Journal of Immigrant and Minority Health
https://doi.org/10.1007/s10903-019-00934-1
ORIGINAL PAPER
Identification of Cultural and Transcultural Health Assets Among
Moroccan, Romanian and Spanish Adolescents Through Photovoice
Encarnación Soriano‑Ayala1 · Verónica C. Cala1
· Diego Ruiz‑Salvador2
© Springer Science+Business Media, LLC, part of Springer Nature 2019
Abstract
The health assets model focuses on recognizing the strengths, capacities and resources of individuals and their communities
to improve health control processes. This study focuses on identifying and comparing the transcultural and cultural assets
in health as accounted for by 45 young Romanians, Moroccans and Spaniards living in southern Spain. The research uses
a photovoice method to understand what young people consider to boost their health. Of all the photographs taken, each
young person selected the six most relevant images, and individual interviews were carried out. Both images and interviews
were analysed qualitatively using Atlas Ti. We identified 40 transcultural assets in health that were common among the 3
cultural groups and 7 cultural assets that were specific to cultural groups. The seven assets include religion and spirituality,
cultural symbols, medicine, traditional food, thinness, freedom/autonomy and plants. The definition of transcultural and
cultural health assets facilitates the development of educational health interventions that reinforce the strengths of others in
a culturally sensitive manner.
Keywords Transcultural health · Photovoice · Health assets · Immigrant · Adolescents · Romanian · Moroccan · Spanish
Introduction
Currently, two of the major challenges in health education
and the promotion of well-being among students are (1) the
lack of studies on how adolescents perceive their problems
and capacities related to health and (2) the shortage of proposals that address the cultural diversity that occurs in classrooms, especially as a result of migration. The adaptation to
new sociocultural realities and the adaptation of programmes
to adolescent subjectivities regarding health are two fundamental aspects in improving the adherence to and effectiveness of educational programmes in health and meeting the
criteria of social equity [1, 2].
* Verónica C. Cala
Vcc284@ual.es
Encarnación Soriano‑Ayala
esoriano@ual.es
Diego Ruiz‑Salvador
rsd375@ual.es
1
Faculty of Educational Sciences, University of Almeria,
Almeria, Spain
2
Faculty of Nursing, University of Almeria, Almeria, Spain
Cultural diversity has proliferated in recent decades as a
result of globalization and the reorganization of labour markets, two trends that have generated strong migratory flows.
In Spain, the number of residents born in other countries
increased fivefold between 1998 and 2008. If we address
the impact of this phenomenon on adolescents, we find that
migratory processes and adaptation to new sociocultural
contexts are associated with a substantial emotional burden
for young immigrants [3, 4].
Health Promotion Model Based on Health Assets
Addressing the various circumstances in which migrants
live requires identification of their strengths. The traditional
approach to health education has received criticism for its
pathogenic vision, which focuses on the recognition of diseases and health problems without addressing the variables
that contribute to health-disease processes. In view of this
focus, the salutogenic model introduces two fundamental
aspects: (1) it denies the existence of absolute well-being
or discomfort and defines health as a continuum in which
different dimensions are intertwined [5, 6], leading to a
definition of health as a series of conflicting forces; and (2)
it opposes preventive models centred on “deficits”. In this
13
Vol.:(0123456789)
Journal of Immigrant and Minority Health
sense, the salutogenic tradition has focused on identifying
competencies, resources and strengths that favour positive
development during adolescence [7]. In this conceptual
framework, Morgan and Ziglio [8] define a “health asset” as
any factor or resource that enhances the capacity of individuals, groups, communities, populations and social systems to
maintain health and well-being and help reduce health inequities (p. 18). On the other hand, Rotegård et al. [9] consider
internal and external strengths that the individual possesses,
in an innate or acquired way, that are associated with positive health behaviours and optimal health and well-being
results (p. 514). Some of the assets that have been identified
in adolescents are support and affection within the family,
positive adult models in the family, school and community,
and the ability to manage the processes of adolescence. Several studies [6, 8–10] have shown that empowerment can be
linked to healthier and more positive development.
This vision has not been explored only on the individual
level; community health plans include maps of community
assets and dynamic inventories of the strengths and capacities of the people who form a community to guide interventions [11, 12]. Several studies have focused on the health
assets of minority groups (immigrant, racial, ethnic or age
groups and people with specific illnesses or disabilities). It
is important to know the specific visions of health that are
held by these groups and the barriers and strengths these
groups identify to make it possible to adjust health care and
prevention programmes according to the identified health
assets [13–17].
Transculturality as an Inclusive Approach:
Transcultural and Cultural Assets in Health
The identification of assets related to health has overlooked
the importance of cultural factors; this oversight is revealed
by the scarcity of work in this regard [17]. This failure is
likely due to the persistence of a western and ethnocentric
concept of health education that is based on health models
that have traditionally been produced in Europe or North
America [18, 19]. The few cultural approaches that have
been undertaken are framed within multiculturalist perspectives that address differences between cultural groups across
a broad range but do not target dialogues and interactions
regarding multicultural realities. One of the fundamental
tasks of intercultural studies is the identification of crosscultural overlaps [19] (beyond Eurocentric knowledge);
knowledge of these overlaps can increase the legitimacy
of universalizing content that is applicable to multicultural
coexistence [20, 21].
