Purpose: This study explored the meaning of smoking from the perspective of rural low-income women and its effect on the relationship to social identity, sociocultural factors, and smoking behavior. Using photovoice from a relativist's perspective, the purposes of this study were to (a) explore cultural and social factors that give meaning to being a smoker in rural low-income women and (b) explore the relationships between social support, social networks, social identity, and the meaning of smoking in rural low-income women's decision to smoke and attempt smoking cessation.
Methods: This is an interpretive focused ethnography using photovoice as the primary method of inquiry to collect data from low-income rural women residing in three homogeneic and neighboring counties located in the mid-Atlantic portion of the United States. Counties selected for recruitment presented high rates of poverty, smoking, and unemployment with similar cultural, economic, geographic, and social characteristics. This naturalistic approach to inquiry included community assessments and individual photo elicited interviews. Participants completed an initial interview focusing on their current smoking behaviors and smoking history. After completing self-produced photographs of smoking experiences, a second individual interview was conducted using the photos as a mechanism to elicit deeper discussion and gain insight into what it means to smoke and be a smoker. Demographic data were recorded and analyzed for similarities and nuances. Transcribed narratives and photographs were analyzed for the complexity of participants' stories, focusing on the phenomenon of smoking in various aspects of their lives, including identity development and the socio-cultural meaning of smoking (Goodall, 2000; Saldana, 2013). ATLAS.ti was used to support descriptive, thematic, and theoretical coding of transcripts and photos to facilitate identifying variations and patterns reflective of the women's experiences, relationships, social and cultural beliefs, and behaviors within the social context of smoking.
Results: Of the 17 women enrolled in the study, 13 completed both interviews and submitted photographs, which resulted in 26 interviews and 196 participant-produced photographs for analysis. For these 13 women between the ages of 25 and 63, social characteristics showed all participants living as single women, most with dependent children, a common history of drug or alcohol abuse, current or previous domestic violence, and exposure to community violence in their current living conditions. All the women wanted to find a job. Seven themes evolved from analysis of the data which add to our understanding of what it means to be a smoker within the social context of low-income rural women: (1) feelings of isolation (2) struggling day to day (3) it’s relaxing (4) looking good and the sense of empowerment (5) family support and expectations (6) being a good mother (7) hope for a better life. Although the interview questions did not specifically ask about rural life, patterns and themes disclosed during narratives and review of the photographs related to social engagement, social identities, and the meaning of the women's social relationships within the context of rural living. Feelings of isolation were associated with the geographic nature of rural living and further amplified by the stigmatization encountered when identified as a smoker. Prominent narrative themes include relationships between smoking and their roles associated with family membership, being a good mother, and their need to feel empowered within their social environments. As established in previous smoking studies, women in the current study described smoking as a tool for relaxation and stress relief.
Conclusion: Photovoice is an effective and creative method for expanding our knowledge of the relationship between smoking and social determinants of health. Findings presented in this study add to our understanding of cultural and social factors that give meaning to smoking in rural low-income woman; and explore the relationships between social support, social networks, social identity, and the decision to smoke or attempt smoking cessation in this marginalized population of smokers that have not responded to current smoking cessation interventions. This knowledge will be useful in the design of smoking cessation interventions that target low-income women living in disadvantaged rural areas and supports the use of this creative research approach in future studies that target disadvantaged or marginalized populations.