Contributions of Structural Racism to the Food Environment: A Photovoice Study of Black Residents With Hypertension in Baltimore, MD
What is Known
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Black people suffer from higher rates of morbidity and mortality related to cardiovascular disease and chronic kidney disease.
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Dietary factors, such as healthy food access and dietary patterns, are thought to underlie these disparities.
What the Study Adds
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This study provides first-hand accounts of residents’ perceptions of how the conditions of the current food environment came to be, including social, cultural, and political considerations.
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Nuanced understanding of how lived experiences of the food environment affect dietary patterns among Black people with hypertension may help to inform effective and sustainable policies.
Black Americans are more likely to develop hypertension1,2 and at a younger age3 compared with White Americans, and despite higher treatment rates, are less likely to achieve blood pressure control.4 Hypertension contributes to high rates of morbidity and mortality from other chronic conditions, including cardiovascular disease, obesity, diabetes, and end-stage kidney disease.5,6 Among young Black adults with normal blood pressure, the risk of developing hypertension by age 55 years is 1.5 to 2 times higher than for White individuals with similar blood pressure.7 Dietary factors, such as limited availability of healthy foods and unhealthy dietary patterns, likely underlie this disparity. In addition to proper nutrition and health, food access has important social implications as it is tied to overall wellness and has strong cultural meaning.8
Poor food environments—the physical distribution of and access to food stores—and food insecurity—the state of being without reliable access to affordable, nutritious food—among Black Americans represent well-documented determinants of chronic disease disparities by race and ethnicity. Social stressors, such as food insecurity, may impact chronic physical and mental health outcomes, including hypertension, hyperlipidemia, diabetes, as well as depression and anxiety.9,10 In 2018, Black and Hispanic households experienced food insecurity disproportionately at rates of 21.2% and 16.2%, respectively, while the national average was 11.1 percent.11 The disproportionate burden of food insecurity often occurs within the context of unhealthy food environments located in racially segregated, predominantly Black neighborhoods. Due to historical and present-day disinvestment, such neighborhoods are often characterized by fewer supermarkets, more fast-food outlets, poorer quality goods, higher prices for nutritious foods,12 longer travel distances,12,13 and less fresh produce.14
Understanding lived experiences of facilitators and barriers in the food environment may help to inform interventions that promote healthy behavioral change. We used a community participatory research method, known as Photovoice, designed to empower communities experiencing marginalization.15 In this method, participants use photography to record features of their community that impact their lived experience, then the images are used to promote discussion and advocacy around critical social issues. Through the Photovoice methodology, we were able to (1) identify salient features of the food environment in Baltimore and (2) identify facilitators and barriers to food procurement, cooking and healthy eating, through the perspectives of Black individuals with hypertension.
Methods
The data that support the findings of this study are available from the corresponding author upon reasonable request. From August 2019 to November 2019, we performed a Photovoice study as an ancillary to the Five Plus Nuts and Beans for Kidneys study (hereafter, “Five Plus for Kidneys”), a randomized control trial of a dietary intervention to improve outcomes among Black adults with hypertension and early chronic kidney disease. Photovoice is a community-based participatory research method that uses photography to engage participants in reflection and dialogue regarding their community’s strengths, needs, and capacity for social change.16 We used the methodology to document participants’ lived experiences of their food environment. The photos served as a foundation for facilitated conversations about benefits, deficits, and proposed solutions to “food desert” conditions perceived by the participants.
“Five Plus for Kidneys” recruited 150 Black adults with chronic kidney disease and hypertension under regular care at Johns Hopkins-affiliated primary care and/or nephrology clinics in Baltimore, MD to participate in a 12-month study. Photovoice participants met initial demographic—age (21 years or older), race (Black)—and clinical criteria (hypertension) for Five Plus for Kidneys as identified through the electronic record, but on further screening were found to be ineligible (e.g., no evidence of chronic kidney disease). In addition, participants were eligible for the Photovoice project if they: (1) lived in Baltimore, MD; (2) were able to manage a camera; and (3) agreed to participate in 5 group sessions over the course of 3 months. Of 146 potentially eligible participants, 81 were contacted, 46 consented (35 declined), and 24 ultimately enrolled in the study. Schedule conflicts were key barriers to enrollment. All eligible residents agreeing to participate completed an oral consent process over the telephone; and survey demographic information was collected at the conclusion of the last discussion session. The Institutional Review Boards of Johns Hopkins School of Medicine as well as the Virginia Commonwealth University School of Medicine approved the study.
