Revista Eletrônica de Enfermagem, v. 09, n. 03, p. 574 - 587, 2007.
Disponível em http://www.fen.ufg.br/revista/v9/n3/v9n3a02.htm
_________________________________________________________ ORIGINAL ARTICLE
Air, water, land: mexican-origin adolescents’ perceptions of health and the environment
Ar, água e terra: percepções de saúde ambiental de adolescentes de origem mexicana
Aire, água y tierra: percepciones de salud ambiental de adolecentes de origen mexicana
Carolyn M. GarciaI, Marcelo MedeirosII
ABSTRACT
Latino adolescents are the fastest growing
population sub-group in the United States
(U.S.). Health disparities exist between Latino
teens and the majority population of
adolescents in the U.S. as evidenced by rates
of health problems including asthma and
depression; environmental factors contribute to
these concerning trends. The objective is to
describe how environmental influences are
perceived by Mexican-origin immigrant
adolescents. A focused ethnography guided by
an ecological framework and symbolic
interactionism was conducted using 1-to-1
interviewing, participant observations, and
visual narratives created using disposable
cameras. Fourteen participants took “pictures
of life as an immigrant Latino adolescent, with
a focus on health.” Interview and photograph
data were organized and analyzed using
Atlas.ti software. Four themes were identified:
“Garbage is everywhere,” “Work hurts me,”
“Air we breathe,” and “Relaxation in nature.”
Findings
demonstrate
comprehensive
appreciation for risk and protective
environmental influences on health. Nurses can
utilize findings to reinforce the need to
holistically assess Latino adolescent health,
examining risk and protective environmental
factors in the context of social determinants of
health and health disparities. Findings support
use of photovoice in research and that nursing
theory can advance the ecological model and
understanding of environmental health
influences on disparities and well-being.
Key words: Immigration; Adolescent Health;
Environmental Health; Qualitative Research.
RESUMO
Adolescentes latinos constituem um subgrupo
que cresce rapidamente nos EUA. Disparidades
entre os adolescentes latinos e a maioria da
população de adolescentes nos EUA são
evidenciadas por taxas de morbidade incluindo
asma e depressão; fatores ambientais
contribuem para estas tendências. Objetivo do
estudo é descrever como as influências
ambientais são percebidas por adolescentes
imigrantes de origem mexicana. Pesquisa
etnográfica orientada no referencial ecológico e
interacionismo simbólico na condução de
entrevistas
individuais,
observação
participante, e narrativas visuais por meio de
câmeras descartáveis. Quatorze participantes
“fotografaram suas vidas como adolescentes
latinos imigrantes, focando a saúde”.
Entrevistas e fotografias foram organizadas e
analisadas utilizando o software Altas.ti®
emergindo quatro temas: “Lixo está em todos
os lugares”, “O trabalho me machuca”, “O ar
que respiramos”, e “Relaxamento na natureza”.
Os resultados demonstram a compreensão
detalhada do risco e influências protetoras do
ambiente na saúde. Enfermeiros podem utilizar
os resultados reforçando a necessidade de
avaliação integral da saúde do adolescente
latino, examinando fatores de risco e proteção
ambiental no contexto dos determinantes
sociais de saúde e disparidades em saúde.
Resultados sustentam uso da foto-voz em
pesquisa e possibilidades de avanço nas teorias
de enfermagem no modelo ecológico para
compreender influências da saúde ambiental
nas disparidades sociais.
Palavras chave: Migração Internacional;
Saúde do Adolescente; Saúde Ambiental;
Pesquisa Qualitativa.
RESUMEN
Adolescentes latinos constituyen subgrupo que
crece rápidamente en los EEUU. Disparidades
entre adolescentes latinos y la mayoría de la
población de adolescentes en EEUU son
evidenciadas por índices de morbidez
incluyendo asma y depresión; factores
I PhD, MPH, RN Assistant Professor, Center for Adolescent
Nursing, School of Nursing, University of Minnesota.
Minneapolis, MN 55455. USA. Email: garcia@umn.edu
II Doutor em Enfermagem. Professor Associado da
Faculdade de Enfermagem da Universidade Federal de
Goiás. Goiânia, GO. Email: marcelo@fen.ufg.br
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Garcia CM, Medeiros M. Air, water, land: mexican-origin adolescents’ perceptions of health and the environment. Revista
Eletrônica de Enfermagem [serial on line] 2007 Set-Dez; 9(3): 574-587. Available from: URL:
http://www.fen.ufg.br/revista/v9/n3/v9n3a02.htm
ambientales contribuyen para estas tendencias.
