J Community Health (2013) 38:463470 DOI 10.

1007/s10900-012-9630-4

ORIGINAL PAPER

The Impact of Student-Directed Videos on Community Asthma Knowledge

Ruchi S. Gupta Claudia H. Lau Christopher M. Warren Alexandra Lelchuk Amber Alencar Elizabeth E. Springston Jane L. Holl

Published online: 25 November 2012 Springer Science+Business Media New York 2012

Abstract The Student Asthma Research Team (START) program was designed to enable students to explore socioecological factors contributing to asthma through the use of Photovoice, a technique that gathers both photographs and personal experiences from participants. The photographs taken by and commentary from student participants were integrated into public service announcements (PSAs) intended to increase community asthma awareness and catalyze behavior change. This article evaluates the effectiveness of these student-directed PSAs at improving asthma awareness among peers and community members. Pre-PSA, immediate post-PSA, and 4 month post-PSA follow-up assessments were conducted to evaluate changes in community members asthma knowledge and behavior. The student-directed PSAs were found to signicantly increase asthma knowledge among community members, irrespective of age, gender, or

race. Increased knowledge persisted through the 4-month post-PSA follow-up. Of the thirty-six participants who were successfully contacted for the follow-up survey, nearly 40 % reported meaningful behavior-change in response to the PSAs. Photovoice and media production techniques were effective in engaging adolescent studentsan under-served and often disenfranchised populationin asthma health education through the development and dissemination of PSAs. The extension of participatory techniques such as Photovoice to include the creation of student-directed PSAs holds promise for engaging adolescents in public health initiatives within their communities. Keywords Asthma Adolescents Photovoice Public service announcements

Introduction/Background
Electronic supplementary material The online version of this article (doi:10.1007/s10900-012-9630-4) contains supplementary material, which is available to authorized users.
R. S. Gupta (&) C. H. Lau Ann & Robert H. Lurie Childrens Hospital of Chicago, 225 E. Chicago Ave., Box 157, Chicago, IL 60611, USA e-mail: RUgupta@childrensmemorial.org; rugupta@luriechildrens.org R. S. Gupta C. M. Warren A. Alencar E. E. Springston J. L. Holl Northwestern University Feinberg School of Medicine, Chicago, IL, USA A. Lelchuk University of Illinois Chicagos School of Public Health, Chicago, IL, USA A. Alencar West Suburban Medical Center, Oak Park, IL, USA

Asthma is one of the most common chronic conditions among youth in the United States, affecting over 9 % of those under the age of 18 [1]. Prevalence rates stand at an all-time high for the general population, with the highest prevalence among those in the 1117 age group [2]. Asthma outcomes are particularly poor among this population, with exacerbations more frequent [2] and severe [3] among adolescents compared to younger children. Alarmingly, asthma mortality rates among adolescents have been reported to be twice the rate observed among younger children over the past two decades [2, 4]. Among minority youth in urban areas, asthma prevalence rates and morbidity remain alarmingly high [5] despite continued medical advances. However, the burden of asthma in urban areas varies signicantly by neighborhood [6]. Prevalence rates have been found to range from 2 % in some

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urban neighborhoods to 44 % in others [6]. In addition to well-known environmental triggers, such as exposure to tobacco smoke, indoor allergens and ambient pollutants [7, 8], many socio-environmental theories have been proposed to explain the disproportionate burden of asthma among urban youth. Financial burden [9], limited access to care [10], exposure to community violence [11, 12] and stress [13], and social capital [14] have been associated with differences in asthma outcomes by neighborhood. Adolescence represents a unique developmental period in which the transition from dependent child to independent adult can markedly impact the management of chronic disease [15]. Among urban adolescents, this transition to disease self-management has been found to be suboptimal [16]. In Chicago, asthma self-management is remarkably poor, with only 20 % of youth in predominantly Black and Latino communities demonstrating optimal medication adherence [17]. Effective asthma interventions among youth must address the unique developmental needs of this population while acknowledging the socio-ecological framework of individual, home, school, and community contributing to outcomes [18]. Asthma morbidity among adolescents has been shown to be largely preventable given appropriate disease selfmanagement initiatives [19], with peer-led programs found to be both feasible and particularly effective [20, 21]. Nevertheless, insufcient effort has been directed toward developing and evaluating asthma self-management programs designed specically for adolescents. Although home-based interventions have been shown to be effective in reducing asthma morbidity, they are generally expensive [22]. Other signicant barriers impeding their wide-scale adoption include: frequent refusal of home visits by low SES families [23, 24], transient residence [24, 25] and poor compliance with recommendations [26, 27]. Given these constraints, the school environment seems to offer a uniquely rich and accessible alternative for interventions that targets urban, low-income adolescents [28, 29]. The Student Asthma Research Team (START) program was designed to enable students to explore socio-ecological factors contributing to asthma through the use of Photovoice techniques. Photovoice is a community-based participatory research (CBPR) technique that encourages participants to take photographs and share personal experiences related to a selected topic. This approach has been found to be particularly suitable for engaging and mobilizing youth in shaping healthy school environments [30] and promoting community health efforts [30, 31]. A growing CBPR literature asserts that engaging community members directly as research partners often results in data that is more congruent to their lived experiences, rendering the resulting community interventions more likely to

