Advancing Nursing Research in the Visual Era: Reenvisioning the Photovoice Process Across Phenomenological, Grounded Theory, and Critical Theory Methodologies

Evans-Agnew, Robin A. PhD, RN; Boutain, Doris M. PhD, RN; Rosemberg, Marie-Anne S. PhD, RN

doi: 10.1097/ANS.0000000000000159
Original Articles

Photovoice is a powerful research method that employs participant photography for advancing voice, knowledge, and transformative change among groups historically or currently marginalized. Paradoxically, this research method risks exploitation of participant voice because of weak methodology to method congruence. The purposes of this retrospective article are to revisit current interdisciplinary research using photovoice and to suggest how to advance photovoice by improving methodology-method congruence. Novel templates are provided for improving the photovoice process across phenomenological, grounded theory, and critical theory methodologies.

Photovoice employs participant photography for advancing voice, knowledge, and transformative change among marginalized groups. Paradoxically, this research method risks exploitation of participant voice because of weak methodology to method congruence. The purposes of this retrospective article are to revisit current interdisciplinary research using photovoice and to suggest how to advance photovoice by improving methodology-method congruence. www.advancesinnursingscience.com

Nursing and Healthcare Leadership Program, School of Nursing, University of Washington Tacoma (Dr Evans-Agnew); School of Nursing, University of Washington, Seattle (Dr Boutain); School of Nursing, University of Michigan, Ann Arbor (Dr Rosemberg).

Correspondence: Robin A. Evans-Agnew, PhD, RN, Nursing & Healthcare Leadership Program, University of Washington Tacoma, Box 358421, 1900 Commerce St, Tacoma, WA 98402 (robagnew@uw.edu).

The authors acknowledge the organizers and participants at the 6th In Sickness and in Health International Conference, Palma, Mallorca, 2015, for their feedback on an earlier draft of the manuscript.

The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

Article Outline

PHOTOVOICE is an increasingly popular method used in social science research that involves participants in the taking, discussing, analyzing, annotating, and displaying of photographs.1 These photographs are then used to support actions to mobilize others for social change.2–5 Wang and Pies defined photovoice as,

...a process in which people (1) photograph their everyday health and work realities, (2) participate in group discussions about their photographs, thereby highlighting personal and community issues of greatest concern, and (3) reach policy makers, health planners, community leaders, and other people who can be mobilized to make change.6(p 96)

As a method, the photovoice process (including data interpretation) is strengthened when well anchored in its guiding methodology. When photograph interpretation becomes unmoored from the methodology that grounds the study, the multiple, complex, and often-contradictory meanings and contexts implicated in these photographs may be misinterpreted or underanalyzed. What are at stake for the advancement of photovoice research are both the resulting quality of data interpretation and the opportunities for advancement of voice and knowledge by those who are already marginalized in society.7

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Statements of Significance

What is known about the topic:

Photovoice is an increasingly popular participatory visual research tool for nursing research. Researchers have used photovoice in phenomenological, grounded theory, and critical theoretical studies but have done little to advance methodology-method congruence. Without sufficient anchoring in methodology, the vulnerability of participants might be reified instead of transformed through the publishing of their photographs.

What this article adds:

We review the important contributions nurse researchers and others have made to the photovoice process. We adva-nce methodology-to-method congruence in photovoice across phenomenological, grounded theory, and critical theory methodologies. We provide 3 questioning strategies for data collection during the following photovoice process components: (1) photo-documentation, (2) photo-elicitation, and (3) audience reflection at the gallery event.

The purposes of this retrospective article are to revisit current interdisciplinary research and to suggest how to advance photovoice by improving methodology-method congruence across 3 methodologies: phenomenology, grounded theory (GT), and critical theory. First, we begin with a background on the 3 underpinnings of the photovoice method identified by Wang and colleagues1,8,9: the discipline of documentary photography; approaches to empowerment education; and critical feminist theory. Second, we provide a detailed description of the components of photovoice outlined in Table 1 including examples from our own research and others. Third, we compare the photovoice process across phenomenological, GT, and critical theoretical methodologies. Finally, in our discussion, we suggest ways to advance methodology-method congruence within photovoice by providing novel templates for questioning strategies.