Objetivo es describir como las influencias
ambientales son percibidas por adolescentes
inmigrantes de origen mexicana. Investigación
etnográfica orientada por referencial ecológico
e interacionismo simbólico en la conducción de
entrevistas
individuales,
observación
participante, y narrativas visuales por medio de
cámaras descartables. Catorce participantes
“fotograbaran sus vidas como adolescentes
latinos inmigrantes, centrando la salud”.
Entrevistas y fotografías fueron organizadas e
analizadas utilizándose el software Atlas.ti®
emergiendo cuatro temas: “la basura asta en
todos lugares”, “El trabajo machuca”, “el aire
que nosotros respiramos”, y “relajamiento y
naturaleza”. Los resultados demuestran
comprensión detallada del riesgo e influencias
protectoras del ambiente en la salud.
Enfermeros pueden utilizar los resultados
reforzando la necesidad de evaluación integral
de la salud del adolescente latino, examinando
factores de riesgo y protección ambiental en el
contexto de los determinantes e disparidades
sociales de salud. Sustentan el uso de la
fotografía en investigaciones y posibilidades de
avanzos en teorías de enfermería en el modelo
ecológico para comprender influencias de la
salud ambiental en las disparidades y bien
estar social.
Palabras clave: Migración Internacional;
Salud del Adolescente; Salud Ambiental;
Investigación Cualitativo.
STUDY RATIONALE
Latino adolescents are the fastest
growing population sub-group in the United
States (U.S.) and are part of the largest ethnic
minority group. Health disparities exist
between Latino teens and the majority
population of adolescents in the U.S. as
evidenced by rates of physical and mental
health problems including asthma and
depression (1,2). Social determinants of health,
notably poverty, result in Latino adolescents
residing where environmental risks are
prevalent while environmental assets may be
lacking (3,4). The influence of environmental
factors, harmful and protective, is recognized
by nurses but how the environment is
perceived by Mexican-origin immigrant Latino
adolescents has not been documented
previously. Their perceptions can provide
useful foundational knowledge for developing
successful health assessment and promotion
nursing initiatives.
For all adolescents, physical and mental
development can be negatively or positively
influenced by environmental factors (5-7).
Immigrant Latino adolescents experience
health disparities resulting from complex
causes including social determinants of health
such as poverty (8,9). Affordable housing in the
U.S. for those in poverty is often situated in
tenuous environments within urban settings;
for immigrant Latino adolescents this increases
their exposure to environmental pollutants that
contribute to development or exacerbation of
health problems such as asthma (1). Lack of
access to safe recreational environmental
resources in conjunction with neighborhood
risks such as gang presence, crime, and illegal
drug sales together compound the potential for
problems such as depression or violence (2,10).
Moreover, concerning rates of obesity among
Latino adolescents are due to complex reasons
that, for those living in low-SES areas, include
the lack of safe access to venues for physical
activity (11).
For those youth who are employed,
occupational hazards comprise an additional
layer of environmental risk though there are
inherent economic benefits. Furthermore, for
the immigrant Latino adolescents who are
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Garcia CM, Medeiros M. Air, water, land: mexican-origin adolescents’ perceptions of health and the environment. Revista
Eletrônica de Enfermagem [serial on line] 2007 Set-Dez; 9(3): 574-587. Available from: URL:
http://www.fen.ufg.br/revista/v9/n3/v9n3a02.htm
migrant and follow agricultural seasons across
the country, environmental risks also include
occupational hazards such as pesticide
exposure (3).
Nurses practice in settings that are
accessed by immigrant Latino adolescents;
namely, school- and community-based health
care centers. It is important that nurses are
able to recognize and assess for environmental
risk and protective factors. A starting point
upon which to build this awareness is to gain
understanding of how immigrant Latino
adolescents’ perceive environmental influences
on their health. This knowledge can inform
practice and research initiatives to minimize
risks and maximize assets within their
experienced physical environment.
LITERATURE REVIEW
Research on environmental exposures
and the subsequent impact on this developing
phase of adolescence provides foundation
understanding of the extent of harm that can
occur during this period of rapid physiological
growth (5,6). Operating with this understanding,
Golub (2000) describes specific effects of
toxicants such as disrupting adolescent
biological maturation and function because of
the uniqueness of this developmental period.
Examining beyond general or random physical
environmental exposures, Golub highlights the
voluntary and involuntary environmental
exposures that make adolescents particularly
susceptible to harmful effects. Specifically
noted are voluntary exposures such as
substance use or experimentation and
involuntary exposures to toxicants in the
workplace (7). This literature provides
foundational understanding but is limited in
that it is not specifically describing Latino
adolescents.
Because many Latino children and
adolescents work in migrant agricultural
settings, researchers examining environmental
exposures in Latino youth have specifically
targeted these high-risk exposure areas.