achieve their designated impact [32]. Student participants in START evaluated individual, home, school, and community-level factors inuencing effective asthma management through photography and group dialogue. Photographs and commentary by the student participants then became the foundation for the development of public service announcements (PSAs) intended to increase community asthma awareness and catalyze behavior change per student ndings and recommendations. We present an evaluation of the effectiveness of these student-directed PSAs at improving asthma awareness and catalyzing behavior change among peers and community members.

Methods START was piloted as an afterschool program during the 2010/2011 school year in an urban, Chicago high school known to have high asthma rates and asthma morbidity. The program was approved by the Northwestern University Institutional Review Board and the Research Review Board of the Chicago Public Schools. Written consent to participate was obtained from primary caregivers as well as written assent from participating students. Participants Phase I (Photovoice) Students with asthma in grades eight through twelve were eligible to participate. Students were recruited by yers posted at school, an information table set up at the schools annual extra-curricular activities fair, and referral from the director of the student health clinic. Participating students met afterschool, twice a week, for 2 hours over 10 weeks, received a digital camera to complete photography assignments and were coached about the importance of their written journal entries, which focused on their community, asthma, and health. Students were given a gift-card honorarium equivalent to $5 for each session attended. Phase II (Public Service Announcements) Peers and community members were recruited at local clinics (the school-based health center afliated with our partner high school and a nearby primary care clinic) and afterschool clubs (a health club in a neighboring high school and a local afterschool youth program). Individuals who agreed to participate were shown the student-produced PSAs on a portable DVD player and were asked to complete pre-/post-assessments. Ninth-grade students at the school were also shown the PSAs during health class

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and individually recruited to complete the pre-/postassessments. Program Design START combined instruction in Photovoice methods with educational sessions addressing asthma self-management. Program goals were two-fold: (1) enable participants to identify and address multi-level factors affecting asthma self-management, and (2) improve community asthma awareness through the production, dissemination and evaluation of two student-directed PSAs. Phase I (Photovoice) Two initial sessions were designed to introduce student participants to program goals and fundamentals of ethnographic research. In subsequent sessions, student participants were given basic training from a photography instructor as well as daily photography and journaling assignments. Over the remaining weeks, student participants framed their day-to-day lives through journal entries and photographs in order to identify and discuss answers to the following research questions: (1) What is your community? (2) What things in your community affect your health? (3) What things in your community hurt or help your asthma? (4) What are the most signicant barriers to your asthma management? (5) How can you improve or control your asthma? Additionally, ve of the twenty sessions included asthma education components led by pediatricians and medical students. For further detail on program development and design, see Gupta et al. [33]. Phase II (Public Service Announcements) In the second phase of the program, photography and videography experts worked with student participants to incorporate student photographs and storyboard concepts into two PSAs via a 4-week iterative, student-directed process This process began with students brainstorming potential narrative structures for each video, lling in blank boxes, which constituted a timeline for each PSA, with their pictures and commentary. Each week the videographer would synthesize students footage and storyboard suggestions into a pair of draft PSAs and bring them back to the students in the following week for renement until students were satised. Each nal PSA, described below and available at http://youtu.be/bEp2fakobtM and http:// youtu.be/yyCQRUG2Zfk, focused on a single question What is asthma? and What can my community do to help kids with asthma? Students showcased the PSAs to peers and community members at a school-wide premiere.