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PHOTOVOICE METHOD: BACKGROUND AND PROCESS

Social science researchers have been using photography since the early 1950s.10 With the advent of affordable cameras and digital developing, participant photography is becoming an attractive and feasible research method in a variety of fields. A recent search for “photovoice” in “Web of Science” produced 530 peer-reviewed articles published between 2001 and 2015, with 124 published in 2015.

In the mid-1990s, Hagedorn11 and Nelson12 were the first nursing researchers to publish independent studies examining the innovative potential of photo-elicitation (the use of photographs to elicit participant responses) and participant photography. Both articles were published in this journal. In 2008 and 2014, Advances in Nursing Science (ANS) also published articles concerning the use of a photo-instrument in a mental health hospital, conducted by Sitvast and colleagues13,14 in the Netherlands. These 4 studies did not involve any work with policy makers and/or action for change, which are underlying principles of the photovoice method.

The question of what exactly constitutes the photovoice method in the way Wang and colleagues envisioned remains a debate in the field, especially in relation to the process of how data are gathered and analyzed. In 2008, Hansen-Ketchum and Myrick15 argued that important differences in realistic and relativistic assumptions by the researcher could be discerned by examining processes of photo-elicitation. For example, by examining how participants took and discussed their photographs with researchers or themselves, one could identify underlying assumptions being made by the researcher. For photovoice researchers with relativistic interests, they observed that there was only a need to have participants discuss their photographs individually with the researcher for an individual interpretation of meaning. Researchers with realistic concerns would need to gather collective meaning imparted inside a group discussion of the photographs. Hansen-Ketchum and Myrick called for researchers to develop “the rationale behind and the impact of photo methods and deliberate on how and why they contribute (or not) to the development of nursing.”15(p211) In our own research, we have found this lack of development of a rationale to be an issue. For example, we have found photovoice researchers whose selection of methods appeared to have limited the advancement of Wang's central concerns (in policy action and voice) without adequate justification of a rationale for their chosen methodology.4,7

Compared with photo-elicitation, photovoice researchers follow 2 unique components: (1) the analysis of photographs and their accompanying titles and captions (hereafter referred to as phototexts) is conducted in both individual and group settings, and (2) the resulting photographs and phototexts are often displayed in community settings.16 Researchers have been concerned about this analytic moment, especially because the perceived meaning and persuasive power of the photographs can shift among researchers, participants, and their intended audiences.16,17 Thomson16 suggests that this power is often left unexamined with respect to the methodology. She suggested that “images [are] not neutral. [They are] literally and socially constructed”16(p10) through their selection, processing, and editing. In other words, the work of the researcher who is using photovoice must be first to recognize his or her own underlying assumptions about the nature of reality and, second, explicitly fit the gathering and analyzing of photographic data to those assumptions and the research methodology.

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Historical development of photovoice

Collier18 first explored documentary photography as a photo-method in the 1950s. Working as an anthropologist with migrant workers in the Canadian Maritimes, he found that the use of photographs he had taken himself of the community elicited richer interviews among migrant workers than those he conducted without photographs. In 1966, communications researchers Adair and Worth19 engaged participants from the Navajo Nation to make their own 35-mm films as biodocumentaries. European artists, such as Jo Spence,20 began experimenting with participant documentary photography as a form of activism in the early 1970s out of spaces such as London's Half Moon Photography workshop. Wendy Ewald was an American photographer who studied at the Half Moon and returned to Appalachia to put cameras into the hands of Kentucky school children in a “photo-novella” project, asking them for “stories they could tell with pictures ... and their dreams or fantasies.”21(p17) The psychologists Ziller and Smith22 placed cameras in the hands of wheelchair-bound college students in 1977 but did not use photo-elicitation. By the 1990s, the trend for participant photography had spread to educators in Europe,23 sociologists in Pennsylvania,24 nurse researchers in Colorado,12 and Wang and Burris8 who were conducting public health research in China.