Data Collection
After recruitment, each participant provided their most convenient day and time to meet and gathered in groups based on their schedules. To promote rich discussions, participants were assigned to groups of 2 to 4 persons varying by gender composition—all men, all women, and 2 equally split mixed-gender groups (n=24). Each group met for at least 4 sessions, which were held weekly and lasted approximately 2 hours. All meetings took place at the Welch Center for Prevention, Epidemiology, and Clinical Research located in East Baltimore near the Johns Hopkins Hospital. We provided healthy foods at each group session as well as transportation to and from the session, if needed. Sessions were audio-recorded and transcribed verbatim by a Health Insurance Portability and Accountability Act compliant transcription service. Photographs included in this article are shared with participants’ permission.
As in previous Photovoice projects, our group sessions included an initial group meeting, small group discussion sessions, and a final meeting.16,17 In session 1, we explained the project aims and scope as well as provided participants with a 1-hour photography lesson with a professional photographer who explained the ethics of making images and basic photography skills (eg, composition, lighting). Participants were instructed on privacy rules and how to obtain consent from persons that they photographed. After training, we invited participants to “photograph everything related to food in your neighborhood” and to return to the next session with at least 5 photographs. Food environment was loosely defined to leave it to participants’ interpretation to capture anything they might consider their food environment, whether this was their own kitchen, local retailers, or macro food systems. Before session 2, participants selected the 5 images to share with their group, which were printed by study staff using a portable color photo printer on site. Sessions 2 to 4 consisted of small group discussions, where participants discussed each selected participant-produced photograph. We used the SHOWED framework—What do you See here? What is really Happening? How does this relate to Our lives? Why does this problem or strength Exist? What can we Do about it? to guide discussions and to make meaning of the photographs captured.18,19 Using a grounded theory approach, the research team allowed topics and themes to arise organically using only the SHOWED framework to start the discussion. Discussions were participant-led with facilitators only intervening to support engagement among all group members, for example, to promote discussion where conversations stalled (referring back to SHOWED framework questions) and to explain study objectives. Trained research assistants took observer notes during the small group sessions. In session 5, participants selected 1 photo each that they felt represented the main message that they wanted to convey to multiple stakeholders through dissemination activities, including a photography exhibition and moderated stakeholder conversations.20
Study participants who contributed data via photos and discussion over 5 sessions were provided $65 for their participation; individuals who were unable to complete all sessions but participated in at least 1 session were given $15 for their time. To ensure that we had achieved thematic saturation, we recruited a second cohort, including 2 mixed-gender groups. We followed the same procedures as the initial cohort, and the data from both cohorts were analyzed as a collective.
Data Analysis
Photographs were used to bring forth discussion and meanings of the images; thus, contents of photographs were not coded separately from the audiotaped discussion in a multi-stage and iterative process of analysis and organization.21 To develop the initial codebook, 2 trained coders (S.V.C. and Z.Z.) each independently coded a sample of the transcripts using a line-by-line inductive approach. Researchers coded all themes related to the research question rather than limiting focus to only the most commonly occurring codes to ensure that the voices of additionally marginalized groups within this sample of Black adults (eg, low mobility, physically disabled, low literacy) would be represented. Then, we used a code-recode process iteratively to ensure reliability of coding among coders. A third coder (R.B.) coded all transcripts as an additional layer of fidelity.
