Abstract
Photovoice is a qualitative research method that can have very positive outcomes, including making marginalized populations visible. Yet we found that traditional Photovoice methods were not fully effective and needed to be adapted with women aged 85 and older in rural Prince Edward Island, Canada. Concerns that required adaptation were time constraints for the researcher and participants, taking appropriate photographs, balancing power between researcher and participants, and ensuring that the women’s voices were heard and presented clearly for them and their communities. Our purpose in this article is to enrich conversations on applying and adapting Photovoice as a research method with older, rural women. With Photovoice, the women in our study learned to use digital cameras to take photographs and told stories about how and why they made choices for their photographs and how they depicted how they were supported or limited to fulfill their vision of aging in place. We address the key features of the data collection process that contributed to the effective use of Photovoice with this population, including photography training and ethical instructions, guiding them in a process for identifying their most important photographs, working out methods for engaging them in codifying the photographs, and involving them in knowledge mobilization with policy makers directly. In addition, we present key benefits they reported from participation in the Photovoice process and the value of Photovoice for them in influencing policies on aging.
Introduction
For each person, aging is a unique set of life experiences that results in many different life circumstances. Angel and Settersten (2013) assert that the different life circumstances are due to individual experiences with social institutions, historical events, policies, the economy, cohorts, social interaction, and intergenerational dynamics. Dominant social institutions often render older women vulnerable and dependent throughout their life course (Estes, 2006). It is ideal to pursue a holistic view of women’s lives, emphasizing strengths, oppression, differences, and abilities; ideally, a holistic view means analyzing influences on old age in a more inclusive manner and advocating social change to reduce inequities (Netting, 2011).
The purpose of this article is to enrich conversations on applying and adapting Photovoice as a research method with rural women aged 85 and older. 1 Photovoice methods (Wang & Burris, 1997) do not always focus on establishing and building relationships with participants, both individually and in group settings, and ensuring they are involved in sharing results. The adaptations we refined to be effective were engaging in relationship building, finding opportunities to explain the specifics of the research study, providing clear instructions for taking pictures, guiding hands-on practice, obtaining consent, and involving the women with policy makers to share their experiences of aging and the supports they need.
Drawing upon a critical feminist, gerontological lens, we explored the meanings and values that encircle the lives of older women and the extent to which political and socioeconomic factors interacted to shape their experiences of aging (Alex, Hammarström, Gustafson, Norberg, & Lundman, 2006; Freixas, Luque, & Reina, 2012). Through utilizing the Photovoice method, we gathered photographs and stories of the lived experiences of these women as they made explicit and implicit choices about the things they want and need to do to fulfill their vision of aging in place at this stage of their life.
Method
Photovoice is a participatory research method pioneered with marginalized populations in 1997 by Caroline Wang and Mary Ann Burris, who identified three main goals of Photovoice to enable people to record and reflect their community’s strengths and concerns, promote critical dialogue and knowledge about important issues individually and through small group discussions, and inform policy makers. It involves individuals taking photographic images to document and reflect on issues significant to them (Baker & Wang, 2006; Garner & Faucher, 2014; Novek, Morris-Oswald, & Menec, 2012; Rush, Murphy, & Kozak, 2012; Wang & Burris, 1997). According to Wang and Redwood-Jones (2001), the employment of the Photovoice method normally includes a group of participants taking photographs to depict their experience with the phenomenon under study, contextualizing the photos by eliciting information from participants about what they have represented in the photographs, the use of a group process to allow collective reflection and dialogue related to the issue under study, and sharing the findings with an audience beyond the group.
Photovoice relies on dialogic methods, combining observation and interviewing to foster conversation and reflection (Foster-Fishman, Nowell, Deacon, Nievar, & McCann, 2005). This method allows one to incorporate empowerment, collaboration, and emancipation by integrating Freire’s (1968/2011) theory of conscientization and dialogue and his liberating education concept, where learning occurs through examining and understanding situations from the prospective of the individual’s own worldview. The Photovoice method for data collection empowers people by inviting them to develop their own voice to visually identify, name, and illuminate a phenomenon they are experiencing (Budig et al., 2018). As such, Photovoice is an empowerment strategy that enables participants to construct new ways of thinking about their lives by using cameras to photograph their daily lives (Morgan et al., 2010). Including Photovoice into the process of data collection furthers critical reflection by the participants and enhances their dialogue about theme selection and subject matter (Mulder & Dull, 2014). This critical component creates connections within the community studied, empowers individuals to assess their individual and collective needs, and assists them to articulate their problems and solutions to appropriate institutions and policy makers (Wang & Burris, 1997). As a participatory approach (Demiris, Oliver, Dickey, Skubic, & Rantz, 2008; Doyle & Timonen, 2010), the researcher emphasizes collaboration between participants who contribute their stories and analytic insights individually with the researcher and in group meetings with each other.