Wang and Burris recruited 62 women from different villages to train them to “photograph the home place, village, or environment where they work play, worry, and love.”8(p178) Their significant innovations in this photo-method were (1) the use of group dialogue to elicit awareness of community issues, (2) the use of dialogue with policy makers and stakeholder as an impetus for action and transformative change, and (3) the empowerment of women through group discussion and construction of phototexts to present at a gallery-style exhibition to local policy makers.3 Indeed, they described in their study how the local officials attending the gallery session went on to make policy changes to childcare and the education of women in the province.9 Wang and Burris1 opted to coin a new word “photovoice” in place of “photo-novella” because photo-novella had been used to describe photo-booklets designed by international development agencies to advance literacy. “Photovoice,” they reasoned, was a term that better emphasized their transformative intent to have participants drive the collection, analysis, and dissemination of these photographs.1

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Feminist theory and empowerment education in photovoice

Critical feminist theory is an important underpinning of photovoice.1 Feminist scholars in addition to Wang have identified the potential of the photovoice method to attend to the voices of those who have been silenced and examine the processes by which power inequities could be transformed.25 As early as the 1970s, the feminist photographer Jo Spence20 was experimenting with participant documentary photography as a way to achieve this. She conducted workshops for low-income women and children in documentary photography to challenge the systems that were oppressing their voice.

The photovoice method is based in the approach espoused by Paolo Freire26,27 of empowerment education. He engaged people to collectively discuss problems pertinent to their particular lives and develop the solidarity to solve them through action. Freire pioneered the use of images and photographs as “codes” contextualized to a group's social lives in order to engage with each other in emancipatory dialogue. In photovoice, participant-derived images are already contextualized, but the process of entering into dialogue with participants was an additional innovation by Wang and Burris.1 In the 1970s, Shafer28 developed a series of focused questions, based on the Freirian technique, to elicit critical reflections among community health workers in Kenya. These questions were adopted almost verbatim by Wang and Burris1 and others thereafter for structuring the dialogue in photovoice.

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The photovoice process

The photovoice method involves several process components (Table 1). These components include issue identification, recruitment, training, photo-documentation, photo-elicitation, analysis, identification and recruitment of policy makers, and planning and action for social change.1–5 We consider these as separate components and not steps because some, such as a focus group discussion, may occur more than once in a particular project. In this section, we describe these components, identify differences and similarities within phenomenology, GT, and critical theoretical approaches from our literature review, and provide illustrative examples from our own research and others.

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A & B. Issue identification and recruitment

Issue identification involves selecting the research topic of interest that would involve photography for enhanced meaning or depth. Recruitment focuses on what is needed to solicit participants who could take photographs that would highlight the research issue under investigation. Hergenrather and others5 have observed that issue identification and recruitment are often not as participatory as other components of the process.

There is little variation between researchers who use phenomenology, GT, and critical theory methodologies in how they describe issue identification and recruitment. In phenomenology and GT studies, the issue is most often selected by the researcher and not by the participants. Other, more critically oriented researchers have suggested that participants who document, discuss, and analyze are by default engaged in a process of problem identification.29 However, few research examples were found whereby participants were actively and consistently engaged in issue identification.

In our own research with Latina mothers who were new immigrants and mothers of children with asthma,30 time constraints necessitated recruitment from an existing Community Advisory Board. We also found that funding issues also precluded our extensive involvement of them in issue identification and recruitment strategies. However, we still were able to recruit from a population whose voice on the environmental threats has been marginalized.

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C. Training

Training participants is an important part of the photovoice method. Training can involve planned education in the issues, problems, or aims of the research. Training can also entail learning about photovoice goals and outcomes, camera equipment, photography techniques, safety issues, ethical issues concerning privacy, public speaking, and advocacy (Table 1). These trainings occur at the beginning of the research and during subsequent interview or group data collection sessions.