After the complete codebook was developed, the research team collated the themes. Disagreements were settled through consensus. Based on the categories of topics that surfaced from the data—including individual, interpersonal, community, and policy levels of information—the socioecological model22 was chosen as a guide for preliminary organization of the several dozens of codes. Finally, we convened as a research team to condense themes among codes into overarching meta-themes (thematic categories that systematically included 2 or more themes) and to discuss interrelationships, which are presented in this article. Resulting themes were reviewed with participants to ensure that the photographs, themes, and framing reflected their intended messages.20,23,24
Results
Study Participants
Twenty-four residents aged 49 to 93 (mean age, 65.1 years) enrolled in this Photovoice project. Two-thirds were female, and 77% had at least a high school education. More than half of the study participants earned < $25 000 per year. Half of the participants were retired, and 23% were not working due to health. Ninety-one percent of the participants had health insurance coverage. Study participants represented 18 residential Zoning Improvement Plan Codes in Baltimore, MD, which ranged in racial composition from 13% to 96% Black residents. Eighteen of twenty-four participants (75%) lived in Zoning Improvement Plan Codes composed of 50% or more Black residents. The median household income across Zoning Improvement Plan Codes was $32 667 (interquartile range, $13 470). Participants produced 1437 photographs through this process and generated over 35 hours of discussion.
Participants described the aspects of the food environment in both physical and social terms. Figure 1 presents a conceptual framework of the relationships among themes identified in the data. Themes with exemplar quotes are explained in subsequent paragraphs.
Figure 1. Relationships among Social Injustice, the Food Environment, Community Asset-Based Approaches, and Health as described by Photovoice Participants. Note: Levels of racism—institutional, personally mediated, internalized—have been previously described25 and were applied to sort participants’ reported experiences of the food environment.
Social Injustice
As it pertains to the physical food environment, participants described a lack of healthy foods in their communities as well as the oversaturation of unhealthy foods, including processed and fast foods offered by convenience stores, liquor stores, and “carry-out” restaurants. They considered these conditions a matter of social injustice. They further drew associations between unhealthy food products and their health.
“But I’m just saying, it’s this [in]equitable distribution of food, I think that’s how it relates to our health. I feel like when you go to certain markets, if they got a lot of processed food, that’s killing us.”
“People come into our community to take the little bit of money that we have. We’re talking about a poor community. I live in a poor community. And sell us things that’s going to hurt us, that’s going to harm us, and that’s not necessarily good for us. But if you’re really concerned about the people even though some people say, “Well, they eat it. They eat it. We bring it in.” That’s all they have. If somebody gave you a couple of dollars, you can go get a couple of chicken wings. But you do this every day over years, and years, and years, it’s going to give you cardiovascular disease because they cook it in hard canola oil. You know?”
“It shouldn’t be a question about whether children are able to have a decent breakfast and lunch while they’re at school… It shouldn’t be a question about whether people are able to have a decent meal every day, or at least a halfway decent doggone meal… It shouldn’t be that you have to make a choice about whether you’re going to pay your rent or your mortgage or go out and buy food for your family. That’s crazy.”
They described aspirations for an environment that would consistently provide access to quality nutrition and food experiences for every person (Figures 2 and 3).
Figure 2. Photo, untitled, produced by a participant at a local store in Baltimore, September 2019. “Even if you don’t have a lot of money or whatever, you still want to live in a neighborhood that’s decent quality food.”
Figure 3. Photo, entitled, “Down by the Lake (water draws people)” produced by study participant in Baltimore, September 2019. “This is [an] experience; there is a better way…you don’t always have to eat out of a greasy spoon. You should treat yourself.”
“…you look at the fruits and vegetables in the picture, and everybody should be able to have fruits and vegetables that look this fabulous, and they should be able to eat those most nights.”
Structural Racism and Classism
Participants further explained that the social injustice that they experienced via the food environment was undergirded by structural racism and classism. They compared the quality of the stores in other neighborhoods to that of their own and provided racism and classism as rationale for observed differences.
[Regarding the lack of supermarkets] “…Because I’m going to say the color of your skin, unfortunately.”
[Regarding the lack of supermarkets and abundance of liquor stores in their neighborhood] “Money. Money. I do believe it’s money because when I moved where I’m at now, we had two supermarkets on Harford Road…Really, they say it’s no money in the area, but you got five liquor stores. So, aren’t these people that’s drinking, eating?”
“Most of them places don’t want to come into the Black community… I guess because they got to put up with too many problems in there.”