Individuals viewed as underserved or marginalized can potentially identify, represent, and enhance their lives and communities through photography (Andonian & MacRae, 2011; Rush et al., 2012; Simmonds, Roux, & Avest, 2015; Wang, 1999). This process assumes that marginalized community members and their ideas are important and can be influential on policy considerations (Catalani & Minkler, 2010). The use of Photovoice can facilitate change, given that it aligns well with social justice frameworks that emphasize the facilitation of just conditions for individual and community well-being (Sanon, Evans-Agnew, & Boutain, 2014).
Societal perceptions of older women as vulnerable little old ladies who are dependent on society for their needs, instead of individuals with strengths and abilities, locate older women as a marginalized group (Carroll, 2007; Jacka, 2014). This perception conceals the real-life experiences of older women and devalues their role in society. The Photovoice method of inquiry recognizes the value of learning from the lived experience is a particularly powerful way for the participants to share their knowledge and strengths and provides an opportunity for policy makers to learn directly from the individual participants.
Through this process, study participants are the source and creators of knowledge (i.e., the knowers) of their experiences and become coresearchers who act and speak on their own behalf (Morgan et al., 2010). Photovoice recognizes the value of participants’ expertise and is a mechanism for decision makers to see and understand the realities of those they rarely hear from.
Photovoice is gaining popularity (Catalani & Minkler, 2010) and has been used to explore a wide variety of topics with diverse populations such as homeless women, immigrant women, women showing their areas of empowerment, and community health workers as agents of change (Bukowski & Buetow, 2011; Duffy, 2011; Mayfield-Johnston, Rachal, & Butler, 2014; Sutherland & Cheng, 2009).
The Utilization of Photovoice and Technology With Women Aged 85 and Older
Given that older women represent an increasingly larger proportion of the population and benefit from being active users of various forms of digital and other technology, issues surrounding aging, gender, and technology are of critical importance. Researchers have found that for older adults, Internet usage frequency was mostly limited to communication or searching for information about community, health, news, and travel (Olson, O’Brien, Rogers, & Charness, 2011). They suggest technology areas not currently used frequently (e.g., banking, education, shopping) may provide opportunities for improved designs to meet the needs of older users. However, Mitzner and colleagues (2019) found that older adults are less likely to begin using new technologies than younger adults. Others (Berner, Rennemark, Jogreus, & Berglund, 2013; Ma, Chan, & Chen, 2016) suggest that those with higher education, those who are nonwidowed, and those with better economic conditions are more likely to use a smartphone. Cost was found to be a critical factor influencing the behavior with technologies of older adults and that the oldest old, both men and women, had lower rates of computer and Internet usage. It is worth noting that Loe (2010) found that some women over age 90 actively and creatively use a wide range of everyday technologies to support their mobility, communication, nourishment, and physiological health to create meaningful lives and maintain health. For example, they readily use walkers, scooters, home security systems, calculators, timers, CD players, television, and computers.
Some researchers have found that the Photovoice method provides an innovative approach to community-based gerontological research that can be very influential in illuminating nuanced details in the results and that it can support deeper and broader reflection on the topic of the study (Garner & Faucher, 2014; Novek et al., 2012; Rush et al., 2012). While there are some studies involving Photovoice with younger seniors, such as a mean age of 65 (Baker & Wang, 2006), our study focused on rural women aged 85 and older. We chose this age-group because they are one of the fastest growing segments of our population and are the least studied portion of the older population. Rural women in this older age-group are almost totally absent from research. Researchers have identified the importance of using the Photovoice method to explore older adults’ perceptions and experiences. In fact, Ronzi, Pope, Orton, and Bruce (2016) found that Photovoice enabled the articulation of “hidden things that are important to people,” which we may not be able “to see” solely through interviews or focus groups. Women aged 85 and older are pioneers in aging with secrets of what normal aging is at the extreme of old age (Bould & Longino, 2001). Thus, it is important for researchers to adapt methods to learn from their knowledge of aging. Novek, Morris-Oswald, and Menec (2012) argued that if adapted to accommodate the needs of seniors, Photovoice provides an innovative approach to community-based gerontological research. Some of the adaptations can be in building relationships, valuing participants’ contributions, and addressing issues related to mobility and seasonality.