Salazar, Napolitano, Scherer, and McCauley
conducted a qualitative, descriptive inquiry
exploring the perceptions of Latino adolescent
farm workers regarding their pesticide
exposures, specifically (3).
Using a focus group methodology based
on an ecological framework, they gained
awareness of the adolescents’ perceptions
regarding their susceptibility to illness because
of the pesticide exposure, their knowledge of
hazards, and the barriers they felt regarding
other employment possibilities. The
participants were not necessarily recently
immigrated, so the findings, while useful and
insightful, are not readily transferable. Another
qualitative study conducted with Latino migrant
school-aged children focused on their
perceptions of health (4). Specific to migrant
Latino youth, the findings from this focus group
study highlighted health perceptions including
acculturation issues and environmental
influences.
Study recommendations centered on
improving the culturally competent care of
pediatric nurses. Both studies provide
understanding but because they had not been
conducted with recently immigrated older
Latino adolescents and were focused on a
migrant population, they could not be used to
move beyond a descriptive study design. Thus,
the proposed study complimented existing
work and was designed to contribute new
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Garcia CM, Medeiros M. Air, water, land: mexican-origin adolescents’ perceptions of health and the environment. Revista
Eletrônica de Enfermagem [serial on line] 2007 Set-Dez; 9(3): 574-587. Available from: URL:
http://www.fen.ufg.br/revista/v9/n3/v9n3a02.htm
understanding about a rapidly growing
population sub-group: immigrant Latino
adolescents.
Beyond the physical environmental risks
and exposures literature, there is a growing
body of literature informing understanding of
the role that social determinants of health play
in affecting the health and health disparities
experienced by adolescents. For youth in
poverty, the environmental absence of
resources such as playgrounds or parks has
substantial influence on their ability to be
physically active and subsequently, at lower
risk for obesity or diabetes (12).
Both diseases are disproportionately
affecting the Latino community; understanding
how social determinants of health, including
poverty, and related environmental risks are
associated with these diseases could lead to
innovative preventive nursing interventions.
Further, physical environmental characteristics
have been shown to contribute to a
developmental-ecological model of violence for
Latino adolescent boys living in poor urban
areas (10). Understanding how Latino
adolescents view the environment surrounding
them will contribute to this developing
knowledge.
Finally, varied qualitative and photovoice
methodologies have been employed with Latino
adolescents to ascertain perceptions of health
and illness (3). The richness of descriptive data
obtained make these methods useful in
exploratory level studies designed to establish
a frame of reference upon which to inform
practice and future research. In particular,
photovoice has been used in the Latino
community to gain perceptions of topics such
as immigration or health-seeking behaviors
including prenatal care (13).
CONCEPTUAL FRAMEWORK
Bronfenbrenner’s ecological theory was
the guiding framework for the study design and
data analysis (14). Though the adolescents
themselves comprised the main source of
primary data, the ethnographic design
incorporated researcher data including
observation, reflective journaling, and field
notes.
Further, symbolic interactionism informed
the study design; emphasis is on the meanings
of an experience attributed by the individual.
In this way, an experience can be positive for
one individual, similar or negative for another
person in the same or different cultural
context. Applied to this study, symbolic
interactionism necessitated a follow-up with
the photographs so that the adolescent could
describe what she/he was thinking when taking
the picture.
Purpose
The original study aims were to describe
immigrant Latino adolescents’ perceptions of
healthy and unhealthy influences and their
experiences accessing the U.S. health care
system. General perceptions of health and
specific perceptions of mental health have been
reported elsewhere (15,16). The purpose of this
article is to describe the perceived healthy and
unhealthy environmental influences of
immigrant Latino adolescents in their own
words and pictures.
METHODS
Study design
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Garcia CM, Medeiros M. Air, water, land: mexican-origin adolescents’ perceptions of health and the environment. Revista
Eletrônica de Enfermagem [serial on line] 2007 Set-Dez; 9(3): 574-587. Available from: URL:
http://www.fen.ufg.br/revista/v9/n3/v9n3a02.htm
This focused ethnography employed one-
to-one interviews and photovoice data
collection techniques. A focused ethnography is
a narrow exploratory study of an area of
concern within a community with time- and
context-specific boundaries. This methodology
contributes understanding that is gained within
a context of environment and culture (17). A
photovoice strategy was selected to
compliment the interview data, which were
thought to possibly be limited due to
discomfort that can be experienced in an
interview setting. An empowering tool, the
photovoice methodology has been used in prior
research with Latino adolescents; it gives
participants the opportunity to contribute data
in their own time and space (18,19).
Participants
Immigrant Latino adolescents were
invited to participate if they had arrived into
the U.S. no more than three years before the
initial interview was conducted; all participants
arrived to the U.S. between 2001 and 2003.