“I think it would educate the powers that be…that when they[‘re] dealing with development…to stop pushing in our communities, especially the African American community. Stop pushing in our communities’ stores that are not good for our children. If you go into counties then look at those demographics, they have some of these stores but…it’s not taking up the block with eight to ten of the same places.”
Participants perceived aspects of the food environment a feature of broader inequitable environmental experiences, including disparities in housing, education, employment opportunities, zoning ordinances, municipal services (eg, sanitation), and taxing practices.
[Regarding property value and gentrification] “They[‘re] pricing you out of your property. Now, I bought this house…[it] was $13,000. I paid cash. My house now is valued at 129. But the thing of it is they[‘re] renovating them and fixing them…selling them for $300,000.”
[Regarding education] “But sometimes, like you say, you have to feed people’s minds…Not just with nutritional food, but you know, education, and encouragement, and empowerment.”
[Regarding unemployment]“… I get men that’s out there on the corners, give them work…”
[Regarding taxes]“We’re always overtaxed, and we get less.”
[Regarding zoning] “Now, people start sitting and drinking in front of [this vacant building]. This is an eyesore. People leave trash and the rats come out. This building could be turned into a [market]. Discriminatory practices [in zoning and business loans] against Black people don’t allow them to buy lots and buildings. It’s not affordable to a lot of people, so they give up.” (Figure 4A)
From their perspectives, these disparate circumstances supported by unfair policies adversely affected the types and quality of food stores and markets that are made available in their neighborhoods on the structural level. They saw these inequities as very much driven by race and socioeconomic means.
Figure 4. A, Photo, entitled, “Baltimore (Ball-mor))” produced by study participant in Baltimore, November 2019. “This building could be turned into a [supermarket]…Discriminatory practices against Black [people] don’t allow them to buy lots and buildings. It’s not affordable to a lot of people, so they give up.” B, Photo entitled, “Closed Market,” produced by study participant in West Baltimore, September 2019. “This closed market was the only market in the area…There is not a fresh food market in the area…”
“I think [the lack of grocery stores] has something to do with the race of people, too…Because when you go into other neighborhoods…Caucasian…even…Mexicans, they have stores. The only ones we have [are] liquor stores or a store where you can buy some hair.”
“And I think they know that there’s a disparity, there’s a shortage of these markets that we have in our area, so they feel like, hey, you can just… give them anything, this is the only place they can go…”
Some participants also noted the complex cycle of crime and poor food options resulting from disproportionate economic disadvantage. Where local markets existed previously, some were forced to close due to product shrinkage (loss of inventory due to factors such as employee theft, shoplifting, damage, administrative errors). Participants also perceived the closures to be related to neighborhood conditions, such as lack of affordable food options within the context of low income, often highly unemployed communities (Figure 4B).
[Regarding markets being closed due to losses] “That’s just why they took and stole for [lack of affordable options]. Everybody taking, doing one thing…That’s why they don’t have…markets in the city…[be]cause they took advantage of [those] markets, [be]cause [those markets] took advantage of us.”
“People with cars can get around. People in the neighborhood have no access. Concerns about crime and safety…if it was easier to get stuff, crime would decrease.”
Interpersonal Racism
These attitudes were also reflected in perceptions of treatment on the individual level, including reports of discrimination and maltreatment by local businesses, often owned by people of other races. Participants drew correlations between the food environment and their experiences as Black consumers, as well as broader social experiences that they found dehumanizing. Experiences in non-food stores helped to shape their overall shopping experiences with spill over into the food environment. Further, broader social experiences, such as violence in the community, shaped the context of how residents engaged the neighborhood’s business landscape and perceptions of maltreatment.
[Regarding discrimination against Black people at stores] “…First of all, I don’t like the fact that when you walk into their stores, everybody’s eyes are on you, watching you like they don’t trust you. I don’t like that…I’m not talking about food, I’m talking like in the beauty lanes and the stuff like that. Those types of stores. You walk in, everybody’s eyes are on you.”
“When I go to the store, I’m a human being period so it [doesn’t]matter…However, when you go to certain places, everybody, every customer [is] not the same.”
“We deserve to be treated better, and people don’t understand if you constantly [live] with all this killing, and I can’t say the killing is equated to food, but what I will say is if [you’re] in the atmosphere…It’s like you feel like you’re a rat, honestly.”
