Improving Access to Care for Immigrant Children

Developing Community Consultation: A PhotoVoice Project

Introduction to Project Proposal

This paper presents a proposal for community consultation, which is expected to bring forward the necessary policy advocacy for an improved access to health care for immigrant children in the United States. The paper consists of several parts. The first part conceptualizes the issue of an access to health care for resident immigrants, summarizes the problematic areas of current policy, and outlines a plausible option for a new policy on care access for underprivileged children. The second part focuses on methodology for community consultations. Here, the paper reviews the literature of PhotoVoice as a proposed method of community consultation. There is an explanation why this method should be applied to consultations regarding care access. Two successful PhotoVoice projects are discussed. The third part of the paper is about the process of community consultation, i.e. the stages of PhotoVoice project.

The community consultation proposal incorporates theoretical and conceptual frameworks from the reviewed literature. The initial objective of the PhotoVoice project is to gather the evidence on the need for policy changes, provide project participants with an awareness of health-related issues, and prepare public organizations to advocate for an improved policy on immigrant children’s access to care [in the hypothetical communities in rural and urban Florida]. The PhotoVoice process adopted for this project follows Wang, Yi, Tao, and Carovano (1998).

Care Access for Immigrant Children in the State of Florida

Conceptualizing the Problem

The problem of care access for new immigrant populations is most often associated with the absence of health insurance, particularly, Medicaid. In the United States, health care is costly, and many new residents are unprepared to deal with the challenges that health care brings. The issue mostly affects the residents of the Southern states, such as Florida, with low rates of insurance and the lack of healthcare access (Ku, 2006).
Care access is exacerbated by other issues, such as language and cultural barriers (Ku, 2006). For example, if immigrants do not speak English, it reduces their ability to receive good medical care. According to the report by Georgetown University’s Health Policy Institute, a disproportionally high number of Hispanic and Asian children who are new immigrants to the United States did not have health insurance: 9.7% of Hispanic and 5.5% of Asian children (Alker & Chester, 2015, p. 5). The total number of children without health insurance in Florida was 377,987 in 2012 (Alker & Chester, 2015, 2015, p. 8), making Florida the third state with the highest number of uninsured children, after California and Texas.

Rationale for the New Methodology for Policy Advocacy

There is no doubt that improving health care access is important. Moreover, having a health insurance results in a better access to care, ensures healthy childhood, and leads to better prospects of education of the affected children (Alker & Chester, 2015, p. 1). The changes in care follow the modifications to policies on immigration and health care, which are partially based on the undertaken studies. In 2014, American Community Survey (ACS) was utilized as the main method to connect surveying with the improved coverage rate (Alker & Chester, 2015, p. 1). The survey was conducted in all the states and resulted in formulating the profile of immigrant children who need access to better care. It also compared the previous rates of insurance coverage with the more recent rates, formulating how the issue developed overtime (Alker & Chester, 2015, p 1). Yet, this data is insufficient for an effective policy advocacy that will deliver all of the necessary improvements.

This project argues for the serious need to improve the methodology and add more interactive methodologies in order to explore the problem of care in more depth. Per Healthy People project by the U.S. government, there are several variables that must be considered when providing care and care access to people. Mainly, the insurance coverage is considered as important as the quality of services, timeliness, and availability of care providers (“Access to Health Services,” n.d.).

Healthy People project also calls for quality healthcare for everyone. This necessitates addressing the differences in care access and determining the real issues that constitute barriers to care. Some barriers mentioned on the project’s website are the availability of care, the cost of care, access to health care system and health services (“Access to Health Services,” n.d.).

For the children who are new immigrants to the United States, possible issues could be their ability to communicate with care provider, build trust, address unmet health needs, receive care in a timely manner, receive preventive care, and prevent hospitalization. In other words, ensuring that care access issues are addressed would propel an increase in the provision of proper health care to immigrant children. This, in turn, would guarantee the prevention of diseases and that diseases are noticed at an early stage when they are still treatable (“Access to Health Services,” n.d.). Therefore, there is a need for new ways and methods to interact with the target group of immigrant children in order to collect quality data on the state of health care in the communities where they live. This kind of data will be useful to support a new policy, which is cognizant of current care access disparities.