Most researchers reported training participants both in the mechanics of using cameras and in the protection of privacy for oneself and others. This sort of training did not vary across research methodology. In studies guided by phenomenology, there was sometimes less interest in providing artistic instruction, as the real interest was in what the participant saw and interpreted as the meaning of the photograph.31 Researchers using GT did report some training of participants related to how to use the camera and the aesthetics of photography related to the research aims.32 Critical theoretical researchers have a relativistic understanding that truth is co-constructed between the researcher and the participant. In one of our asthma studies, for example, we were concerned that the youth might not know how to take a photograph on the topic of asthma management disparities, so we provided an information sheet about the issue and produced a short video slideshow that provided multiple examples of ways to communicate ideas about asthma inequities.33 In another of our studies34 working with Haitian hotel workers, we became aware of the heightened vulnerability of study participants relating to their employment while in the study. We had to provide specific instructions about taking representation pictures, for example, a picture of a tie, desk, or a shoe that would represent their boss. In this way, researchers with a critical theoretical orientation are also concerned about the power imbalances in society and how those many manifest to influence or constrain the knowledge produced in research.

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D. Photo-documentation

Photographic documentation occurs when participants procure and return photographs illustrating the chosen problem or issue. The participants are usually guided by 1 or several prompts as they discern which photographs to attain. In the phenomenological studies we reviewed, researchers often gave participants journals or logbooks to capture the essence of why a particular photograph was taken or of a feeling.35 Photographs were also collected to document lived experiences. In GT investigations, participants were often asked to identify factors (barriers and facilitators) related to the identified issue.36 In studies involving a critical theory orientation, participants were asked explicitly about power relationships and dynamics that may be influencing the research topic. In our study with African American adolescents,33 for example, we wanted to understand the power dynamics at play in their management of asthma and how in their view this was related to inequities. To achieve this, we asked participants to take a photograph that would help show “What may make it harder for you to manage asthma than others?”

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E. Photo-elicitation discussions

Photo-elicitation is defined as the process by which the researcher uses participant photographs to broach discussion and reflection on their (and sometimes other participants') photographs.18 Photo-elicitation is a fundamental component of the photovoice process as described by Wang and colleagues.1,6 Once the photographs are viewable, participants and researchers engage in a facilitated dialogue concerning these images using a series of questions. Wang proposed using questions originally suggested by Shafer28 in his work with community health workers in Kenya in the 1970s using the acronym SHOWeD. The SHOWeD acronym is a mnemonic to help recall questions of inquiry for researchers: (1) what do you See here, (2) What is really Happening, (3) how does this affect Our lives, (4) Why does this situation exist, and (5) What can we Do about it? In the Freirian sense, participants are asked not only to consider what is “really happening” in the image but also to consider how these images as metaphors could elicit a critical consciousness to “do something about it.” Participants then would codify their photographs by creating phototexts out of titles and captions.

We have observed that the SHOWeD questioning strategy has remained largely unchanged within both GT and critical theoretical studies. In phenomenological studies, however, researchers more often used individual rather than group interviews. They employed only the first 3 questions in SHOWeD (up to “how does this affect ‘your' life”) to focus their discussions with participants on the essence of the lived experience of their participants. They focused on participant feelings about their photographs and the meaning of the photograph. For example, Sitvast and colleagues13,14 described a technique of photo-elicitation where (in this instance, working in groups of psychiatric patients) they asked participants to take photographs of something that “was dear to them” and something that was a “visualization or goal for the near future.”

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F. Analysis

Analysis is the component through which meaning is made of the photographs and phototexts and by which the participant(s) develop an awareness of the research issue. This awareness is an outcome of photovoice.3 The methodology guiding the research offers unique approaches to meaning creation. Analysis may occur iteratively across a series of interview or focus group sessions. Analysis also is accomplished through the selection and annotation of photographs with phototexts as a way to characterize themes for display in dissemination activities. Analysis is the component in the photovoice process where the differences across the 3 methodologies are most apparent.