The founders of Photovoice Wang and Burris (1997) outlined a series of procedures. We followed their process yet modified it to accommodate our study participants. Relationship-building and the engagement of participants in the study were accomplished through extra one-on-one meetings, group socializing opportunities, hands-on learning to take and analyze photographs, written instructions, practice opportunities, and encouraging participants themselves in sharing their photographs and stories with others through a knowledge sharing open house. Dialogic methods allowed the researcher and participants to explore and question the programs and services currently available (or not) to support older women who are aging in place in Prince Edward Island’s rural communities and to learn together while engaging in the research process. We discuss five refinements to Photovoice that enabled us to be effective with rural women aged 85 and older: a focus on relationship-building through individual meetings, technology training and individual instructions, a process to support identifying the most important photographs, engaging the participants in codifying the photographs, and a focus on knowledge mobilization.
A Focus on Relationship-Building Through Individual Meetings
The recruitment of participants for this study required that they self-select. Self-selection involved two steps for the researcher: (1) publicizing the need for participants and (2) checking to ensure that the participants met the eligibility criteria. Based on criteria and interest, 10 women became study participants.
Building relationships was an important part of our Photovoice process. Maidment and MacFarlane (2011) identified that the relationship between informal group work with principles of empowerment and self-efficacy was unmistakable. We paid attention to ensuring that each potential participant was fully informed about the study and that they understood their role in the Photovoice process. Our application of Photovoice involved individual meetings with the study participants prior to the Photovoice group meetings. We deemed this necessary in order to build trust and to ensure that the participants fully understood that if they agreed to participate, their anonymity would not be possible. This was because their involvement would include group sessions with their fellow participants and a public knowledge sharing open house. We also included individual meetings to view their chosen photographs and to ensure they understood their task of sharing.
The first author visited initially to introduce potential participants to the research, provide information about the study, and answer any questions. At the initial meeting, if the woman was willing to participate in the study, with the understanding that they would not be anonymous, informed consent was obtained. This meant that they would meet other participants, and they would be identified through their narratives and potentially also be identified in the pictures taken. For those who agreed to participate, a second face-to-face meeting was arranged for an individual interview that focused on the lived realities of being a woman aged 85 and older, living in a rural community without readily available amenities.
While Photovoice sometimes involves only group meetings with participants (Annang et al., 2016; Novek et al., 2012; Wang & Burris, 1997), in our experience, the first two individual meetings helped to build rapport and trust between the participants and interviewer (Kaufman, 1994) that supported the engagement of participants throughout the study and likely reduced participant dropout identified in other studies with older adults (Baker & Wang, 2006). While ethical aspects of the study were discussed during group meetings, explaining these components to the participants individually appeared to encourage more open dialogue, built the women’s confidence to participate, and did not impact negatively on their behavior in the field, such as the avoidance of taking pictures of people (Hannes & Parylo, 2014).
