The study was conducted during 2011 and 2012 in Lenoir County, North Carolina, a rural community with a large African American (40%), low-income population (23.2% poverty rate in 2010) that is situated in the widely known “stroke belt” that runs through the southeastern United States (7,17). Institutional review board approval for this research was obtained through the University of North Carolina at Chapel Hill, and written consent from all participants and parents or guardians of participating adolescents was given before participation in discussion groups. We sought participants who were African American, able to commit to attending multiple sessions, and willing to share their perspectives on the health of people in their community. A total of 6 adults (5 female, 1 male) and 9 adolescents aged 14 to 17 (6 female, 3 male) participated in 2 different photovoice projects, each conducted over 6 months with 4 photo discussion sessions each. Participants were recruited through purposive sampling via 2 local community leaders (a community advisory committee member and a participant assisting with HHL formative research). For the adult group, the community leader (a coauthor of this paper) was a former health educator with deep roots in the African American community. Building on her connections in the community, she identified potential adult participants from diverse settings (churches, community-based organizations, rural and urban sections of the county) and invited them to an informational meeting with the research team where a face-to-face recruitment and informed consent process took place (Figure 2). The community leader who recruited the adolescent group was the director of a community-based organization serving African American youth. She identified potential youth participants in her organization and invited them and their parents or guardians to an informational meeting with the research team.

After orientation and providing consent, participants were asked to generate photo assignments related to barriers to and facilitators of heart health. Participants were given a camera and took photos each week of the agreed-upon photo assignment. When the groups reconvened a week later, each participant shared 2 to 3 photographs he or she had taken related to the photo assignment (Figure 2). Each group discussion was moderated by 2 research team facilitators and lasted approximately 90 minutes. Through discussion and voting, the participant group then selected 1 to 2 “trigger” photographs (ie, photographs that could trigger critical reflection) for in-depth discussion. For each trigger photograph, facilitators led the group through a structured discussion using the SHOWED mnemonic to generate new understanding about barriers and strategies for improving cardiovascular health in the community (16). All group discussion sessions were transcribed verbatim and imported into Atlas.ti version 7 (Scientific Software Development GmbH) for further analysis (18).

Data from the 2 photovoice groups were initially analyzed separately by the photovoice facilitators and member-checked by adolescent and adult participants to ensure the themes that emerged reflected their perspectives. Results from each photovoice project were shared through a joint community forum to present the findings to the community, friends and family, and other stakeholders and to initiate conversations about heart health. Subsequently, these data were reanalyzed jointly in fall 2014. Through a data-driven, inductive approach, the first author read through each transcript several times and developed a set of codes (19), which were systematically applied to all transcripts. After coding, matrices were developed for all topical and interpretive codes to clarify understanding of concepts and relationships between codes. The entire research team discussed emergent themes in team meetings to distill data into key themes. All photographs shared in sessions (n = 126) were analyzed according to photographic-specific codes to identify key themes, such as participants’ descriptions of the photographs, imagery, and connections to the photo assignment. To ensure trustworthiness and rigor, research themes were based on participants’ perspectives and photographs, themes were member-checked with the participants, quotations and photographs were presented to illustrate key themes, a log was kept of all analysis decisions, and repeated sessions allowed us to iterate findings (19).

Throughout the group discussions, adult and adolescent participants described cardiovascular health in line with the AHA definition (ie, not smoking, engaging in regular physical activity, eating a healthy diet, maintaining a healthy body weight, and keeping cholesterol, blood pressure, and fasting blood glucose below recommended levels). In addition to these domains, participants also spoke about the importance of mental (ie, depressive and anxiety symptoms, psychological stress, and anger), spiritual (ie, meaning and purpose), and social (ie, belongingness) components of heart health (20,21). For mental health, adults consistently described stress as adversely affecting health behaviors (eg, unhealthy eating, sedentary behavior) and physical health outcomes (eg, hypertension) related to CVD. Stress was described as being so powerful that even if individuals pursued other healthy behaviors (eg, marathon running), they could still end up dying prematurely or unexpectedly. Despite the influence of stress, it was frequently underestimated as a health factor by others in the community. As one adult explained,

As the quote illustrates, adult participants described stress as a product of race-based prejudice, as an artifact of everyday life, and as a mindset. Because it was embodied and experienced day-to-day, it was not recognized as a health factor. Only adults discussed stress and its relationship with racism. In explanation of this phenomenon, one adult stated, “The adults lived it [racism]. The children don’t know. They’ve been told about it.” As the quote suggests, adults believed adolescents were not as familiar with encounters of race-based prejudice and any resulting stress.