In phenomenological analysis, the researchers we reviewed considered the image as a portal to understand the meaning of the lived experience of the individual participant.14,35 They used bracketing to make visible their subjective interpretation of the data, often summarizing their initial expectations of what the photograph meant before interviewing participants. Content analysis was often used to analyze the interview text, although some phenomenological studies31,37 used a 4-stage approach to analysis: (1) previewing interview text with photograph for congruity, (2) reviewing photograph and interview text with respect to the contexts of the lived experience, (3) conducting a cross-photo comparison of the entire collection of photographs for themes and categories, and (4) theorizing the links between categories, themes, and the particular theoretical perspective of the study. Sitvast and other phenomenological researchers14,38,39 have utilized semiotic techniques to analyze the photograph for (1) content, tone, and setting; (2) symbolic meaning; and (3) abstract interpretation based on additional research.

The researchers we reviewed who based their photovoice methods in GT have yet to be comprehensive enough in their approach for us to evaluate their analytic rigor. Our review indicated that although a few GT researchers generated theoretical constructs,32 most did not use photographs to assist with theory generation.36,40,41 Researchers have so far only selected features of the GT analytic approach with the photovoice method and have not explicitly used the methodology to create a substantive theory. For example, Warne and colleagues40 used GT to explore factors associated with student health and well-being in a Swedish vocational school but did not fully develop any new theory.

Researchers applying GT analysis relied on iterative feedback from both individuals and the group as their theoretical understanding of the process was being developed. In this methodology, groups participated in thematic analysis of all photographs and phototexts. They also provided member-checking opportunities for researchers using more complex analysis strategies and software; for example, in a study concerned with exploring empowerment processes,41 researchers asked the group to determine which photographs to display at the gallery event as a form of member checking.

During analysis, researchers using critical theoretical methodologies kept reflective journals to monitor power relations between themselves and participants.42 Documenting the experience of meaning creation could itself become research data. Investigating how others created meaning when viewing photographs could help researchers note how viewers consumed the images within ranges of familiarity or unfamiliarity. As critical theoretical researchers, we explored how participants viewed the photograph and the phototext and also how audiences derived understandings about the data. In our study with African American adolescents with asthma,42 notes taken during the gallery exhibition with policy makers helped us observe how some images were being promoted or minimized by those in positions of power.

Other critical theoretical researchers facilitated discussions about the photographs to engage participants and others to analyze the image for institutional discourses that may be at play within the photograph itself.29 Foster-Fishman and colleagues described a process of participatory analysis (using facilitator prompts and structured games with youth participants) that “preserves the voice of the original photographer while also promoting larger group reflection and critical dialogue.”29(p70)

In a recent study,30 we applied a critical narrative approach to an analysis of photographs and phototexts from a group of Mexican American mothers of children with asthma. We examined the subject positions the participants took in their photographs and phototexts. We considered how these positions either affirmed or contested dominant discourses concerning asthma management, and we explored any tensions existing between the photographs and phototexts.

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G. Policy maker and stakeholder involvement

Policy maker and stakeholder involvement entails identifying, recruiting, and engaging those who can develop, create, or influence policy or outcomes about the topic of interest. This is viewed as an important component of photovoice studies oriented to transformational change such as participatory action research projects and critical theoretical methodologies. The phenomenological researchers included in this review did not include this component in their process.35,43 While Wang and colleagues9 appeared to only involve policy makers at study conclusion, it has been suggested that early involvement of policy makers may be more effective in building a commitment for change.44

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H & I. Dissemination and action