The transcultural approach to the study and evaluation
of health levels lies in the identification of transcultural
health assets that are shared between different groups while
also recognizing cultural health assets that differ and are
13
related to the cultures and lifestyles of group members. The
transcultural perspective has proven beneficial in improving
the understanding of the health of migrants, promoting communication about health, reducing racism and rehumanizing
health care [22, 23].
This study represents part of a national project on
transcultural health education in immigrant and native
populations.
Aim
To identify transcultural and cultural assets related to health
in a group of Moroccan, Romanian and Spanish adolescents
using the photovoice method.
Method
Participants
Forty-five adolescents ultimately participated in the study;
10 of the participants were from Romania, 15 were from
Morocco, and 20 were from southeastern Spain. All the
selected adolescents were enrolled in public secondary
schools and were in their 3rd year of secondary school. The
immigrant participants belonged to what has been called
the “generation and a half”; that is, those who were born in
their countries of origin and migrated to Spain at an early
age. Only the participants who met the established criteria
(attended the training, returned authorizations by parents or
guardians, presented the photographs and were interviewed)
and remained in the study until the last phase of the investigation were part of the sample.
Of the 45 interviewed participants (P), 22 were females,
and 23 were males. Their ages ranged from 13 to 17 years,
with an average age of 14.46 years. Five of the participants
presented chronic diseases, including one participant who
had a serious disease. The residence time of the immigrant
adolescents ranged from 5 to 11 years, with a mode of
8 years. These dates coincide with the migratory boom that
was experienced in the south of Spain in the 2000s. High
residence time is associated with important acculturation
processes, indicating that part of the immigrants’ processes
of socialization and acquisition of habits in their styles of
secondary health (those that occur in schools and health centres and among peers) has occurred predominantly in the
Spanish context.
Differences were found in the family compositions and
structures of the different cultural groups. The marital statuses of the parents of the Romanian participants revealed a
high number of separations and divorces; half (5/10) of the
participants reported living alone with their mothers and
Journal of Immigrant and Minority Health
siblings, 2/10 lived with their mothers and stepparents, and
3/10 lived with their mothers and fathers with or without siblings. Most (18/20) of the Spanish adolescents conformed to
the traditional nuclear family model composed of a mother
and a father with or without siblings, while the Moroccans
presented nuclear or extensive family models that sometimes
included grandparents. The location of residence was also
apparent in the participants’ dialects; there were differences
between those who lived within villages and those who lived
on the outskirts of towns, specifically in farmhouses.
The lifestyles of young people are also conditioned by
the socio-labour situations of their families. The residences
of the adolescents were predominantly located in agricultural areas, with some professional activities performed in
greenhouses (intensive agriculture); greater migrant labour
was observed in this context. Despite overlaps in the labour
sector, notable differences among Spanish, Moroccan and
Romanian families were identified in the distribution of
work activities. All the mothers of the participating Romanian adolescents had jobs outside the home to which they
dedicated many hours and which served as the primary
source of family support, largely because of their civil status.
In contrast, the Spanish and Moroccan families presented a
“more traditional” labour distribution in which the individual primarily responsible for family support was the father.
Of the Spanish mothers, 57% were housewives, and among
the Moroccan mothers, 39% were housewives.
Photovoice Method
Photovoice is a research method that was originally developed as a way to study aspects of health in diverse cultural
contexts through photography. Wang and Burris [20] created
this method and used it to study the main health concerns
among rural women in China. They defined it as “a process
in which individuals use the camera to photograph their
daily health activities and their realities of work, focusing
on the issues of greatest concern in order to communicate
these issues to policy makers, health providers and influential advocates with mobilization possibilities to achieve
changes in this regard.” Photovoice has been used frequently
to highlight the needs and resources of excluded populations and especially to capture and present the voices of
these communities [13–17, 24–31], demonstrating that it is
one of the most appropriate methods available for deepening the representations of health of immigrant adolescents.
The method includes several phases [32, 33]. It begins with
training participants in visual investigation techniques that
allow them to reflect on their strengths and concerns through
photography; it includes a subsequent phase in which photographs are taken and used to establish a critical dialogue
through interviews and discussion groups and a final phase
of exhibition of the work to reach those who design policies
[30, 31].
This study uses the photovoice method and not the photoelicitation method because the goal of this study is transformation and social action. Although a joint analysis of the
identified issues is presented, the social action phase is not
reflected in the results presented in the article because that
phase is outside the proposed objectives.
Procedure
The photovoice study included three phases that took place
between September 2015 and June 2016. In the first phase,
ten high school educational centres in southeastern Spain,
specifically those located in the towns with the highest percentages of immigrant populations, were contacted. The
management and orientation teams of the centres were asked
to collaborate in participant recruitment. For the selected
students, training sessions were held on the photovoice technique, the use of photography, and images as a research tool.
