues of time and distance (Novek et al., 2012), we did not find similar challenges in our project. Two reasons may account for this. First, we contend that the participatory and democratic features (e.g., voting for a particular community topic that older adult themselves found important) of the photo-voice training model allowed participants to feel a sense of ownership, control, and decision-making power in shaping the photo-voice project. Unlike existing service programs that are primarily designed and implemented by professionals (e.g., social workers), and that treat older adults simply as participants or service recipients, the photo-voice training model conceived older adults as co-designers. This may be an important factor in attracting and retaining older adults.
Second, it is probable that the relative ease of conducting the entire training process was due to our collaboration with a district-based elderly center that had a long presence in the local district. As a trustworthy beacon in the community, recruiting older adults and gaining traction and trust with participants were not problematic. As advocated by scholars elsewhere (Jordan, Chui, Larmar, & O’Leary, 2018), social work, together with academic and field research collaboration, have significant potential to foster tangible changes in the community.
Last, while photo-voice appears to be a useful and empowering tool in communicating older adults’ views to the wider community, it is equally important for the government to institutionalize formal channels for older adults to express their views. Photo-voice remains a bottom–up approach, the implementation of which is often constrained by limited resources typically found within voluntary or community-based organizations (Lam & Perry, 2000; Lee, 2012; Salamon, 1987). Hence, both formal (top–down) and informal (bottom–up) channels that enable older adults to participate meaningfully in formal community and civic affairs are imperative.
Our findings are relevant to other developing contexts where older adults have lower education levels and resources to engage in community and civic affairs and processes (Henriquez-Camacho, Losa, Miranda, & Cheyne, 2014). Using novel models such as photo-voice can provide older adults with equal opportunities to participate in formal civic activities and to ensure that their views are properly represented and articulated in the community. Doing so aligns with both the active aging and AFC frameworks espoused by the WHO (2002, 2007).
To conclude, this study demonstrated that an empowerment-based participatory photo-voice training model was able to foster a heightened sense of civic awareness and participation among low-income older adults. We advocate for a departure from the traditional conception of later life as one that is characterized by dependency and passivity to one that promotes active engagement and continuous contribution to society.
Limitations
Our findings should be interpreted in light of several limitations. First, although we gained an in-depth understanding of how these 12 participants viewed photo-voice, our findings may not be directly transferable to other older adults, especially those who may be at increased risk of different types of vulnerabilities, including older adults with a disability and ethnic minority older adults, among others. Whether or not similar benefits can be gleaned among older adults with different characteristics remains unexplored. Second, because participation in this photo-voice project was entirely voluntary, older adults who are willing to participate may already have been the more “active” group, thus creating a self-selection effect. Future studies may consider engaging older adults who have less involvement in community or social activities. Nevertheless, seeing that this group of older adults was still able to generate positive effects from the process, it is arguable that those who are more passive to begin with may benefit even more from the process. However, this conjecture warrants further research.
Footnotes
Authors’ Note
This study was approved by the Human Research Ethics Committee (HREC) of the University of Hong Kong (HREC EA1711034).
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by the Hong Kong Jockey Club Charities Trust.