Dissemination for researchers using photovoice includes exhibiting the photographs and phototexts in community gallery events, on Web sites, or in journals. Action involves mobilizing groups for improvement of social conditions. A significant innovation of photovoice is the photo-exhibition or gallery event in the community setting where the research was conducted. Consistent with the documentary photography underpinnings of the method, participants in many photovoice studies end up exhibiting selected photographs and phototexts in community settings. Gallery events draw participants into new roles, and form the basis for planning and mobilizing for action, and provide an excellent opportunity to promote empowerment in participants, a third outcome of photovoice.3,45 Unlike the community exhibits, dissemination in journals can be challenging, given the many restrictions (ie, page numbers) regarding manuscript preparations.4

The researchers we reviewed who used phenomenology rarely disseminated photographs and phototexts in any way other than through journal publication.35,43 Some have argued that the emancipation and political engagement of participants that occurs with the discussion of their photographs meets the photovoice goals of policy engagement.38 Sitvast and colleagues14 made no claims to this effect in their phenomenological examination of participant photo-stories of their recovery from psychosis. They did choose, however, to include an opportunity for their participants to select a subset of their photographs for an exposition that were emblematic of emerged themes.

Few photovoice researchers using GT have included an exhibition. Instead, photographs included in journal articles support the contribution the researcher is making to a substantive theory. For example, Freedman and colleagues32 inserted a photograph of a person removing a pair of shoes from a power line to support their identification of a basic social process that contributed to substantive theory about socioenvironmental well-being. However, they did not discuss action planning for policy change.

In research with a critical theoretical orientation, photographs were a way to extend multiple participant discourses.46 Citing Barthes, van Leeuwen47 argued that if images “just seem to allude to things,” then the work of visual analytics is to interrogate these allusions and make them visible. The preservation of this integrity of image and text ensures participant voice is tangible within the noise of other, more dominant discourses.48 In our own research, we have made a concerted effort to ensure this integrity between the photograph and the participant-created phototext through not allowing, for example, the press to publish a participant photograph without the associated phototext.

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ADVANCING PHOTOVOICE BY IMPROVING METHODOLOGY-METHOD CONGRUENCE

Despite being informed by different methodologies, none of the studies we identified engaged participations in the problem identification and recruitment components of the photovoice process. All participants, however, were trained in topics including ethics, photo taking, and device handling. The SHOWeD questioning approach was used in all the studies we reviewed, and participants were involved in photo analysis and discussion. Finally, all the studies selected only a limited number of photographs for publication and dissemination.

Photovoice researchers have rarely achieved policy change. In a previous review of 30 photovoice studies, we found only a small proportion of researchers reported on policy change activities and that less than half of the studies actually described a methodology.7 We also found it surprising that so few studies were explicit about their dissemination methods and whether they included gallery showing.4 Phenomenological and GT-oriented researchers did produce actionable knowledge from using photovoice methods that could have been translated into policy actions.

There continued to be a clear incongruence between the methodology and the photovoice method in photovoice. Researchers using phenomenology and GT have not explicitly described social action or change impact. Phenomenological methodologies do not include group analysis of the photographs.43 Researchers seem to be diverging from Wang and Burris' original photovoice processes that include “group discussions” and “reaching policymakers ... who can be mobilized to make change [through gallery exhibitions]”6(p96) to selectively using components of this method.

Following the work of other critical theorists such as van Leeuwen47 and Barthes,49 it might be possible to reinvigorate the participatory (and sometimes critical) analysis of not only the phototexts produced but also the photograph and the interplay between it and the phototext. For example, participants could be prompted to reflect on the topic of what they chose to include, which might lead to a deeper analysis of the meaning-making process and the influence of societal forces.29 Both Sitvast and colleagues13,14 and Carlson and colleagues38 emphasized the importance of viewing photovoice as a method that was only useful when guided by a methodology. Although they used different terminologies, Sitvast's approach mirrored the participatory and dialogical aspects of photovoice by combining group photo sharing with a gallery exhibition of photo-stories. Ricoeur's concept of mimesis was used to describe the process of going beyond participants' reflection on the photographs that they had taken to empower them with a deeper understanding (meaning making) of the forces that underlay their life experiences and with an opportunity to reformulate these realities. Sitvast's13 focus was on the therapeutic aspects of participant photography, including empowerment for self-management, and explicitly did not seek the strong advocacy role of more traditional photovoice methods.