The students were asked to take 15 to 20 photographs that
answered the following questions: What makes me lead a
healthy life? What objects, persons or situations do I associate with health? What favours and maintains my health?
When the photographs had been taken, each participant was
asked to select his or her six most important or representative
images. In a second phase, we collected photographs from
the students who voluntarily participated in the project and
conducted semi-structured and personalized interviews. The
interviews included notation of the participants’ affiliations
and analysis of each participant’s six selected photographs
using the SHOWeD method [34] (See, Happening, relation
in Our lives, Why, if Educate others, what to Do), that is,
what the participant sees in the images, what is happening
(meaning and interpretation), whether these observations
coincide with events that personally affect the participant or
his/her community, and why these events occur and how to
manage them (solutions). The individual interviews ranged
from 50 to 70 min in duration. The final phase consisted of
an analysis of the interviews.
Data Analysis
This study utilized a mixed-method qualitative analysis
approach, combining phenomenological and grounded theory analyses. The combination allows understanding the own
experiences of the health assets narrated by the adolescents
(phenomenological approach) and, in a second moment, to
deepen in the processes that underlie the phenomenological
descriptions (grounded theory) [35–37]. So there was a first
step of adolescent experience description, and then a second
one focused on understanding the meanings grounded in the
participant narratives, done with participant and researcher’s
13
Journal of Immigrant and Minority Health
collaboration. For the data analysis, the interviews were
recorded using a digital recorder and later transcribed. The
interviews were analysed using the qualitative data analysis
programme ATLAS.ti7 according to the phases proposed
by Corbin and Strauss [38], which include axial, selective and open coding, resulting in a total of 457 categories
grouped into 21 families. The images were analysed and
coded according to the specific families that were identified.
Ethical Considerations
To guarantee the informed, voluntary and conscious participation of all the participants, a written informed consent
form was provided that explained the anonymous and confidential nature of the extracted data. The form was signed by
the parents or legal guardians of each participant. In addition, verbal consent of the participants to participation in
the study was recorded in all the interviews. To reduce the
socioeconomic bias, cameras were made available to participants who did not possess cameras or mobile phones.
Results and Discussion
Identification of Transcultural Health Assets
Using the classification of Morgan and Haglund [39],
transcultural health assets were categorized according to
whether they were external or internal to the individual. In
addition, a category of assets associated with lifestyles was
created to link the internal and external assets. Table 1 lists
the identified assets.
Among the identified internal assets were well-being,
happiness, a positive attitude towards health, self-confidence,
acceptance, respect, self-esteem, and the ability to handle
difficulties and challenges. Likewise, special attention was
directed towards identity and the capacity for expression and
Table 1 List of transcultural assets referred by Spanish, Romanian and Moroccan adolescents
Transcultural assets identified
1. Internal assets
2. Assets related to lifestyle
3. External assets
a. Assets present in health socialization structures (family, peers, educational centres and
health centres)
b. Assets related to the environment and
society
13
Feeling of well-being
Proactive attitude towards health
Perception of happiness
Being young
Personal identity (recognize and accept oneself, be as one wants to be)
Gender identity
Cultural identity and feeling of belonging
Wanting and feeling loved
Trust and security, living without fear
Willpower and overcoming adversity
Access to healthy food consumption: varied
diet and not hypercaloric
Ability to carry out a number of regular daily
meals
Space, time and capacity for physical activity
Sense of humour (knowing how to laugh)
Decision capacity
Reflective and critical capacity
Maturity, empathy and sincerity
Respect/tolerance
Moderation and self-control
Sociability, ability to generate and maintain
social relationships
Communicative skills
Creativity
Regular body and oral hygiene
Rest, a sufficient number of hours of sleep
Access to positive forms of leisure without
drugs
Access to public health and social services
Family support relationships, especially
maternal
Positive peer relationships/friendships: supGood relationship with health professionals
port, counselling, mutual protection
Access to formal knowledge about health at
Connectivity, social networks as forms of
school
communication and relationships
Good academic results and future expectations New technologies as a source of health information
Good relationships with teachers
Group integration, feeling of belonging
Security and peace in the community
Moderate/not very extreme climates
Clean and uncontaminated neighbourhoods
Vegetation-nature-sea, beach and green spaces
Environments without addictions: no consumption of tobacco, alcohol, or drugs
Journal of Immigrant and Minority Health
relationships with others. Among the assets associated with
lifestyles, items related to access to healthy products and the
construction of behaviours were recognized. Based on the
results obtained after coding and prior to the interviews,
it was observed that the participants considered eating and
physical exercise to be the aspects with the greatest influence
on health; these aspects were represented in more than half
of the photographs presented. Of the six photographs that
each participant selected, at least one was related to physical
health in all cases, and 94% of the participants presented at
least one image related to eating. On the other hand, images
related to medical health care and assistance, neighbourhood
environment, family, sleep hygiene, leisure time and psychoemotional aspects of health constituted more than 90% of the
total images received. A quarter of the participants presented
images related to addiction or social networks.