Generational Effects
Participants expressed concern regarding the transgenerational effects of their food environment on their children to include poor eating habits that may promote chronic disease among their children. They perceived that there were aggressive investments in businesses that would not positively affect the health and well-being of their children. Further, they voiced concerns that the current business landscape, including food stores, would not promote opportunities for social mobility among their children or community development.
“Well, this is an inner city-school, and supermarkets that have fresh fruit and vegetables are a long way away. But there are a lot of fast food restaurants nearby…And then other restaurants that sell the chicken box. And those meals do not come with fresh vegetables a lot of times. Now with the Chinese meals, they do have vegetables in there, but it’s mostly rice and gravy….So like I said, [the children are] not really exposed to a lot of fresh fruit and vegetables, I think, on a daily basis.”
“And like I always say that in the city, the kids are learning how to be governed, not how to govern.”
“They closed all the communities as far as the kids to go out and do things. They had camps, neighborhood camps, and yeah, they put things together where kids can have places to go, and things to do… They even supported the meals for those that didn’t have any food.”
Participants also described how historical and current parental experiences affected the trajectory of eating habits for children. They acknowledged the eating habits of parents were highly influential in the dietary habits of their children. Moreover, parents’ experiences with food in their childhood household influenced what they prepared for their own children. Lack of leisure time also represented a barrier to healthy eating. Respondents noted lack of time or energy to navigate the food landscape to secure and prepare healthy foods.
“I think that is a cycle. More than likely the parents’ parents did not prepare those kinds of meals. So, the parents just follow the same guidelines or procedures that followed when she was a child, and the parent was never introduced to salads, so therefore, because she doesn’t necessarily require a salad or want a salad, she won’t give it to the children….”
“I think part of the problem too is our lifestyle choices. We’re busy. We are in a very busy society now. A lot of parents are working, sometimes more than one job, and they just don’t have the time or energy to, first of all, get to the store and think about buying nutritional food. But then you know, you have to think about how you’re going to prepare it later on. And sometimes you just get whatever’s going to be easiest. You know something that’s packaged, something that you could microwave.”
Mistrust
Participants communicated that mistrust of the food environment stemmed from broader mistrust of institutions and their actors. The perception that leaders were concerned more about money or power than members of the community was a cause for mistrust of systems of power. In addition, a lack of progress on issues of concern despite conversations with the community made residents mistrustful of leaders’ intentions. In some cases, this mistrust of leaders and their intentions caused residents to question the food sources themselves, for example, questioning the origins and authenticity of foods labeled “organic,” use of pesticides, and the nutritional value of genetically modified produce. To respondents, leaders’ lack of attention to an issue as essential as healthy food caused them to question other social policies, such as investments in community projects and school programs versus prisons.
“And the interest is in the people that, it’s all about money, it’s in the people that’s going to give the money. If you’re in a poor neighborhood and you’re not going to give them any money towards their campaign, they’re less likely to even show up.”
[Regarding inaction by decision-makers]: “They’re just listening to people… Just giving you a voice to vent, basically. But not going to do anything about it cause the plan is already set.”
[Regarding the cancellation of community projects and school programs]: “I know what happened, they said they allocated the money in a different way. They got that same money and put it into the prison. Right. And they said that they didn’t have the money to have these certain things, that’s why they took out gym, music, all the music and instruments and all that. But they spent millions of dollars to build a new prison. But they don’t have the money. They’re misusing our taxpayers’ money. That’s what happened, there’s a new agenda.”
In addition to the lack of representation in the food landscape presenting gaps in role modeling for youth, respondents discussed how lack of racial/ethnic representation among vendors further bolstered their sense of mistrust.
“And if you go in the market and you see people that don’t even represent you, I have an issue with that. In these neighborhoods, we always got a million and one people and I failed to realize that Black people could own a business, too.”