Additional inclusion criteria included being
between 15 and 20 years of age, self-
identifying as Mexican, and willingness to
participate. Fourteen adolescents were
purposively recruited from a public charter
school and a church using verbal invitation
augmented with written information sheets.
Both settings have large Latino populations and
are located in neighboring urban cities in a
mid-western State experiencing rapid Latino
population growth. A church was selected to
facilitate recruitment of Latino adolescents who
may not be attending school because the drop-
out rate for Latino youth is high.
Data collection
Following University of Minnesota
Institutional Review Board (IRB) approval, a
purposive sampling strategy was employed to
recruit participants. Verbal explanation of the
study and an informational sheet were
provided to interested adolescents. The IRB
waived the need for active parental consent;
an informational sheet was given to parents
when they were present or to adolescents to
bring home. There was no mechanism to
ensure that when the informational sheet was
given to the adolescent to bring home, it was
in fact delivered to the parent.
Approximately a week lapsed before
commencing the study with interested
adolescents so parents could contact the PI as
desired. There were no parental inquiries over
the course of the study. Adolescent verbal
assent was obtained before beginning the
initial interview; the IRB did not require written
assent because it was felt this might limit
willingness to participate because of
participants
possibly
lacking
legal
documentation of residency or citizenship. The
assent process addressed content of the
photographs and what the PI or research team
would be required to report, such as apparent
abuse. The initial interview took place where
the adolescent preferred; all selected the
recruitment site (school or church) for this
interview.
The goals of the first semi-structured
interview were to elicit the adolescent’s health
perceptions and his/her experiences accessing
the U.S. health care system. At this interview
participants completed a demographic
questionnaire including a language-based
acculturation scale developed for Latinos. The
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Garcia CM, Medeiros M. Air, water, land: mexican-origin adolescents’ perceptions of health and the environment. Revista
Eletrônica de Enfermagem [serial on line] 2007 Set-Dez; 9(3): 574-587. Available from: URL:
http://www.fen.ufg.br/revista/v9/n3/v9n3a02.htm
interview was conducted in English or Spanish
according to the participant’s preference; a
Latino professional interpreter was present at
all interviews. Interview lengths ranged from
45 minutes to nearly 2 hours, and all were
audio recorded to facilitate verbatim
transcription and translation of Spanish into
English.
Each adolescent was then given a
disposable camera with 24 exposures and
instructions to “Take pictures of healthy and
unhealthy influences in your life.” Participants
were asked to complete their photographs
within two weeks though on average, the
cameras were returned a month after the initial
interview. Following film development, a
second interview was conducted to ascertain
the meanings behind each photograph; key
questions asked included “Why did you take
this picture?” and “What were thinking of when
you took this picture?”
These interviews were also conducted
where the participants preferred; for most, this
remained the school and church but for a few,
the interview took place in their homes. At the
end of each second interview, a second assent
process was followed to determine which
photographs the adolescent would allow the PI
to use in public data dissemination activities
such as presentations and publications.
Because the adolescents gave permission for
most photographs to be used, those they did
not give permission to use were signed and
dated on the back to identify them.
Each participant received a 25$ gift card
for Target following the completion of each
interview so each adolescent completing both
interviews received a total of $50. Each
participant also received a copy of his/her
photographs to keep.
In addition to the interviews and
photographs, the PI completed extensive field
notes, noting observations and interactions
throughout the study process. Journaling by
the PI contributed in-depth reflection on the
process and experience of conducting this
study. These data were referred to during the
analysis of the interview and photograph data
in order to provide contextual understanding
for some of the findings. These components of
the study were important given the non-Latino
ethnicity of the PI and the need for maximizing
interpretation of data were within the
appropriate context. The PI spent extensive
time at each study site, participating in various
activities in order to gain in-depth
understanding of the environment in which the
adolescents resided. The PI lives within one of
the urban cities and spent time immersing
within the local Latino community beginning
two years prior to the actual study
commencing.
In addition to quality time in the field,
reflective journaling, and field notes, the study
rigor was strengthened by using triangulation
of data sources, consulting method and cultural
experts throughout the research process,
comparing oral and written interview data, and
maintaining an audit trail of process and
paperwork.
Analysis
All interviews were successfully recorded;
these were transcribed and translated by a
professional not associated with the study.
Where questions arose, the transcriber kept
the Spanish text in parentheses next to the
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Garcia CM, Medeiros M. Air, water, land: mexican-origin adolescents’ perceptions of health and the environment. Revista
Eletrônica de Enfermagem [serial on line] 2007 Set-Dez; 9(3): 574-587. Available from: URL:
http://www.fen.ufg.br/revista/v9/n3/v9n3a02.htm
English translation for the PI to examine and
address with the interpreter, listening to the
recorded interview as needed. All interview
text and photographs were imported into
Atlas.ti® software to facilitate an inductive
coding process.