A Focus on Photovoice Training and Specific Instructions
Through reviewing the available literature, we identified several specific challenges in prior studies to inform the utilization of Photovoice. Researchers (Ma, Chan, & Chen, 2016; Novek et al., 2012; Ronzi, Pope, Orton, & Bruce, 2016) identified challenges to inform the utilization of Photovoice with older adults. Two specific challenges included paying attention to providing specific instructions related to photography training and retrieving consent forms (Novek et al., 2012). Ronzi et al. (2016) found similar challenges to Novek et al. (2012) when conducting Photovoice with older participants. In particular, they reported that participants expressed anxiety when being asked to take “proper” pictures. However, Ronzi et al. (2016) identified that improved self-esteem as a result of using Photovoice was a mediating factor that may lead to improvements in health outcomes. Building on their work and the research of Ma, Chan, and Chen (2016), we ensured that we paid careful attention to training in using the digital camera technology. At the first group meeting, the participants received identical user-friendly digital cameras that facilitated the training process. The cameras were donated by the University’s Department of Development and Alumni Engagement. Participants learned the basics about the cameras and had hands-on training for taking digital pictures. This training included tips on subject matter for the photographs. Very importantly, they had the opportunity during this meeting to practice taking pictures and describing why they took the picture and how it could support or limit their capacity to age in place. For example, participants were asked to photograph something they used every day, something that helped them remain healthy, and something that supported their mobility. As advocated by others (Ma et al., 2016; Novek et al., 2012), proper training before the use of unfamiliar technology is necessary and especially important for older adults. For some, there was prior familiarity with a digital camera. For others, they had used other types of cameras, but not digital cameras. One participant had never used any type of camera previously. Because of the diversity of prior photography knowledge, adequate training was important. Once all participants were comfortable with taking pictures, they received written instructions and expectations of them in taking the pictures, log sheets to keep track of pictures they took (e.g., date, description, importance in supporting or limiting aging in place), and information to assist them when contextualizing their photographs. Log sheets were developed based on what the authors believed would be useful to the participants. We also built in the opportunity for the participants to get to know each other through an icebreaker and providing lunch. Two of the participants were unable to attend this meeting, so the first author met with them together in one of their homes and provided the exact training; the two women decided on their own to provide lunch to emulate the original training. This provided identical training and instruction and kept them informed about how the overall process would evolve.
All participants were advised that they had 2 weeks to take photographs showing what supported or limited their ability to remain living in their location of choice and that they could take as many photographs as they wished. Before the first author met with them, they must select the six photographs that they liked the best to discuss. The reason we chose six photographs was due to limitations on time and resources, but this number still gave the participants some choices. Having 2 weeks to take the pictures and specific instructions of what to do before the next individual meeting worked very well in facilitating the next steps in the research.
In some Photovoice studies with older adults, participants were instructed to not take pictures of people to avoid having to obtain consent to use the pictures (e.g., Rush et al., 2012). However, we felt that pictures of people would be of importance to the participants, so we carefully developed a process to obtain consent of those who appeared in the participant pictures. Similar to procedures outlined by Hannes and Parylo (2014), the women had forms to obtain consent from any people they wished to photograph.
Most participants had selected the six photographs that they liked the most, before the first author met with them individually. Although they all could view their photographs on the digital cameras, it was helpful for them to have the hard copy of their six pictures as they discussed them and made it easier for the participants to select the four photographs they believed best represented their realities.
A Process to Support Identifying the Most Important Photographs
While some researchers have limited the number of pictures participants could take and conducted meetings to identify photographs with older adult participants by telephone or in person depending on their location (Novek et al., 2012), we found that face-to-face meetings were most advantageous for this stage of the study. Printing of the pictures was an important aspect of this study and appreciated by the women who enjoyed having a copy of their photographs. Having the photograph in hand facilitated discussion at this individual meeting and at future group meetings. Thus, researchers are encouraged to consider printing pictures as part of the Photovoice process and budget for such in research with older adults.
From printed photographs, plus those displayed on the laptop, the participants then selected four that they believed best represented their reality. The participants were then asked to contextualize and label each of the four selected photographs (Evans-Agnew & Rosemberg, 2016). Each participant discussed and contextualized their photographs using the SHOWED process (Annang et al., 2016; Palibroda, Krieg, Murdock, & Havelock, 2009; Wang, 1999) that involved asking the following questions: What do we See here? What is really Happening here? How does this relate to Our lives? Why does this situation, concern, or strength Exist? What can we Do about it?” This process helped the participants think about their photographs, describe their photograph, and explain why they took it and whether it represented supports or limits to their ability to age in place. This in-person process of documenting information about each picture helped to ensure that the meaning was captured accurately and not misinterpreted by the researcher (Novek et al., 2012).
At the second group session, the socialization opportunity of providing lunch was also built into the session. The participants presented their own photographs and explained them to the group. They were a bit timid and used their own write-up about each photograph to explain what it meant and why they took it. By using the written material, they did not allow themselves to truly express and describe their photographs and the purpose for that photograph. We made note of this for future presentations, such as the knowledge sharing open house, because we felt they were not telling their story and would be better without written material.