New Policy on Care Access for Immigrant Children

While the policy on care access for immigrant children could remain as it is, this will result in no immediate improvements for the affected children. There is also an option to extend Medicaid coverage to this population group. The status quo of the policy means that the newly legalized and resident immigrants must wait for several years before enrolling in a health insurance plan. In addition, care access should be improved to ensure that care is timely and culturally relevant, i.e. that the children in need of care can find a health specialist without delays and be able to communicate with them with help of an interpreter.

Before an expected policy change, advocates for the new policy need to have the capacity to determine to which extent the secondary issues, such as language barriers are important for the immigrant children. The data generated as a part of a research project can identify such areas of concern and be used for convincing the policy makers (Lorenx & Kolb, 2009). The degree of urgency (as expressed during the proposed community consultations) can be the basis for the policy advocacy. Therefore, this project is directly linked to the recommendation for a new policy.

PhotoVoice as the Method of Community Consultation

Literature Review on PhotoVoice

The creative methods, such as PhotoVoice have numerous advantages. First, they are useful for improving the understanding of values that are prevalent in the community, where research subjects live. Second, these methods really engage participants in issues of their community. Last, they improve the involvement of stakeholders who are capable of implementing policy advocacy and changes (American Planning Association, n.d.).

As discussed in a published book on health research by Oliffe and Greaves (2016), PhotoVoice was invented by Caroline Wang and her colleagues with the purpose of collaborating with women from marginal communities in China. This method often complements other research methodologies, such as ethnographic studies. It is helpful for emphasizing the point of view of the communities under study instead of the view of social workers and researchers. This method consists in applying photos, videos and other visual information towards explaining the challenges and opportunities in the researched communities, and its outcome can be policy advocacy or a community event. PhotoVoice can be useful for studying about intimate aspects of an illness, because it lets the patient be comfortable when talking about the things that are not usually discussed with care providers (Oliffe & Greaves, 2016).

Taking a more narrow view on the kinds of patients who would benefit from PhotoVoice, Lorenz and Kolb (2009) argue that the public should be more involved in the research of participatory nature. The authors say that this visual research method provides the ground for involving the most vulnerable constituents, such as persons with disabilities and people with a low social and economic status (Lorenz & Kolb, 2009, p. 262). According to Moxley, Bishop, and Miler-Cribbs (2017), PhotoVoice is a recognized method of social work that utilizes visual materials like cameras and the narrative techniques for participation in research discussions. It is considered to be advantageous for empowering communities and recognizing the factors that influence these communities. With the help of PhotoVoice, social workers can collaborate with underprivileged people (Moxley et al., 2017).

Catalani and Minkler (2010) maintain that PhotoVoice should take place in the context of interactions with health care providers and individuals, since it results in better partnerships between them (p. 439). The authors point out that target communities normally do not take part in the initial project’s stages (p. 440), yet their commitment to participation is essential for the success of training, documenting the problematic aspects of life in the community, and discussing the photos individually or in a group (p. 440).

Wang and Buris (1994) suggest that this method can also be termed a photo novella, as it paints a detailed picture of researched populations, such as children and women who live in rural areas. They consider that PhotoVoice promotes Paulo Freire’s concept of “education for critical consciousness”, as people preserve and discuss their own lives according to own terms, when subjected to this method (Wang & Buris, 1994, p. 171). PhotoVoice derives its origins from the feminist theory and participatory methodology, therefore Wang’s research was critical for the experience of rural Chinese women who participated in her research (Wang & Buris, 1994).

Wallerstein and Bernstein (1988) argue that health behaviors need to be changed by improving individuals’ beliefs, so that they start to change their own lives (p. 379). This will help to address the powerlessness associated with disease, and more empowerment should deliver more health. However, the degree of empowerment may depend on the mode of participation. If individuals collaborate and consult social workers, then they are more empowered since they can initiate and enhance research by providing opinions before policy interventions (Wang et al., 1998, p. 76). On the one hand, unless project participants are placed as first and equal in the research, the research outcomes would privilege the researcher’s point of view. An empowered participation, on the other hand, will lead to better self-esteem, status, and connections to social workers (Wang et al., 1998). With the less participatory stance, there is also less awareness of community needs, assets, and urgency for changes (Wang et al., 1998, p. 75).