In total, nearly twenty hours of interview
were coded along with 180 pictures. The
pictures were coded based on the meanings
provided by the adolescents rather than using
a pre-identified list of possible codes. As new
codes were created to describe interview or
photograph data, the previously coded data
were re-examined to determine if the new
codes were applicable to that data. The
assigned labels, or codes, were combined into
categories that were organized in a manner
that facilitated identifying thematic patterns
that aligned with the original study aims. The
environmental-focused codes and categories
were re-organized in subsequent analysis in
order to identify representative environmental
themes. These themes, with supportive original
data quotations and thick descriptions, are
presented below.
RESULTS
Sample
The sample (N=14) included 9 females
and 5 males, 15 to 20 years of age (mean =
16.6), who emigrated from Mexico within 3
years of being recruited (range = 2 months to
3 years). They were equally recruited from
both settings (7 participants from each).
Thirteen participants emigrated from Central
Mexico with the 14th reporting being from
Northern Mexico. Data were not collected
regarding whether or not the participants came
from urban or rural areas within their State in
Mexico; however, through the interview
process many participants described living in
Mexico City rather than in rural areas of
Mexico. All participants reported attending
school in Mexico prior to immigrating. Six
participants, all recruited from the church
setting, were not in school; of these, four had
either graduated or were in the process of
being admitted. Five of the 14 were employed;
employment settings included retail,
construction, and manufacturing. The
Bidimensional Acculturation Scale, a language-
based measure of acculturation, reflected the
recent immigrant status of the participants. All
14 scored high in their self-reported comfort
with the Spanish language; only 5 scored high
in their self-reported comfort with English.
Three of the participants did not have
their parents living in the U.S.; the other 11
reported living with their parents. Ten of the
participants reported living in a household with
five or more persons; three reported household
size of four and the final participant reported
living in a household size of three. Large
household sizes are common among the Latino
community for cultural and economic reasons.
All but two of the participants lived in a house;
the two resided in apartments. This was the
only indirect measure of economic position and
quantitative data do not exist to further
understand the economic position of the
sample. Photos demonstrated a range of living
situations, ranging from photos of housing that
appeared to be in low-income parts of the city
to photos of organic juice in the refrigerator
within a tidy, attractive kitchen.
Three youth did not complete the visual
narrative or 2nd interview. Two of these had
580
Garcia CM, Medeiros M. Air, water, land: mexican-origin adolescents’ perceptions of health and the environment. Revista
Eletrônica de Enfermagem [serial on line] 2007 Set-Dez; 9(3): 574-587. Available from: URL:
http://www.fen.ufg.br/revista/v9/n3/v9n3a02.htm
returned to Mexico following the first interview;
the third did not return follow-up phone calls.
Thematic overview
In doing the data analysis, an important
point became very clear. The initial interview
data from all participants did not include
references to environmental health influences
with the exception of work related exposures.
Indeed, the rich environmental health data
came when the participants completed their
photovoice project and presented numerous
photos of environmental influences, positive
and negative. The follow-up interviews
reinforced the importance of environmental
influences as perceived by the adolescents. The
four environmental themes that were identified
and are described below include: “Garbage is
everywhere”, “Work hurts me”, “Air we
breathe”, and “Relaxation in nature”. Real
participant names have not been used when
quotes are provided.
Theme I: “Garbage is everywhere”
Participants portrayed indoor and outdoor
garbage, including kitchen trash bags,
collection bins, litter on the ground near their
homes and in parks. Differentiating organic and
inorganic garbage, Liselle shared, “Garbage
can be good and bad. I see organic trash as
good and I see inorganic trash as bad. The
inorganic, as I see, its stuff [that] doesn’t
dissolve and ends up contaminating the rivers
and other parts that actually do affect us
health wise.” Miguel addressed this as well,
stating, “It is non-degradable material. These
probably don’t smell as much as the
degradable ones but they are still polluting. If
nobody picks them up they would accumulate.”
Miguel also addressed the litter in the park and
in the lake, “Here is trash in the lake; [it] is
really bad. You can’t see (pointing to park of a
picture of the lake) but if you go there it is
really dirty. You can see trash there is really
bad. It takes away from the beauty of nature.”
Figure 1: Indoor garbage
Figure 2: Litter in the lake
Talking about indoor trash, Esmiralda
said, “If it is not kept controlled and it is placed
in places where people can be contaminated,
people can be affected by it and it actually can
be bad for your health because you can
actually get sick from it, get an infirmity from it
because of the bacteria.” Focusing on the
bacterial and germ effects, Maria shared, “This
is trash, [it] brings germs and bacteria.”