Public Service Announcements PSA 1, What is Asthma? (1:07 min) The PSA starts with the question Did you know? followed by three asthma statistics, a denition of asthma, three consequences of asthma, and an example of how to control asthma. Cartoon animations and student faces ll the screen, accompanied by student commentary. The PSA ends with students emphasizing their ability to do anything anyone else can if I take care of my asthma and provides a resource for viewers desiring more information. PSA 2, What can my Community do to Help Kids with Asthma? (1:28 min) The PSA depicts a female, African-American high school student in black and white standing in front of a collection of photographs with slow music playing. One-by-one she drops photographs depicting six community asthma triggers onto a table. The music becomes upbeat, the images turn to color, and the student now drops photos that depict four community asthma aids. The PSA ends encouraging viewers to become active in reducing community asthma triggers and again provides a resource for viewers desiring more information. Outcome Measures Phase I (Photovoice) Phase I outcomes are reported in Gupta et al. [33]. Phase II (Public Service Announcements) Pre-PSA, immediate post-PSA, and 4-month post-PSA follow-up assessments were conducted to evaluate changes in community members asthma knowledge immediately before and after as well as 14 months after viewing the PSAs. Assessments evaluated participant knowledge of the denition of asthma, statistics presented in the PSAs, and asthma-related morbidity, as well as community aids and triggers. Demographic characteristics and data on prior experiences with asthma were also collected. In addition, self-reported changes in awareness and behavior were documented during the 14 month follow-up telephone survey. Statistical Analysis Relative frequencies of correct responses for the pre-PSA, immediate post-PSA, and 4-month post-PSA follow-up assessments were calculated. T-tests were performed to

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determine if knowledge increased signicantly after reviewing the PSAs. Multiple regression models were estimated to examine association of demographic characteristics with overall change in knowledge. Separate models were also estimated to examine the association of demographic characteristics with change in asthma knowledge in ve domains (denition, statistics, morbidity, community aids, and community triggers). For these analyses, knowledge was dichotomized into correct or incorrect. Models were adjusted for race, gender, and age. All statistical analyses were performed using Stata/SE 11.0 (Stata Corp LP, College Station, TX, USA) with a Type I error of P \ .05.

average score of 34.8 % correct pre-PSA compared to 53.1 % immediately post-PSA (P \ .001). Signicance remained after adjusting for age, gender, race, and prior experience with asthma (Supplementary e-table 1). Asthma knowledge was also evaluated with regards to the ve PSA domains (denition, statistics, morbidity, community aids, and community triggers). Itemized scores are presented in Table 2. Scores increased across each domain immediately after viewing the PSAs irrespective of age, gender or race, though not all domains reached signicance. The increase trended towards signicance in the domains of asthma morbidity (P = .071), community aids (P = .078), and community triggers (P = .070), and was signicant in the domains of asthma denition (P \ .05) and statistics (P \ .001). Follow-up Assessments

Results Participant Characteristics A total of 228 community members viewed the PSAs and participated in the knowledge assessments. Thirty-nine percent of participants (n = 89) either had asthma or lived with someone with asthma. Demographic characteristics are presented in Table 1 by report of prior experience with asthma. The majority of participants were Black (51.3 %), female (74.1 %), and aged 1115 years (32.0 %). Immediate pre-/post-PSA Assessments Participants answered signicantly more knowledge items correctly immediately after viewing the PSAs with an
Table 1 Demographic characteristics of surveyed community members

Multiple attempts were made to follow-up with all participants who completed the immediate pre-/post-assessments and who had provided telephone numbers for the follow-up interview (n = 131). Thirty-six participants (27.5 %) were successfully contacted 14 months after viewing the PSAs. Eleven telephone numbers were disconnected, twenty-four phone numbers had been reassigned, and there were no responses from the remaining sixty participants after multiple attempts to reach them at different times of the day. Participants answered an average of 44.9 % of items correctly at follow-up, representing an increase from pre-PSA assessment (10.1 % points higher) but a decrease from immediate post-PSA assessment (8.2 % points lower).