Engaging the Participants in Codifying the Photographs
After the participants took their pictures and met individually to discuss them with the first author, they participated in a group meeting with the other study participants, the first author, and two additional research team members. At this meeting, each participant presented their four contextualized photographs. It was during the dialogue and guided discussion that participants voiced their individual and group experiences. Voicing Our Individualized and Collective Experiences (VOICE) was utilized to encourage the participants to think not just about their own life condition but also about shared life experiences, events, and conditions (Palibroda et al., 2009). The VOICE process appeared to foster critical thinking and in-depth discussion.
After the discussion process, the participants were invited to codify through identifying and sorting photographs into themes or categories related to their lived experience and how the content in the photographs supported or limited their capabilities to age in place. As described by Palibroda and colleagues (2009), codifying takes place in Photovoice through group discussions where participants share photographs and discuss common themes and issues. The process of participants theming or categorizing their photographs began with the photographs scattered on the table facedown. As a group, the participants began looking at the photographs and identifying what category they might represent. They themselves decided on the categories. For example, they identified such categories as mobility, family support, community involvement, and they then placed the photographs in the various categories. The role of the researchers was to observe the process and answer questions. We did find participants began to see the link between personal and common experience during the sorting process in this meeting (Palibroda et al., 2009). The process we used was to support the women as they progressed through the process and to ensure the older women felt they were valued and that the information they provided was meaningful and necessary.
A Focus on Knowledge Mobilization
A knowledge sharing open house was organized to display the photographs, hear the women’s stories, and inform policy makers. To ensure a variety of people would attend, the first author and the participants personally invited family, friends, academics, and policy makers.
Evans-Agnew and Rosemberg (2016) asked whose voice is reflected when Photovoice is employed? In this study, we paid particular attention to ensuring that the women’s voices were heard in a knowledge sharing open house where the focus was on the women and their photographs (see Table 1). At this event, each woman stood or sat beside her four framed photographs, and when the visitors approached them, they described the purpose of their photographs, how these supported or limited their capability to age in place, and responded to any questions the visitors had. This environment enabled each participant to express the various concerns and strategies for aging in place. This exercise demonstrated the empowerment that these women had achieved not only through aging in place but by being given the opportunity to present their lived experiences. As noted below, these stories had a profound influence on attendees, which included policy makers. We did not keep track of the number of people who attended this event, but attendees included family members and friends of the participants, the first author and her research team, students, academics, policy makers, and the general public.
Summary of the Photovoice Research Process Utilized.
In particular, the then Minister responsible for seniors in the Canadian province where the study occurred was specifically invited, and she attended. The knowledge sharing open house was a very strong knowledge exchange activity for the minister who spent a large amount of time engaging with each participant. Consequently, she attributed what she learned at the knowledge sharing open house as the inspiration for a new program, the Seniors Independence Initiative (https://www.princeedwardisland.ca/en/information/seniors-independence-initiative), to support seniors to remain in their own home. The opportunity to meet the study participants face-to-face and to view the visual images the women displayed had a convincing impact on policy change. It was clear that the Photovoice process we followed facilitated the women to make their life experiences visible and known. We suggest that without the mechanism of holding the knowledge sharing open house, the impact of the research would have been much less persuasive. As Harley (2012) emphasizes, Photovoice is an influential research method as it provides a view from the research participants’ perspective of their daily lived experience and shifts power from the researchers to the researched.
The Impact of Photovoice on the Participants
The Photovoice process brings forth many of Freire’s (1968/2011) concepts of learning including emancipation, empowerment, and consciousness rising. It evokes the notion of praxis, which is theory based on action (Budig et al., 2018). As noted by Findsen and Formosa (2011), Photovoice is a practice based on dialogue between the researcher and the people researched that facilitates communication, openness, trust, and commitment. Photovoice research methods reflect feminist understandings of research accountability based on a nothing for us, without us approach that fosters empowerment and liberation (Catalani & Minkler, 2010; Hergenrather, Rhodes, Cowan, Bardhoshi, & Pula, 2009; Wang, Yuan, & Feng, 1996).