Talking about a picture of school trash, Flor
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Garcia CM, Medeiros M. Air, water, land: mexican-origin adolescents’ perceptions of health and the environment. Revista
Eletrônica de Enfermagem [serial on line] 2007 Set-Dez; 9(3): 574-587. Available from: URL:
http://www.fen.ufg.br/revista/v9/n3/v9n3a02.htm
shared, “In this picture there is trash strewn
and it is not healthy because some times, in
other places, it remains for two and three days
and that is harmful specially for kids, not so
much the adults.”
Home trash was photographed primarily
in the kitchen or near an outside door; in this
context home cleanliness was described as
important to health. Flor photographed a clean
kitchen setting to emphasize the importance of
environmental cleanliness for her health.
Miguel described the negative environmental
influence of his neighbor’s trash, “Here is like
really direty in here, that blue house is my
neighbor. There is a lot of trash. You can’t see
the flies but around there is not healthy. Like
bad smells. [The poop]. They got a dog.”
Theme II: “Work hurts me”
Participants described harmful work
factors ranging from back pain and fatigue to
dust and noise exposure. Mario, employed in
construction, shared, “I work with sheetrock
and there’s a lot of dust. And we don’t wear
any protection. [I feel it] in my nose.” Negative
coworker influences were noted, “No one uses
it [mask] and if I do, they tease me.” Also
describing the health effects of dust, Javier
talked about his work environment, “Where I
work there’s a lot of dust. And when I get out
of work, I feel it in my throat.” He also spoke
about noise exposure, “There’s a lot of noise
because we use a machine gun and the tool
that cuts in the middle of the tile.”
Physical strain evidenced in back pain
and headaches resulted from strenuous work
and long shifts. Mario described back pain,
“Before sometimes I would say, I have to work,
but I told my uncle I started to feel back pain.
And he noticed that he was only 26 and had to
be careful too.” Sagitario described a picture of
her dad resting on his back,
Sagitario: “This one is my dad. Because lately
he’s been working a lot. It’s like physically
tired. So he came home and laid down and I
took the picture.”
PI: “So do you think that his being tired and
working too hard is unhealthy?”
Sagitario: “Not healthy because he’s getting
really tired. Because he can faint or any other
thing; it’s not good.”
Describing another photograph, she
shared,
Sagitario: “And because my friend’s face. She’s
sad. But here you could see black eyes (dark
shadows under her eyes). Because she sleeps
really late and she works.”
PI: “Tell me more about the work. Is that a
healthy or unhealthy thing?”
Sagitario: “Yes and no. Yes because it’s
important. And the money helps you.
Sometimes no because you overwork yourself.
And that’s bad. Sometimes you can’t do the
things you want, cause you have to rest. The
first think you want to do is go home and
sleep.”
Flor, employed in retail, had limited time
to eat as noted in this interview exchange with
the PI:
PI: “Do you have time at work to eat?”
Flor: “They give me ten minutes only.”
PI: “Ten minutes is not enough.”
Flor: “I don’t know because I only eat snacks. I
do eat food, but just a little bit.”
PI: “Do you eat food at home?”
Flor: “Yes, but I hardly have time.”
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Garcia CM, Medeiros M. Air, water, land: mexican-origin adolescents’ perceptions of health and the environment. Revista
Eletrônica de Enfermagem [serial on line] 2007 Set-Dez; 9(3): 574-587. Available from: URL:
http://www.fen.ufg.br/revista/v9/n3/v9n3a02.htm
PI: “But why don’t you have time? Is it
because of work?”
Flor: “Yes, because [of] school and work.”
Theme III: “Air we breathe”
Healthy and unhealthy air was described
by most participants; sources of harmful air, or
air pollution, included occupational and
automobile. Healthy air was viewed by some,
who compared the visual air quality with what
they had observed or experienced in Mexico.
The lack of air pollution in the U.S. was noted
by Mario who photographed freeway traffic and
a blue sky above. He described the trees he
photographed in his neighborhood as healthy
and contributing to good air quality for him. He
also photographed car exhaust and
neighborhood litter to demonstrate conflicting
environmental influences surrounding him.
Figure 3: Blue sky, clean air
Liselle pointed out the harmful effects of
air pollution from a nearby manufacturing
plant, “…with the smog they contaminate the
air, everything we breathe, the air we inhale
and exhale and that is what makes us healthy
or unhealthy.” She went on to clarify that she
did not live near factors but that if she did, she
was sure she would be breathing contaminated
air and would experience specific health
problems with her kidneys.
Picturing a family enjoying a picnic, Maria
shared about what she perceived, “The family
they go out and get fun. It’s good. That’s
relaxing. Like not a lot of smog. It’s healthy.”