The external assets were differentiated into health assets
present within the main structures of socialization (family,
peers, school, health centres and social networks) and those
in the environment. These groups of assets include support,
trust and information-sharing among family members [40],
peers, teachers [41] and doctors associated with the school
[42].
The internal and external assets identified in this study
coincide significantly with those identified in other studies
of young people and adults [42]. Therefore, studies focusing
on intergenerational differences between health assets should
be extended to provide a more dynamic vision of the ageing
process and health.
Although individual assets were identified in the different
cultural groups, cultural and gender differences were apparent in terms of the importance and meaning the participants
gave to each. Romanian females placed greater emphasis on
psycho-emotional factors and on the ability to make decisions and address problems that arise around health. Males
of all cultural groups especially valued participation in physical exercise. Among Spanish women and Moroccan men,
technology played a very important role, while this asset had
little significance among the Romanian families.
One of the shared health assets that has special importance is family support; in fact, it has been identified as one
of the main health assets among immigrant adolescents
[43]. In this study, all cultural groups presented this asset
as a source of support and protection. However, the dialogues with the three groups showed differentiating elements
with respect to the role of family support. In the case of the
migrant populations, special emphasis was placed on the
social cohesive role, while in the Spanish group, the idea
of emotional support and economic support was reinforced.
Likewise, the migratory projects that the young immigrants
described were treated as family projects; therefore, migration is associated with a specific role. The Romanian participants expressed yearning for Romania and the relatives
who were left there (the idea presented in Fig. 1), while the
women interviewed reported little contact and no interest. I
live with my sister… My mother, who is working,… is taking
care of a woman… and comes only on Saturdays and Sundays […] I’m alone, alone at home, only in the afternoons
that my sister works and that… (P27, male, Romanian).
Another element that should be emphasized is that in
certain groups the family is far from being an asset and can
actually represent a problem associated with health. Several
Moroccan females reported conflicting relationships with the
family, describing them as triggers of personal and identity
conflicts. This indicates that health assets should not be evaluated in absolute terms but rather in relation to the context.
Identification of Cultural Health Assets
In addition to the health assets that were common to the
three cultural groups, another series of assets appeared to be
unique to specific groups or cultures. This study identified
eight cultural health assets.
Religion and Spirituality
Religion appears as a health asset mainly in the group of
young Moroccans and appears to both affirm health and to
deny it. Other studies of Muslim populations also point to
religion as an asset for health [14, 44]. However, despite discussions of religion and spirituality in most interviews with
Moroccans, no homogeneous view of the role played by religious beliefs was evident. Two opposing positions existed.
On the one hand, some participants recognized the value of
religion for well-being and health (Fig. 2): It is also important for us to pray five times a day: when we get up, at two,
at six, at seven and at nine. (P35, female, Moroccan). These
Fig. 1 Photograph taken by a Romanian male student focused on
family support
13
Journal of Immigrant and Minority Health
Fig. 2 Photograph taken by a Moroccan female student depicting the
importance of Islam to health
participants associated religion with a sense of well-being
and superior health and referred to its organizational role in
healthy lifestyles by prohibiting the consumption of alcohol
and tobacco, promoting improved nutrition and emphasizing
avoidance of risky sexual relationships.
In contrast, another group of Moroccans do not assign
such value to this religious practice and described religion
as a source of contention with parents: “As for religion, I do
not pray, my parents want [me to], but I do not.” (P40, male,
Moroccan).
This polarization can be explained according to the concept of “contradictory modernity” in which a segment of a
population that is associated with more westernized patterns
claims liberalization of lifestyles, while another part of the
population is marked by a process of re-Islamization [46].
Among Romanian women, a positive sense of spirituality was identified that was less linked to a normative concept of religion. As participant 14 reported, “Yes, let’s see,
I’m Orthodox in my own right, but I do not like going to
church or sermons […] see, I think, I believe in something,
a God and such, but not much, no” (P22, female, Romanian). Therefore, emphasizing differences in spirituality is
necessary. The concept of spirituality, which is associated
more with tranquillity, appears to be less linked to religious
organization and more to transcendence [45], whereas religiosity is linked to a series of normative prescriptions such as
prohibition of alcohol consumption.
Unlike the immigrant groups, among the Spaniards religion and spirituality either did not appear in discourses or
were associated with a negative view. A Spanish teenager
considered the Islamic religion negative for health. In his
presentation, “There are extremist Muslim countries where
for any little thing they stone women, they kill them… they
cut off men’s hands… for stealing. There, I believe that it is
linked to health… how much… the more tolerant a religion
13
Fig. 3 Photograph taken by a Moroccan female student depicting
Moroccan identity
is, the less it influences the health of a person” (P4, male,
Spanish).
Cultural Symbols
Certain cultural elements such as hijabs or traditional clothing appeared in the photographs taken by Moroccan women
(Fig. 3). For some, this type of cultural identification is associated with a religious practice and a habit that serves to
fit in socially. Therefore, they recognize Moroccan clothing
as an asset to health: “I always wear a scarf or a handkerchief because it does me good when I wear it for my religion. When I wear it I feel good; when I’m not wearing it I
feel strange because I’m used to wearing it” (P41, female,
Moroccan). Regardless of religious affiliations, these cultural objects are understood as a resource for health because
they favour social acceptance, a feeling of well-being and the
identity of those who carry them [47, 48].