“Okay, when I grew up – I grew up in the city – and when I grew up in the city, I knew some of the homeowners [and business owners] in the city. They looked like me, they were Black people…Yeah, so, most of all the stores [were] owned by people who were living there. Some of the Black people that lived there, they lived over top of the store. And then it was an influx of Asians coming in. They came here, they had the opportunity. So, when they came here, I guess the Black businesses [weren’t] doing as well. So, what they did, they went around knocking on people’s doors just like my mother-in-law, and they asked could they buy their business. It’s not their fault that they’re here, it’s the fault of the people who sold them the business. You should’ve said ‘no’if you wanted to keep your community.”
Social Programs
Participants discussed social programs and their impact—both intended and unintended—on the community. Participants spoke highly of some of the local food service programs for older adults and mobile programs to support people with disabilities. They saw this as effective use of funding and helpful for those who face food insecurity.
“It’s done by the Baltimore City Health Department, and it’s a nominal fee you pay, and the meal I’ve had, Eating Together menu, it varies. It could be maybe a piece of fish, two vegetables, fruit, and juice, and sometimes milk. Might even be a cookie. It’s usually a dollar, or sometimes it’s free. Again, it’s free. The nominal, the requested price of a dollar or a dollar and a quarter, and most senior buildings provide the Eating Together Program.”
However, administrative rules surrounding other programs compromised trust that the system had their communities’ well-being in mind. For example, regulations around employment and distribution of Supplemental Nutrition Assistance Program benefits raised concerns. Residents argued that the program lacked the buffer of time required between gaining employment and stabilizing expenses of a household before reducing benefits for young families. Ultimately, participants argued that this type of governance trapped even motivated individuals in a cycle of poverty and related issues in accessing food.
Community Asset-Based Approaches
Participants also enumerated community asset-based approaches towards the social issues that they perceived within their neighborhoods and the food environment, specifically. Knowledge regarding home gardening and healthy food preparation were among actionable skills that participants acknowledged within their groups (Figure 5). They also spoke about cultivating community gardens more broadly in the city and raising awareness about their accessibility to residents.
Figure 5. Photo, untitled, produced by a participant in East Baltimore in his backyard garden, September 2019. “…because one of the brothers who comes to the program, he grows his own food…”
“Find a couple people who like to cook…because one of the brothers who come to the program, he grows his own food…And open up a health kitchen…Health kitchen in our community. That thing we can do on our own, really. Because we[‘ve] got the talent and the skill.”
[Regarding building a community garden]: “I mean, if the neighborhood got together and talked to them, they might. That is a lot of land. Let’s say taking a few square feet isn’t going to take away from the park. In [redacted name]’s case, I think the community association got together and they talked to some people and then they put some pressure on them, look, this is what we’d like to do. It would be better for us to do this. Rather than let it stay vacant and people throw trash up there.”
“I think that there are several cooking and nutritional programs in the community, and they were free programs, but how do you disseminate that information and let community members know, this is what’s available and you’re invited?… You can [canvas the] neighborhood and take it door, to door, to door, to door. [inaudible] and have it advertised, this will put work here… Or maybe take it to the school and let the students take it home to the parents.”
Advocacy and Civic Engagement
Participants also claimed ownership of their role in changing their neighborhood and food environments. They discussed how buying power may be used to leverage change. Moreover, they offered voting in local, state, and national elections and referenda as key to thriving as a community.
“So, with the powers that be, we demand, because you know, African Americans, we have a lot of buying power. We spend billions of dollars. If African Americans said, ‘Hey, I ain’t coming to your hair store’ if they said, ‘We ain’t getting your chicken box.’ Because we can fry our own chicken with…air fryers, I’m frying chicken. But you know what I’m saying? You know, the chicken boxes and all that… if we took a stand, taking our money back, it would be [another] story.”
“You think that your vote isn’t important. Your vote is important. I say…we will survive regardless. You know what I’m saying? We are doing so much stuff that we will survive, but I just want more for us.”
Discussion
We used Photovoice methodology—a participatory approach—to understand how Black adults with hypertension in Baltimore, Maryland perceived their food environment. Some of the findings—that there was an abundance of unhealthy foods and a dearth of healthy food options at premium prices—are consistent with what we know about urban food environments from previous literature.12–14,26 This study offers the perspective of residents that the food environment was manifested through structural racism—that conditions were more socially engineered through unfair policies than by natural occurrence or mere happenstance. Through a series of small group discussions with photos captured in the city, participants described how broader social policies and related social determinants—housing, taxes, zoning ordinances, education, employment, and municipal services—sculpt their food options in terms of quality and quantity. Participants went further to voice concerns about the effects of this environment on well-being and its underlying drivers on future generations, as well as opportunities for community-based solutions, such as community farms, health education kitchens, and the role of voting.