Theme IV: “Relaxation in nature”
Access to recreational parks, nature trails,
and lakes was pictured and described as a
positive contributor to mental health and
physical health with concurrent opportunities to
relax and exercise. Miguel took pictures of
flowers in the park because he felt the scent
and visual aspects of the flowers helped make
him feel good, including his self-esteem. His
pictures also focused heavily on a variety of
exercise venues available at a local urban park,
including canoeing, paddle boating, running,
biking, and fishing. Other participants also
emphasized physical exercise within a park
setting in their pictures, describing mental and
emotional benefits derived in addition to the
physical benefits. Maria described benefits of a
park including to “use it to run, to go for walks
and to do exercises.” Liselle shared,
“I took these pictures, as you can see they
relate to each other, because exercising,
whether it is walking, running, gymnastics,
sports, and all that, and good communication,
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Garcia CM, Medeiros M. Air, water, land: mexican-origin adolescents’ perceptions of health and the environment. Revista
Eletrônica de Enfermagem [serial on line] 2007 Set-Dez; 9(3): 574-587. Available from: URL:
http://www.fen.ufg.br/revista/v9/n3/v9n3a02.htm
that is family unity [picture of family at a
park], can help us lead a better life. If we can
put aside our thoughts and for a while we go
outside of our daily routine. . . that is to lead a
better life.”
When probed, Liselle elaborated on the
nature and relaxation gained from exercise in a
park setting rather than simply doing
something on one’s own home: “I am not
talking about regular walks. Yes, you can take
regular walks but the ones that help clear your
mind are the ones like a nature walk, through
nature taking a walk by yourself. Those are the
types of things that help you mentally. Not a
walk or on a machine.”
Figure 4: Park recreation
Figure 5: Exercise in nature
Linking the mental and physical benefits,
Jose shared, “canoeing is healthy too and
relaxing and is a little bit romantic.”
Despite all participants residing in urban
settings surrounded by parks, some did not
experience or demonstrate opportunity to find
and use the recreation areas near them. Citing
safety and lack of knowledge of resources,
Esmiralda summarized her current physical
exercise, “Actually I just walk and when I was
in Mexico I used to practice sports. I’m looking
for a place to go.” In her situation, she wanted
to play soccer in the U.S. but did not know how
to find a community center or place where she
could play.
DISCUSSION
Social determinants of health include
important
environmental
determinants
recognized and described by immigrant Latino
adolescents.3,4,12 The participants in this study
demonstrated acute awareness of harmful and
beneficial environmental influences on their
physical and mental health. The identified
asset, or protective nature, of environmental
resources such as lakes and parks for physical
and mental health are supported with literature
that identifies health problems and disparities
associated
when
these
protective
environmental factors are absent.2,12 In
addition, health risks resulting from
environmental hazards ranging from pollution
and garbage to occupational hazards have
been linked to prevalent diseases in the Latino
community such as asthma that warrant
attention and intervention (1,3,4). Though
unaware of an existing ecological theoretical
framework, the adolescents provided
photographs and stories about environmental
risks and assets in the Microsystems
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Garcia CM, Medeiros M. Air, water, land: mexican-origin adolescents’ perceptions of health and the environment. Revista
Eletrônica de Enfermagem [serial on line] 2007 Set-Dez; 9(3): 574-587. Available from: URL:
http://www.fen.ufg.br/revista/v9/n3/v9n3a02.htm
surrounding them, including family,
neighborhood, school, and places of
employment, worship, and recreation. For
some of the adolescents, the Microsystems
provided
complimentary
protective
environmental resources while for others the
systems compounded risk. Set within the
broader
ecological
context,
these
environmental influences may be further
exaggerated by Ecosystem deficits such as
limited access to health care services including
health screening, assessment, and education
and Macrosystem challenges such as conflicting
cultural values with the majority culture. Use of
an ecological framework facilitates the ability of
nursing to proactively and strategically
influence the health and well-being of
immigrant Latino adolescents at the varied
system levels.
Strengths and limitations
A strength of this study is that it was
conducted with community engagement and
support; Latino community members informed
the design, implementation, analysis, and
dissemination of findings. Recruiting from non-
health based community settings avoided
possible bias toward health-based responses;
in addition, not being solely school-based
allowed for participation of Latino adolescents
who were not in school due to drop-out. A
homogenous sampling approach strengths
study validity; this approach is recommended
in the literature addressing research with
Latino sub-groups (20). The use of photovoice
strengthened the study design and subsequent
data collected, which would have been more
limited with an interview only approach.
Limitations of the study include self-selection
to participate, reduced transferability to non-
Central Mexican immigrant Latino adolescent
populations, use of an interpreter, and settings
solely based in an urban Mid-western state
environment.