An important benefit we identified was the positive impact on the study participants throughout the Photovoice process. Because participation in research is voluntary, we were careful not to overburden the participants and focused on learning from the participants through involvement, knowledge sharing, and consciousness raising. We also used individual face-to-face meetings to obtain rich descriptions of experiences and to reduce the possibility of limiting commentary due to the reluctance to discuss intimate or personal information in a group setting (Murray & Nash, 2017). In this study, the women did not have input into the research design or questions but did have a long commitment of approximately 9 months to the study. The first author met face-to-face with the participants in their own homes 4 times and in a group setting 3 times.
The women spoke about a variety of ways they perceived that the study was a unique way of learning about themselves. Betty said “we learned that we were unique individuals in body and mind, in every aspect, we are developing new ideas and techniques as we age.” Geraldine suggested that participation in the study opened her eyes to the fact that she did have knowledge to share. She said, “as we shared ideas with each other at group meetings, I realized I did have valuable knowledge to share.” Another participant Ida said “this study impacted me by making me more aware of my good fortune of being ‘enabled’ to live in my beloved home and longtime surroundings.” Another participant Harriet, age 91, truly felt she was in a learning environment when she wrote about her experience she wrote: It was with great pleasure that I was a part of this. Since I had so little education, my eyes were opened to many things I never even heard of. I am so glad I took part…I know I have learned a lot and taking pictures was fun…I had never done that before…I am sure we all learned a lot. I still cannot explain well what supports or creates barriers of aging in place. I did my best to find out what it meant.
All 10 participants felt they were not explicitly educating others, yet they were implicitly educating others by modeling how they managed to age in place without needing to leave their home to live in a retirement community or care home. The Photovoice method of inquiry empowered participant voices and supported the development of critical knowledge to moderate and transform social injustices for older women. This empowerment, enhanced through education and learning opportunities, can improve self-identity and expose new possibilities (Duffy, 2011; Mayfield-Johnson, Rachal, & Butler, 2014). As posited by Krašovec, Golding, Findsen, and Schmidt-Hertha (2017), learning in later life is not so much concerned with the issue of aging itself but more about quality of life regardless of age.
Older women do not need to learn that they are old, but they would benefit from education and learning opportunities that enhance their quality of life, notably learning how to pursue what they need and want to do as they age (Boulton-Lewis, 2010). This could include approaches that help them realize their own power and agency and how sharing their knowledge informs others. By their involvement in the Photovoice process, the older women learned that their own life experience was of value and of interest to others.
Although the group sessions were very valuable, there were times when four individual participants were unable to attend group meetings for various reasons such as weather conditions or transportation challenges. At these times, individual meetings were organized with the participants who missed the meetings, and the first author went to their house to provide the same training or information given to the other participants. Two of the participants got together for the training, and the other two were provided information in their individual homes. The flexibility to hold individual meetings with women who missed group meetings may have encouraged ongoing participation of participants who may have withdrawn from the study otherwise. Other researchers (Baker & Wang, 2006; Novek et al., 2012) also identified that physical limitations and challenges with transportation can limit the ability of older adults to participate in group meetings as part of the Photovoice process. We do recommend that transportation be arranged for participants to ensure that they are able to attend valuable group sessions.
Conclusions
In this study, we developed new knowledge about how to adapt and refine Photovoice methods with rural women aged 85 and older. We paid extra attention in providing a comprehensive introduction and bringing individuals together for several face-to-face group sessions. The study also provided opportunities to support the empowerment of participants through direct engagement and a chance to express their voice in the Photovoice process. In addition, we provided a model of how to incorporate knowledge mobilization into the Photovoice process, through direct contact by study participants with government decision makers. Our results indicate that Photovoice can be successfully utilized with rural women aged 85 and older through paying attention to specific details and that they can benefit greatly from participating in Photovoice research. The most unique adaptation of Photovoice was engaging them as knowers in presenting their photographs in a public, knowledge sharing open house. Their voices and photographs had a strong influence on creating social change with a new program for seniors being developed in Prince Edward Island.
Footnotes
Acknowledgments
The authors acknowledge editorial support from Vicki Bryanton and Debra Bryanton. Finally, they acknowledge the generous contributions of the study participants, the women who engaged fully in the Photovoice process.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Financial support for this research was provided through the University of Prince Edward Island’s Faculty of Education, the University of Prince Edward Island Department of Development and Alumni Engagement, and the Strategy for Patient Oriented Research.