This view was not shared by all Moroccan participants.
Some refer to their adherence to Western symbols as a form
of mimicry in the new society. “I love buying clothes, shoes,
in El Corte Inglés… I like western clothes, but when I go
down to Morocco I have to dress traditionally, and I do not
like it because I’m not used to it. Since I was little and came
to Spain I have dressed like that, and I’m not used to it; in
high school I do not even think about putting on Moroccan
clothes. I like to fit in with Western clothes.” (P33, female,
Moroccan).
Medications
The use of pharmacological medicine appeared to be differ
greatly among the groups. Images of medicine were much
more frequent in the Spanish group. Spanish females were
Journal of Immigrant and Minority Health
the most concerned about avoiding disease and medically
addressing problematic situations. All discourses included
the need to avoid risks and injuries and to address problems
medically and pharmacologically through professional care
(Fig. 4). In contrast, young Moroccans and Romanians were
much more reluctant to use medicines and sometimes used
other remedies from traditional medicine (in the case of
Moroccans) and home remedies (in the case of Romanians).
Traditional Food
Similarly, young Moroccan people incorporate foods associated with their culture of origin as a key element in the
maintenance of health. All of the Moroccan participants
conformed to dietary guidelines that were strongly influenced by Moroccan foods because their mothers maintained
these customs (Fig. 5). They attributed beneficial properties
to foods and tended to relate these benefits to the use of
fresh foods. “…to eat the best eat our bread from Morocco,
it has many vitamins, it is good at snack…” (P36, male,
Moroccan). “Nutritional food is the rfisa, soup, couscous,
Tallinn, and everything that my family cooks” (P35, female,
Moroccan).
Despite the processes of food acculturation described in
the Moroccan population, the study found a persistence of
traditional food patterns that were recognized as sources of
health. The young Romanians, however, referred to food customs that are very similar to the Mediterranean-Western diet
and did not discuss the role of traditional dishes.
Thinness
Thinness appears as a positive resource in Spanish and
Romanian women. The possession of a slim and athletic
body and the consumption of hypocaloric diets and light
products are recurrent in the images and interviews. A thin
woman of Romanian origin states “To be healthier, I would
need to lose weight”. There is a constant linkage of health
and healthy eating with weight reduction: “A healthy food is
Fig. 5 Photographs taken by a Moroccan male adolescent centred on
home country food
a group of foods but not with fat, something healthy, a dish
of “stew”, salad and water because it is important; daily I
drink two or three glasses of water. I never have dessert, I
worry about my weight, I think I have some weight to lose”
(p8, female, Spanish). This linkage materializes in the image
of the apple (Fig. 6). A high proportion of the photographs
selected by Spaniards and Romanians include this fruit as a
way to represent hypocaloric diets.
Freedom and Autonomy
The image of butterflies (Fig. 7) is recurrent in Moroccan
women “In my room I have a flower and butterflies on the
wall, butterflies express freedom… the fluttering of a butterfly can be felt on the other side of the world or it can cause
a tsunami” (P41, female, Moroccan).
In their interviews, young Romanian females also
expressed a desire for freedom and autonomy. They recognize isolation and lack of communication due to living in
cortijo homes that are located in the periphery at distances
Fig. 4 Photographs taken by
a Spanish female adolescent
depicting injuries and medications
13
Journal of Immigrant and Minority Health
counterparts and their male counterparts. The restrictions
are due to the fact that their mothers fear the risks posed
by the neighbourhood and consider the street to represent
a conflict space within which they may be exposed to rape,
pregnancy and theft; most of their leisure activities are therefore limited to the family environment.
Fig. 6 Photograph taken by a Romanian female participant depicting
thinness and health
Sometimes I do not like that there are many people;
when I go for a walk sometimes I do not like it. Some
are bad people and as others I do not know them, my
parents do not let me go for a walk, I can only go out
with my sister or my mother. If I want to go alone,
in the end they allow me, but then the people (also
Moroccans) look at me like I don’t know… […]…
they look at you in another way…. especially at night
and when there are many people. When you go alone,
the Moroccans look at you in a different way, as if
you were bad, as if you did not have a father; they
think that because you do not have a father or you are
bad, you go out with men. They think badly, they start
talking among themselves, the men, and I do not feel
good… (P41, female, Moroccan).
Plants and Environment
Fig. 7 Photograph taken by a Moroccan female adolescent depicting
butterflies
that made them more dependent on automobiles and on their
mothers to get to the city, to the detriment of contact with
people their age. In many cases, their free time is dedicated
to helping their mothers, who work in greenhouses, and they
are not able to perform other activities that are more associated with health. “I, I cannot do much sport, because when
I finish eating I help my mother in the greenhouse and I do
sports and all that” (P30, female, Romanian). Most of them
do not maintain close relationships with groups of peers, and
this is expressed in discourses that reflect a vision of idealized friendship and love. Curiously, they introduce into their
stories aspects related to art, beauty and nature, a feature that
is not observed in either of the other groups.