Practice recommendations
Nurses assessing the health concerns of
Latino adolescents should holistically consider
causal or contributing environmental risks.
Asking about employment should lead nurses
to examine possible occupational risks or
hazards for Latino adolescents. Holistic clinical
assessments could improve diagnosis and
treatment of environment-exacerbated
conditions such as asthma, hearing loss, and
depression. Nursing health promotion
resources should include environmental assets,
when available, including parks, lakes,
playgrounds, and trails. Latino adolescents,
and their families, will benefit from information
provided by nurses, especially when they are
recently immigrated and may be experiencing
isolation or uncertainty of where environmental
resources are and how to access them.
For those who reside in low-income or
impoverished areas, environmental resources
such as parks or lakes are important protective
assets to bring awareness to because they
typically are accessible at no cost and in urban
areas, may be accessible using public
transportation. Encouraging use of these
environmental resources serves many
purposes, including the more obvious physical
and mental health promotion results and the
not so obvious but important outcomes such as
facilitating family connectedness and
communication when family can find relaxation
and recreation in a common area like a park.
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Garcia CM, Medeiros M. Air, water, land: mexican-origin adolescents’ perceptions of health and the environment. Revista
Eletrônica de Enfermagem [serial on line] 2007 Set-Dez; 9(3): 574-587. Available from: URL:
http://www.fen.ufg.br/revista/v9/n3/v9n3a02.htm
Finally, consider the contributions
adolescents can make in community
assessment, activism and empowerment
endeavors through the use of photovoice.
Photovoice is a tool useful to these processes
and one that adolescents eagerly engage (18,19).
Theory development
This study contributes to the knowledge
base of application of the ecological framework
in nursing research with Latino adolescents.
The discipline of Nursing with its holistic
perspective makes nursing an ideal discipline
to build upon Bronfenbrenner’s work and
explicate an ecological model for
individual/family, community, and system
health and health promotion.
RESEARCH RECOMMENDATIONS
Further research should build on this
descriptive work to examine environmental
influences on the physical and mental health of
Latino adolescents, including occupational,
residential, and community environmental risks
and assets. Studies employing neighborhood
mapping and GPS strategies to examine health
disparities experienced in Latino dominant
communities should incorporate assessment of
natural environmental factors and not be
limited solely to assessing the presence or
absence of physical environment risks such as
liquor stores.
Researchers
should
employ
methodologies that encourage participant
creativity, such as visual narratives, so that
optimal data are obtained. This could be
especially relevant for research involving
adolescents, who might experience feelings of
powerlessness in more traditional research
strategies such as interviews. Further, for
English Language Learners (ELL), photovoice
might be an appealing data collection strategy
that is not dependent on speaking, reading or
writing abilities. When the research question
can be answered in part or fully through use of
photovoice, the method should be critically
examined and considered.
Health promotion research with Latino
adolescents should consider incorporating
environmental components to intervention
strategies in order to optimize positive
outcomes such as family connectedness,
physical health, and mental health.
CONCLUSION
In conclusion, this study contributes to
understanding in nursing regarding the health
of immigrant Latino adolescents and
specifically, the environmental factors that
influence or have the potential to influence
their physical and mental well-being. Nursing is
poised to creatively build on this descriptive
research to inform health promotion
interventions designed using an ecological
framework. Photovoice is a useful tool for
nursing practice and research with many
populations, including immigrant Latino
adolescents. Nursing practice and research can
act upon the study findings to holistically
assess and intervene to promote health and
reduce environmental risks experienced by
immigrant Latino youth. These efforts and
actions can positively influence the health of
immigrant Latino adolescents, working toward
eliminating health disparities experienced here
in the U.S.
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Garcia CM, Medeiros M. Air, water, land: mexican-origin adolescents’ perceptions of health and the environment. Revista
Eletrônica de Enfermagem [serial on line] 2007 Set-Dez; 9(3): 574-587. Available from: URL:
http://www.fen.ufg.br/revista/v9/n3/v9n3a02.htm
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Artigo recebido em 10.07.07
Aprovado para publicação em 10.12.07
Notes
Thank you to the adolescents who graciously
participated in this research. Thank you to my
research advisors and mentors, including Drs.
Laura Duckett, Linda H. Bearinger, Elizabeth
Saewyc, and Michael Resnick. This research
was supported in part by the SAM Career
Development Award, grants R03 MC 01029-01-
01, T80 MC00021-13 and T71 MC00025-01
from the Maternal and Child Health Bureau,
Health Resources and Services Administration,
Department of Health and Human Services;
grants T01 DP000112-02 and U48
CCCU513331 from the Centers for Disease
Control and Prevention; and grants from the
University of Minnesota Graduate School and
Zeta Chapter of Sigma Theta Tau International.
587