Variable

Participants % (n) All participants (n = 228) Participants with asthma (n = 49) Participants with household members with asthma (n = 71)

Race/ethnicity Asian Black Hispanic White Multiple/other Gender Female Male Age, year 1115 1620 2130 3145 [45 74.1 (169) 25.9 (59) 32.0 (73) 26.3 (60) 15.8 (36) 18.0 (41) 4.4 (10) 73.5 (36) 26.5 (13) 30.6 (15) 32.7 (16) 10.2 (5) 22.4 (11) 4.1 (2) 67.6 (48) 32.4 (23) 39.4 (28) 23.9 (17) 15.5 (11) 15.5 (11) 4.2 (3) 5.7 (13) 51.3 (117) 21.9 (50) 13.2 (30) 7.9 (18) 0.0 (0) 69.4 (34) 10.2 (5) 10.2 (5) 10.2 (5) 0.0 (0) 69.0 (49) 15.5 (11) 7.0 (5) 8.5 (6)

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J Community Health (2013) 38:463470 Table 2 Knowledge scores pre-/post-viewing PSAs Item Correct response (%) All participants (n = 228) Pre Asthma denition Lungs* Inammation* Asthma statistics Prevalence of asthma among children in Chicago* Prevalence of asthma among children in the neighborhood* Economic cost of asthma per year in the US* Asthma morbidity Miss school* Hospitalization* Stigmatization* Decreased participation in sports Death Asthma attack Community triggers Alcohol/drugs* Tobacco smoke* Stress* Air pollution* Violence* Stigmatization* Strenuous exercise Strong odors Weather Allergens Dirty environment Community aids Stress-free environment* Access to healthcare* Supportive community* Clean air* Asthma education/awareness* Healthy lifestyle* * Factors addressed in the PSAs 0.9 24.1 5.3 16.2 14.0 15.8 25.4 38.2 7.0 14.5 9.6 4.8 ?24.6 ?14.0 ?1.8 -1.8 -4.4 -11.0 0.0 39.3 5.6 19.1 21.3 25.8 32.6 50.6 12.4 13.5 12.4 4.5 ?32.6 ?11.2 ?6.7 -5.6 -9.0 -21.3 1.3 5.7 0.9 17.5 37.7 60.1 6.6 56.1 5.3 53.9 4.4 2.6 8.8 10.1 11.8 19.7 28.1 19.3 13.2 3.9 5.7 18.0 39.5 51.3 75.9 13.6 61.8 9.2 3.5 3.5 2.2 1.8 3.9 10.1 ?18.0 ?7.5 ?3.1 -11.8 -19.7 -47.0 ?44.7 ?19.7 ?8.3 ?7.9 ?4.8 ?0.9 -5.3 -7.9 -10.1 -15.8 -18.0 0.0 10.1 2.2 21.3 59.6 82.0 10.1 79.8 6.7 71.9 6.7 3.4 11.2 18.0 24.7 30.3 40.4 25.8 15.7 6.7 9.0 27.0 42.7 69.7 102.2 21.3 82.0 15.7 3.4 5.6 5.6 4.5 7.9 12.4 ?25.8 ?5.6 ?4.5 -12.4 -32.6 -39.3 ?59.6 ?22.5 ?14.6 ?10.1 ?9.0 0.0 -5.6 -12.4 -20.2 -22.5 -28.1 7.0 11.8 3.5 66.7 63.6 55.3 ?59.6 ?51.8 ?51.8 10.1 12.4 4.5 84.3 80.9 69.7 ?74.2 ?68.5 ?65.2 31.1 7.0 75.0 52.2 ?43.9 ?45.2 47.2 9.0 98.9 62.9 ?51.7 ?53.9 Post Gain

467

Had asthma and/or household member with asthma (n = 89) Pre Post Gain

Eighty-six percent (n = 31) of participants felt they knew more about asthma at follow-up, with participants citing community asthma aids (22.5 %) and the prevalence of asthma (19.4 %) as the most important facts imparted by the PSAs. Seventy-ve percent (n = 27) of follow-up telephone call respondents reported that the PSAs improved their awareness of community triggers and aids, with smoking being most commonly identied (51.9 %). Thirty-nine percent (n = 14) of these respondents reported behavior

changes in response to the PSAs, most often in the form of smoking less (35.7 %). Other reported behavior modications included using public transportation and making efforts to improve air quality by planting trees/or other plants.