Experiences of unfair treatment as well as racial and economic segregation in the local food environment has been previously identified as a theme of shopping experiences among Black caregivers.27 Participants in our study went further to link what they observed to not only other features of the neighborhood, such as poor sanitation conditions and abandoned buildings, but also deeper root causes embedded in social institutions. For participants, the quality of goods in stores and services that they received represented beliefs and attitudes not only about their socioeconomic status or willingness to pay for goods but also their value as human beings.
In addition to study participants’ concerns about the impact of the food environment on their own health, they expressed even greater concerns about the effect of the food environment on the psychosocial and physical well being of their children. This is consistent with a Photovoice study of children who lived in Supplemental Nutrition Assistance Program-eligible households that found that unhealthy food was readily available and that challenges such as functioning kitchen equipment in the food environment served as a barrier to healthy eating.28 In another study of youth ages 11 to 14 years from low-income neighborhoods in New York City, respondents voiced similar concerns about the unsanitary presentation of foods in markets and the effects of pesticides on health.29 Participants in our study thought beyond the implications of healthy food on their children’s health but also how the food landscape in the city offered few opportunities for employment or role-modeling for entrepreneurship, which could be detrimental to their social mobility and, subsequently, their psychosocial wellness.
Our findings suggest that mistrust in institutions and their leaders can impact how people engage in obtaining food. The perception that leaders were more concerned about money and power than the well-being of citizens, and Black residents, specifically, represented a great source of mistrust in institutions. Mistrust in governmental entities and businesses transferred to concerns about the food itself and the motivations of those who procure it, which may affect how individuals engage with the food environment. Although medical mistrust—distrust of medical personnel or organizations—due to historical mistreatment is well-documented among Black patients,30 less has been written about the role of broader institutional mistrust on health behaviors. Medical mistrust has been linked to several negative health outcomes as well as health care utilization, preventive care, and treatment delays.30–33 More research is needed to understand how institutional mistrust related to prior and ongoing mistreatment and discrimination affect health behaviors and outcomes.
Despite challenges in the food environment, our study participants expressed a level of self-efficacy in their ability to make their circumstances better—an asset-based perspective. Similar to Black respondents in previous studies,27 these Photovoice participants discussed resilience and resourcefulness as key community-based assets. At the same time, they offered ways in which changes to national and local policies—extending beyond food provision programming—could improve their access and consumption of healthy foods. In the end, residents acknowledged their roles in improving their food environment, including sharing knowledge within their communities, becoming self-sufficient by leveraging community assets, and participating in civic activities, such as city council meetings and voting.
Practice and Policy Implications
The information gained from this qualitative research study may be used to inform both clinical practice and health policy. The American Heart Association has recently made a call to action to address structural racism as a fundamental driver of health disparities, including transforming the living conditions of historically marginalized groups, correcting disadvantages in their housing and neighborhoods as well as changes in policy that promote economic and educational opportunities34; these sentiments were reflected in the photographs and discussion of the food environment among participants in this study. Moreover, participants in our study communicated that community voices should be engaged when addressing issues of the local food environment.
In clinical practice, a greater understanding of a patient’s local food environment could facilitate clinicians making recommendations their patients are more equipped to follow. Engaging with patients in equipoised discussions about navigating barriers to attaining healthy food could promote more successful dietary behavioral change and outcomes. Clinicians can also provide proper referral to existing food resources. Utilizing community assets may help to address systemic issues as well as encourage health-promoting behaviors at the individual level among Black patients with hypertension. Additionally, clinicians and policy makers should be aware of the nuances individuals face regarding their food environment, including the role of structural racism in its construction and the subsequent impact on residents’ health outcomes. Acknowledging the role of structural factors in creating these unfair conditions may open the opportunity to create counter policies to correct adverse direct and indirect effects. For example, policy changes that enhance opportunities in the food landscape mentioned by our participants, such as zoning laws and subsidies for “homegrown” markets and food businesses, could have long-term effects on both eating behaviors and job opportunities within the city.