In addition to mental health, adults also described the roles of faith, meaning, and purpose in their lives (eg, spiritual health) in relation to cardiovascular health. For instance, adults talked about how their faith in God could “take a piece of that cancer,” how Jesus set an example for healthy living, and how understanding one’s larger meaning in life could inspire healthy behaviors. Although adolescents did not explicitly discuss faith and God as connected to cardiovascular health, they did emphasize the importance of family and relationships (ie, social health) and their effect on cardiovascular health behaviors (eg, exercise, diet).

Given the broad conceptualization of cardiovascular health dimensions, adult and adolescent participants discussed many barriers to cardiovascular health, which have been organized according to the Social Ecological Framework (5). These barriers included problems with the physical environment, the social environment, a lack of resources, and advertising for unhealthy lifestyles (Table 1).

Despite acknowledging these barriers to cardiovascular health, participants attributed responsibility to individuals. Particularly among adults, many participants affirmed that, despite community, institutional, and interpersonal barriers, they were still able to choose healthy behaviors:

From photographs 1 and 2 in Table 2, the juxtaposition between ecological influences on health decisions and individual responsibility is clear. In the foreground, the convenience, affordability, and accessibility of processed, cheap food is apparent through the sales and advertising for snack foods; in the background, fruits and vegetables are visible, yet they are presented without any type of positive promotion. As many participants emphasized, despite barriers that may make it difficult to be healthy, “it’s up to the person to make the choices.” Accordingly, in talking about instances when adults failed to make healthy choices, participants discussed having a lapse in determination, lacking a “strong mind,” and not staying “conscious” to their true goals. Through these descriptors, the emphasis on mental (ie, psychological willpower and fortitude) and spiritual (ie, purpose, meaning) health is evident.

All participants endorsed the idea of choice and individual agency in cardiovascular health behaviors to some extent, yet 2 nuances emerged. First, discussions over individual responsibility for cardiovascular health were at times contentious and one adult participant reported feeling “personally attacked” by her peers for not making enough healthy choices. This sentiment exemplifies the challenges and tensions that participants may feel in having to be responsible for health decisions as well as the judgment and social pressure attached to being healthy. Second, similar to adults, adolescents attributed responsibility for individuals to make healthy choices; however, they described less ability to stay healthy in the future. For instance, although some adolescents reported that they could stay healthy if they got their “priorities straight,” others discussed challenges, such as the inability to choose what foods their parents purchased. For instance, one adolescent reported in reference to the allure of candy and chips, “Because like I’ll try to stay healthy, but there’s always gonna be something that gets you off track.” Thus, although adults described greater agency to be healthy, adolescents explicitly discounted their ability to stay healthy, at least when faced with temptation from unhealthy foods.

Participants also discussed several communitywide strengths and assets that could be used to improve heart health. These facilitators were related to participants’ conceptualization of heart health and included social, spiritual, and mental health dimensions. For instance, given the importance of social health, both adults and adolescents discussed how family and community relationships could be used to promote heart health. Although adults sometimes spoke of making unhealthy choices, they consistently emphasized how their experiences and knowledge could be used to help adolescents make better decisions. As one adult said,

Likewise, adolescents discussed how they often relied on family members and elders to determine what was healthy or not. Although adolescents discussed how adults could sometimes negatively influence their health through poor eating and drinking habits (eg, one adolescent described his grandma as having Pepsi running through her veins), when asked about adolescents’ role models for health, family members were always mentioned. Therefore, both adults and adolescents discussed the importance of family and community members in the behaviors they engaged in and choices they made about their health.

Adults also mentioned that spiritual health dimensions could be used as a means for improving cardiovascular health. Adult participants discussed how understanding one’s purpose and finding meaning in life could improve health behaviors. For example, when asked about how the community could improve adolescent sedentary behavior, one adult said,

When I look at it, it comes to purpose. ’Cause we all have a purpose for doing whatever we do, so each individual have to look within and see and know, ‘Okay, what is my purpose for this?’