Both Moroccans and Romanians complain about having more stringent rules in the domestic realm than most
of their classmates. They affirm a greater degree of restrictions against going out on the street than their Spanish
13
In the Romanian collective, there is a predilection for images
centred on vegetation. This is manifested as a vision of a
green and leafy Romania against the desert-like Almería. It
seems that, for cultural reasons, vegetation is a resource for
health (an asset) that is much more highly valued by the people who migrated to Spain than by the autochthonous ones.
Many of the interventions in this regard take their families
into account: “…In Romania, for example, there we lived
well at home, right? with a whole garden, with all the plants,
that had grass… There it was full of flowers and plants and
everything. […] The photo reminds me a bit of Romania.
For the trees, the garden and everything. In Almería, there
is little.” (P22, female, Romanian).
Biases and Limitations
This investigation was limited to Almerian localities that
were rural and agricultural in character. There were difficulties in recruiting Romanian participants. Arranging the
participation of the Romanian students (men) was a task that
required strong coordination efforts by the guidance teams.
In addition, given the characteristics of the technique used,
the fact that the study was based on voluntary participation,
and the non-material gratification that was obtained through
participation, there was a natural bias towards participation
of students with high interest in the subject (volunteer bias)
and acceptable or good/very good academic performance.
Journal of Immigrant and Minority Health
Discussion
The goal of this study was to identify the main strengths
and resources related to health in the main groups of immigrant and native populations [48]. With this objective in
mind, cross-cutting and other specific aspects were shown
to be necessary for constructing culturally appropriate,
inclusive health education programmes that reduce disparities in health.
The study reinforces the classification of the health
assets that are found in different cultural groups into assets
that we call transcultural and assets that are specific to
each group. The nature of transcultural assets is not ahistorical, universal or essential but reflects the existence of
shared living conditions [49]. Talking about transcultural
health assets is not equivalent to talking about assets that
are specific to humans. Instead, transcultural assets are the
social and cultural aspects of different cultural groups that
coincide; are explicable according to the structures, ways
of life and suffering of the groups; and are governed by
similar logic as a result of processes of cultural homogenization and globalization. Thus, social networks are
recognized as an asset in health due to their capacity to
provide access to health information and their ability to
foster interaction with peers.
The analysis of transcultural and cultural health assets
in different cultural groups allows us to outline how society and culture influence the health processes of these
groups and how processes of cultural assimilation develop.
Most of the transcultural assets identified in our research
are consistent with the findings of other studies. Among
the identified internal assets, empowerment, emotional
expression and a positive attitude have been recognized
in several studies [13]. Among the assets associated with
lifestyles, access to healthy food, anti-tobacco banners
and practising sports appeared [16]. The external assets
include social networks, access to public services, and a
good and beautiful environment.
On the other hand, cultural assets show differences among
cultural groups, but they are not exclusive to individual
groups; such differences have also been reported in other
studies [15–17]. The cultural assets that are concentrated
in the Moroccan population, including religious beliefs, the
use of cultural symbols, consumption of traditional food,
and freedom, were found in studies of Somali populations
in the US [17]. The importance of vegetation and the need
for freedom and autonomy that predominated in the Romanian population in our study were also found in other ethnic groups [15, 16]. These items are recognized as cultural
assets in health, while drugs appear important almost exclusively in the Spanish group, and in Spanish and Romanian
women, thinness and light diets appear as assets.
Although this work has not focused in depth on gender differences, we see a differentiated recognition between what is
identified as active for males and females in each of the cultural groups, as well as a special emphasis on the problems
experienced by each group and the sociocultural influences
to which they are exposed. In fact, it is important to highlight
the existence of strongly mediated assets such as the exaltation
of thinness.
Finally, this analysis allows us to consider some of the
weaknesses of the health asset model itself. The health assets
perceived by the population are sometimes the result of strong
mediation (drugs, thinness). This result means that to achieve
their health objectives, educational intervention programmes
must start from assets but from a perspective of questioning
them.
Acknowledgements The authors would like to thank the participant
educational centres and the adolescents for their support.
Author Contributions ES conceived and design the presented project.
ES, VC and DR contributed to the implementation of the research, to
the analysis of the results and to the writing of the final report. VC and
ES authors wrote this version of the manuscript.
Funding This study was funded by a grant from Ministry of Economy
and Competitiviness of Spain (Grant/Award No. EDU2011-26887).
Data Availability The datasets used and/or analysed during the current study are available from the corresponding author on reasonable
request.
Compliance with Ethical Standards
Competing interests The authors declare that they have no competing
interests.
Ethical Approval The Ministry of Economy and Competitiveness of
Spain evaluated the ethical dimension of the study and approved the
project. In addition the Bioethics Commission from the University of
Almeria accepted and approved the study.