Ruby (1992) stated that the quality of research depends on whether the researcher asks correct questions, which reflect the interests of the researched individuals instead of the researcher’s concerns (p. 42). In other words, consultative research needs to address the interests that are embedded within the culture and the context of studied groups (Ruby, 1992). A more recent study by Castleden and Garvin (2008) finds that creative content, like photos, is useful for recruiting participants in the First Nation communities in view of its capacity to equalize power relations, foster the sense of owning the product of research, and address the preferences of indigenous people (Castleden & Garvin, 2008).

Cave (2016) emphasized that the right messengers must be selected for policy advocacy, who are representative of the populations and, therefore, can be considered as credible sources (p. 166). During research, the utilized visual materials are not limited to photos and can include postcards and flyers, which are beneficial for winning votes on new policy initiatives, as well as encouraging new members and supporters (Cave, 2016).

Project Lives in NYC and Caregiving Children’s Strategies in Kenya: The Best Practices of PhotoVoice
As discussed by Skovdal (2011), for the project on strategies of caregiving children in the Bodo district in Western Kenya, 48 children who were providers of care were selected, aged from 12 to 17 (p. 452). The researchers gave them disposable cameras and asked to document everything that was a part of caregiving. The objective of the project was to first, explore, and, second, to improve the coping strategies of children. Children took pictures of things like hens in the backyard and salad leaves growing on a small farm. The lessons learned from the project was that it was possible to enlist children in the project. Moreover, children took an active part in this collaboration, and they could become the beneficiaries of care improvements since the participating children were supplied with resources that helped them to become better caregivers (Skovdal, 2011).

Another successful case study is Project Lives, a collaboration of community organizations with the residents of underprivileged communities in New York City. According to Anzilotti (2016), 200 residents from various development districts in Brooklyn and Bronx were supplied with single-use cameras to take photos of their housing environments. Due to the resultant photo content, the researchers discovered the real issues with public housing: water leaks, chipped paint, and slow elevators (Anzilotti, 2016). Because of the new focus on involving the target community in research, the project’s findings pinpointed the areas where government support was lacking. Unlike in the case of caregiving children in Kenya, the residents of poor housing districts did not directly benefit from the project. Yet, they received the much-needed public attention to their home conditions—preparing the ground for a new policy on improved public housing.

Proposal for PhotoVoice Project and the Process of Community Consultations

The proposed PhotoVoice Project will be implemented in one urban and one rural location [in a hypothetical community] in Florida. The project’s participants will be selected from a group of 100 children, who are permanent residents and recent immigrants to the U.S. The project is envisaged as including the following stages:
Defining the problem: Participants will contribute to initial stages of the project development, when the problem will be re-defined from the point of view of the affected children. This means that the children will voice the most disturbing aspects of access to care. For example, having a coverage may be as important as communications with care provider. In this case, the provision of health insurance will not be the problem; instead, it will be the language barrier and developing trust.

Setting objectives and goals: The objectives of the project will be determined together with the participating children. They may wish to be empowered via information about health care, or to improve their life quality by addressing the need to be healthy in order to go to school, the need to prevent disease, or to receive quality care, access to care where they live.

Among possible goals can be the ability to converse with care provider in languages other than English in order to be heard and understood.


Project participants will be taught to take photos with their cell-phones, to be able to photograph the scenes, people, and objects that are related to health and wellbeing. Ethical issues of taking photos will be discussed in detail.

Determining key themes:

The participants will devise key themes that connect the goals and objectives of research, in cooperation with social workers who administer the research project. Some initial themes for photos can be based on previous photos and documentation of healthcare for immigrant communities (see Attachment A), i.e. the visits to local care facilities, such as public hospital and private care centers, home-based health care, healthy lifestyle, and communicating about health.

Taking pictures:

The participating children will be given a timeframe of three weeks to take photos. After three weeks, they will save the photos they took on a laptop and select ten favorite photos, for which they will write brief captions.

Selecting important themes that emerge from photos and captions: A series of discussions will take place, where children will address the themes depicted in photos. The themes that matter most to children will be written down and broken into several categories, such as “cultural aspects of healthcare” and “linguistic aspects of healthcare”. Children will be encouraged to be critical about the themes and suggest better ways to resolve them. This way they will develop their knowledge and understanding about the health-related subjects.

Conducting evaluations:

The project will be concluded with the formative and participatory outcome evaluations. Participants will discuss how PhotoVoice helped them to address the access to care and health-related issues in their communities. The researches will develop the recommendations for policy advocacy, based on findings of the community consultations.

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