With the conclusion of this study, photos will be exhibited and used during a moderated stakeholder conversation on the food environment in Baltimore. Photos will be accompanied by proposed solutions to address community-identified problems with the local food environment as well as address racial disparities in chronic diseases.
Limitations
This in-depth, community-based qualitative analysis bears similar limitations as other qualitative studies. First, this population of participants was a self-selected, purposive sample. Participants in this Photovoice study met initial clinical criteria (elevated blood pressure and kidney concerns) and were interested in participating, but ultimately screened out of a community-based dietary trial. This may reflect increased motivation regarding their health relative to individuals who were enrolled in the trial as well as those who were never contacted to participate. Therefore, their perceptions may differ from those who are, perhaps, less health conscious as well as those who are in better health. While this may limit generalizability to other populations, it may provide additional insight to our research question as the responses come from individuals who both have a health condition and are actively seeking healthier food options. Challenges in the food environment differ and may even be amplified for individuals with dietary restrictions. In this way, understanding the food environment and access needs of this at-risk group could have the potential for even greater public health and health equity impact. Secondly, this is a localized data set, reflecting the experiences of residents of Baltimore, MD, further restricting generalizability. Different themes might emerge from another geographical context. Despite the limitations of this small, localized sample, findings from this data are corroborated by other quantitative and qualitative studies conducted beyond this specific setting. We have provided a sample description including demographic and geographic representation to aid other researchers in discerning the applicability of our findings to other populations.35,36
Despite these limitations, this study was able to reveal a deep understanding of the lived experience of the food environment in Baltimore, MD, including the perspectives of life-long residents, which is a strength of this qualitative inquiry. We incorporated several practices into the data collection and analytic processes to support scientific rigor and data quality.35,36 First, data were collected across the course of serial encounters with participants to ensure that themes were reliable rather than the product of a single encounter. We subsequently recruited a second cohort of participants from a second site in the city to further assess internal validity of themes from the initial cohort. We also incorporated single gender (all male, all female) and mixed gender (male and female) discussion groups to account for any imbalance in perceptions of the food environment by gender and to promote cross talk regarding these potential incongruencies. Secondly, our study sample was geographically diverse—representing 18 different Zoning Improvement Plan Codes in Baltimore, MD, which supports external validity to this locale. Finally, we used participatory analysis and member checking to ensure that the research team’s analysis reflected participants’ intended messages. Our participants ranged in age (49–93 years), household status (lived alone or with others), family status (have children under the age of 18 years, adult children, or no children), marital status (single or married/partnered), employment status (employed, unemployed, retired), and self-identified gender (woman or man), representing diverse intersectional perspectives with rich nuance even if not completely transferable to other populations. The study benefited especially from the participation of senior participants (aged 70 or older) who were natives of the city, which allowed for rich historical and longitudinal perspectives on the food environment, its origins, and its evolution.
Conclusions
We used Photovoice research methodology to identify facilitators, barriers, and opportunities for change among Black residents in a large urban city regarding their food environment. Participants noted their lived experiences of the food environment on the individual, community, and broader policy levels. Social injustice, with foundations rooted in structural racism and classism, emerged as key themes that were discussed across participant groups. Participants took stock of their communities’ strength, ingenuity, and resilience as key assets in making meaningful changes to the food landscape.
Article Information
Acknowledgments
We would like to acknowledge the efforts of our Photovoice study participants without whom this participatory data collection and analysis would not have been possible.
Sources of Funding
Dr Hines’ effort was supported by National Institutes of Health (NIH)/NIHMD Investigator Research Supplement 3U01MD010550 as well as Career Development Award NIH/NHLBI 1K01HL152011 (PI: Hines) through data collection, analysis, and article preparation. The efforts of Ms Brody, Mr Zhou, Ms Omenyi, and Drs Miller, Cooper, and Crews were supported by NIH/NIMHD U01MD010550 (PIs: Miller, Crews).
Footnotes
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