Consent to Participate To guarantee the information, voluntary and
conscious participation of all the participants, a written informed consent was provided, explaining the anonymous and confidential nature
of the extracted data, which had to be signed by the parents or legal
guardians and. In addition, a verbal consent was recorded in all the
interviews. Likewise, to reduce the socioeconomic bias, cameras were
made available to the participants who did not have cameras or mobile
phones.
Consent for Publication Written informed consent was obtained from
the participants for publication of their individual details and accompanying images in this manuscript. The consent form is held by the
authors and is available for review by the Editor-in-Chief.
13
Journal of Immigrant and Minority Health
References
1. Eriksson M, Lindström B. A salutogenic interpretation of the
Ottawa Charter. Health Promot Int. 2008;23(2):190–9.
2. WHO. Ottawa charter for health promotion: an International
Conference on Health Promotion, the move towards a new public health. Ottawa, Geneva, Canada: World Health Organization;
1986.
3. Suárez-Orozco C, Suárez-Orozco MM. Children of immigration. Harvard: Harvard University Press; 2009.
4. Phalet K, Fleischmann F, Hillekens J. Religious identity and
acculturation of immigrant minority youth: toward a contextual
and developmental approach. Eur Psychol. 2018;23(1):32–43.
5. Hernández-Girón C, Orozco-Núñez E, Arredondo-López A.
Public health conceptual models and paradigms. Revista de
Salud Pública. 2012;14(2):315–24.
6. Rivera de los Santos F, Ramos Valverde P, Moreno Rodríguez
C, Hernán García M. Análisis del modelo salutogénico en
España: aplicación en salud pública e implicaciones para el
modelo de activos en salud. Revista española de salud pública.
2011;85(2):129–39.
7. Vaandrager L, Kennedy L. The application of salutogenesis in
communities and neighborhoods. In: Mittelmark M, et al., editors. The handbook of salutogenesis. Cham: Springer; 2017. p.
159–70.
8. Morgan A, Ziglio E. Revitalising the evidence base for public
health: an assets model. Promot Educ. 2007;14(2):17–22.
9. Rotegård A, Moore S, Fagermoen M, Ruland C. Health assets:
a concept analysis. Int J Nurs Stud. 2010;47(4):513–25.
10. Lindström B, Eriksson M. Un enfoque salutogénico para abordar
las desigualdades sanitarias. In: Hernán M, Antony M, Mena
Á, editors. Formación en salutogénesis y activos para la salud,
vol. 16. Consejería de salud y bienestar social. Sevilla: Junta de
Andalucía; 2010. pp. 67–102.
11. Ickovics JR, Carroll-Scott A, Peters SM, Schwartz M, GilstadHayden K, McCaslin C. Health and academic achievement: cumulative effects of health assets on standardized test scores among
urban youth in the United States. J Sch Health. 2014;84(1):40–8.
12. Morgan A, Davies M, Ziglio E. Health assets in a global context: theory, methods, action. New York: Springer; 2010.
13. Cubilla-Batista I, Andrade EL, Cleary SD, Edberg MC, Evans
WD, Simmons LK, Sojo-Lara G. Picturing adelante: Latino
youth participate in CBPR using place-based PhotoVoice. Soc
Market Q. 2017;23(1):18–35.
14. Bonmatí-Tomás A, del Carmen Malagón-Aguilera M, Bosch-Farré
C, Gelabert-Vilella S, Juvinyà-Canal D, Gil MDMG. Reducing
health inequities affecting immigrant women: a qualitative study
of their available assets. Glob Health. 2016;12(1):37.
15. Baquero B, Goldman S, Simán F, Muqueeth S, Villa-Torres L,
Eng E, Rhodes SD. Mi Cuerpo, Nuestra Responsabilidad: using
Photovoice to describe the assets and barriers to sexual and
reproductive health among Latinos in North Carolina. J Health
Dispar Res Pract. 2014;7(1):7–27.
16. Downey L, Anyaegbunam C. Your lives through your eyes:
rural Appalachian youth identify community needs and assets
through the use of photovoice. J Appalach Stud. 2010;1:42–60.
17. Lightfoot E, Blevins J, Lum T, Lum T. Cultural health assets
of Somali and Oromo refugees and immigrants in Minnesota:
findings from a community-based participatory research project.
J Health Care Poor Underserved. 2016;27(1):252–60.
18. Airhihenbuwa CO. Health and culture: beyond the western paradigm. Thousand Oaks: Sage; 1995.
19. Menéndez EL. Poder, estratificación y salud: Análisis de las
condiciones sociales y económicas de la enfermedad en Yucatán, vol. 15. Editorial Universitat Roviri i Virgili-, 2018.
13
20. Leininger M. Transcultural nursing: concepts, theories and practices. New York: Wiley; 1978.
21. Welsch W. Transculturality: the changing form of cultures today.
Filozofski Vestnik. 2001;22(2):59–86.
22. Hammer MR. The developmental paradigm for intercultural
competence research. Int J Intercult Relat. 2015;48(1):12–3.
23. Albarran J, Rosser E, Bach S, Uhrenfeldt L, Lundberg P, Law
K. Exploring the development of a cultural care framework for
European caring science. Int J Qual Stud Health Well-being.