Discussion Student-directed PSAs, developed as part of the START intervention, were found to signicantly increase asthma

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knowledge among community members, irrespective of age, gender, or race. Increased knowledge persisted at 14 months post-PSA follow-up. Of the thirty-six participants who were successfully contacted for the follow-up survey, nearly 40 % reported meaningful behavior-change in response to the PSAs. Many asthma interventions have embraced the socioecological model and thus incorporate home, school, and community-based components to address the multi-factorial nature of asthma self-management [18, 34]. However, the majority of school-based asthma interventions have targeted pre-adolescent youth, often with mixed results [35]. Among the few school-based interventions designed specically for adolescents, the Classical Health Promotion model prevails, in which a prescribed, knowledge-based curriculum is presented in a didactic manner by experts [36]. Though our intervention incorporated such didactic sessions, most learning was imparted through student-led and hands-on investigation into factors affecting asthma in the context of each students unique environment. We believe that this more collaborative, community-based approach may have helped to bridge the gap between each individual student and his or her community [37], making each PSA all the more personally relevant. A similar approach was used by Shah et als Adolescent Asthma Action (Triple A) program [38]. Much like our intervention, Shah et al. found the program to be well-received and effective at increasing asthma knowledge; Shah also observed improvements in asthma-related quality of life among participants. Future work will be needed to link the effect of a Photovoice intervention like ours to specic clinical outcomes. While most Photovoice interventions seek to create community-level change, few efforts have been made to evaluate the impact of such projects within the community [39]. In the grand majority of Photovoice projects with an advocacy component, public photo exhibitions are utilized to present participants photos to community stakeholders [39]. To our knowledge, START is the rst program to utilize Photovoice techniques as an instrument to create PSAs for the purpose of community health promotion. Public service announcements have long been used as a social marketing tool in public health [40], and may be particularly effective in communities with low literacy and limited educational opportunities, such as is often the case in lowincome urban environments. Additionally a substantial CBPR literature supports the idea that PSAs generated from within the community may be more effective at reaching community members both by nature of relevant content and acceptable format to the intended audience [41]. It is important to note that the PSAs were effective at improving knowledge among community members of all age groups, not just the students peers. In fact, knowledge

scores increased most among older participants (ages 2145 years). Such ndings hold promise for the role of future school-based interventions in the promotion of healthy behaviors at the individual and community level. Taking Photovoice methods one step further, a recent project conducted by Catalani et al. [42] incorporated participatory videography, which is suggested to be an effective way to mobilize community in the production and dissemination of ndings [43]. Given the dynamic nature of video and the creative exibility it affords, as well as rapidly decreasing costs, we recommend that future interventions incorporate participatory videography into the START curriculum. This approach will likely expand the students purview while allowing for more robust integration of their footage directly into the PSAs, further empowering participants. Moreover, the increasing ubiquity of video-editing software provides students, with little prior experience, an opportunity to create their own PSAs with relatively little expert supervision. Finally, the growing popularity of video sharing sites like youtube.com, which provides automatic captioning and translation of videos into dozens of languages, provides a means to disseminate video content to an ever-growing online audience. This study has a number of limitations. The PSAs focused predominately on negative environmental factors that contribute to asthma exacerbations and were reective of the personally relevant factors affecting asthma identied by students in this feasibility pilot study. Additionally, since few adults identied their highest level of education completed, we are not able to draw evidence-based conclusions about the effectiveness of the PSAs in relationship to the education level of viewers. Moreover, only a small portion of the total number of PSA viewers completed the follow-up phone assessments. Finally, given that all measures of behavior change were self-reported and only administered to a minority of participants, further evaluation is needed to determine whether asthma knowledge and awareness gained from student-directed PSAs really persists over time, and whether this knowledge and awareness translates into measurable behavior change leading to improved asthma outcomes.

Conclusion Student-directed Public Service Announcements (PSAs) were found to signicantly increase community asthma knowledge, with some evidence that this effect may persist over time and lead to positive behavior change. Photovoice and media production techniques were effective in engaging adolescent studentsan underserved and often disenfranchised populationin asthma health education through

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the development and dissemination of PSAs. Participatory techniques in the development of student-directed PSAs hold promise for future public health initiatives, especially those targeting adolescent youth in the context of community.
Acknowledgments We thank the Robert Wood Johnson Foundation for their support of this research.

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36.

37.

38.

39.

123