2011;6(4):1145–57.
24. Pies C, Parthasarathy P, Posner SF. Integrating the life course
perspective into a local maternal and child health program.
Matern Child Health J. 2012;16(3):649–55.
25. Royce SW, Parra-Medina D, Messias DH. Using photovoice
to examine and initiate youth empowerment in communitybased programs: a picture of process and lessons learned. Calif
J Health Promot. 2006;4(3):80–91.
26. Walker A, Early J. “We have to do something for ourselves”:
using photovoice and participatory action research to assess the
barriers to caregiving for abandoned and orphaned children in
Sierra Leone. Int Electron J Health Educ. 2010;13(1):33–48.
27. Wang C, Burris MA. Photovoice: concept, methodology, and
use for participatory needs assessment. Health Educ Behav.
1997;24(3):369–87.
28. Wang CC, Pies CA. Family, maternal, and child health through
photovoice. Matern Child Health J. 2004;8(2):95–102.
29. Hergenrather KC, Rhodes SD, Cowan CA, Bardhoshi G, Pula
S. Photovoice as community-based participatory research: a
qualitative review. Am J Health Behav. 2009;33(6):686–98.
30. Wang C. Photovoice: a participatory action research strategy
applied to women’s health. J Women’s Health. 1999;8:185–92.
31. Wang CC, Redwood-Jones YA. Photovoice ethics: perspectives
from Flint photovoice. Health Educ Behav. 2001;28(5):560–72.
32. Wang C, Burris MA. Empowerment through photo novella: portraits of participation. Health Educ Q. 1994;21(2):171–86.
33. Castleden H, Garvin T. Modifying photovoice for community-based participatory Indigenous research. Soc Sci Med.
2008;66(6):1393–405.
34. Shaffer D, Gould MS, Brasic J, Ambrosini P, Fisher P, Bird
H, Aluwahlia S. A children’s global assessment scale (CGAS).
Arch Gen Psychiatry. 1983;40(11):1228–31.
35. Evans-Agnew RA, Boutain DM, Rosemberg MAS. Advancing
nursing research in the visual era: reenvisioning the photovoice
process across phenomenological, grounded theory, and critical
theory methodologies. Adv Nurs Sci. 2017;40(1):E1–15.
36. Hansen-Ketchum P, Myrick F. Photo methods for qualitative
research in nursing: an ontological and epistemological perspective. Nurs Philos. 2008;9(3):205–13.
37. Salmon J, Buetow S. Transcendental phenomenology and classic grounded theory as mixed data collection methods in a study
exploring foetal alcohol spectrum disorder in New Zealand. J
Popul Ther Clin Pharmacol. 2013;20(2):e82–90.
38. Corbin J, Strauss A. Basics of qualitative research: techniques
and procedures for developing grounded theory. Thousand
Oaks: Sage Publications; 2008.
39. Morgan A, Haglund BJ. Social capital does matter for adolescent health: evidence from the English HBSC study. Health
Promot Int. 2009;24(4):363–72.
40. Fenton C, Brooks F, Spencer NH, Morgan A. Sustaining a positive body image in adolescence: an assets-based analysis. Health
Soc Care Community. 2010;18(2):189–98.
41. García-Moya I, Brooks F, Morgan A, Moreno C. Subjective
well-being in adolescence and teacher connectedness: a health
asset analysis. Health Educ J. 2014;74(6):641–54.
Journal of Immigrant and Minority Health
42. Kia-Keating M, Dowdy E, Morgan M, Noam G. Protecting and
promoting: an integrative conceptual model for healthy development of adolescents. J Adolesc Health. 2011;48(3):220–8.
43. Hornby-Turner Y, Peel N, Hubbard R. Health assets in older age:
a systematic review. BMJ Open. 2017;7(5):e013226.
44. Pfarrwaller E, Suris J. Determinants of health in recently arrived
young migrants and refugees: a review of the literature. Ital J
Public Health. 2012. https​://doi.org/10.2427/7529.
45. Luque-Morales L, Castien-Maestro JI. Apuntes sobre la vivencia
de la sexualidad entre la juventud marroquí: investigaciones en
Marruecos y en España. Prisma Soc. 2014;13:492–541.
46. Pàmies J. Las identidades escolares y sociales de los jóvenes
marroquíes en Cataluña (España). Psicoperspectivas.
2011;10(1):144–68.
47. Cotton S, Zebracki K, Rosenthal S, Tsevat J, Drotar D. Religion/
spirituality and adolescent health outcomes: a review. J Adolesc
Health. 2006;38(4):472–80.
48. Wilkin A, Liamputtong P. The photovoice method: researching the
experiences of Aboriginal health workers through photographs.
Aust J Prim Health. 2010;16(3):231–9.
49. Pérez-Wilson P, Hernán M, Morgan AR, Mena A. Health assets
for adolescents: opinions from a neighbourhood in Spain. Health
Promot Int. 2013;30(3):552–62.
Publisher’s Note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.
13