It is problematic that there is still little variation in the SHOWeD questioning strategy across studies, given that the researchers all have different aims related to the use of photovoice. A questioning strategy assumes a shared/implied theory about what the photographs might represent. As previously discussed, these questions were based on critical theory and the Freirian principles of empowerment education.1,26 New questioning strategies might improve the analysis by improving methodology-method congruence. It may also be possible also to extend the opportunity for reflection on the image to the photo-exhibition and include policy maker and stakeholder opinions as data for participants to refine their intended meanings in their photographs and phototexts. For example, in our research with African American adolescents and asthma management disparities,33 we discussed which photographs the audience at the gallery event selected to discuss as a group and included quotes from those discussions.

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Implications: Proposed questioning strategies to improve methodology-method congruence

Much remains to be done in improving methodology-method congruence in photovoice research. If phenomenology and GT are used for photovoice method application, despite their lack of a critical theoretical lens, researchers need to consider forming a congruent linkage to all components of the photovoice process (Table 1). One way to address this methodology-method congruency is through advancing the questioning approach within the photovoice process. In Table 2, we suggest questioning strategies for 3 components of the photovoice process: (1) how to prompt participants to conduct photo-documentation, (2) how to use the methodology to support photo-elicitation, and (3) how to use the methodology to advance data collection at the gallery event.

For researchers using phenomenology, we suggest that participants be prompted to take photographs that document what they think contributes to the issue in question and photographs that help them express feelings about their lived experience within the situation (Table 2). Photo-elicitation discussions could be broadened to considering alternative meanings and titles for the photographs in order to deepen the discussion about lived experiences. Participants could also be asked to identify photographs that reveal positive, negative, or neutral aspects of the situation. Audiences can be asked for reflection on the meaning of the photographs, especially with respect to their impression on how this situation affects the lived experience of the photographer.

For researchers using GT methodology, photographic images could be viewed as visual information to shape and contextualize substantial theory generation. Images could aid in the process of development of theoretical constructs, theory exploration, identification, or synthesis. The researcher could encourage participants to question the meaning of an image as a way to develop theoretical insights that are more nuanced than asking direction questions alone. For GT, photo-elicitation discussion questions might become more central to research analysis (Table 2). For example, “What in this photograph helps you communicate the process by which you came to know (identify the research topic/issue); does this process resonate or fit with others in the room, what about this photograph grabs or is useful to you as we talk about the process of (identify the research topic/issue); and what in this photograph is modifiable or could change the process you used for (identify the concept of interest)?”

Beyond using the SHOWeD questioning strategy to collectively discuss with participants their photographs, Wang and Burris1 do not describe critical theoretical approaches for image analysis. Given, however, their emphasis on feminist theory and critical consciousness institutional discourses, influencing both the production and interpretation of the image can be interrogated. Institutional assumptions and power relations can also be explored. To achieve such deeper understanding of power relations and stay faithful to the methodology-method congruence, we suggest that questioning strategies relating to power be used to prompt participants to take photographs, such as: “Who has the power to change/improve my situation?” (Table 2). We suggest that the SHOWeD questions be evolved into SHOWeVD (Table 2): (1) what do you See here, (2) what is really Happening, (3) how does this relate to Our lives, (4) Why does problem or strength exist, (5) Who is responsible for silencing or promoting our Voice, and (6) what can we Do about this?

Audience responses to the phototexts become an important part of creating effective phototexts for social justice transformation. We suggest a line of questioning for audience members when viewing these photographs that will help accomplish this (Table 2), by both assessing how well they agree with the voice of the participants in the phototext (eg, “Is it [the phototext] accurate from your perspective?”) and what they could use the phototext for (eg, “How could you use this photo to transform...?”).

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CONCLUSION

Our goal in this article was to revisit current interdisciplinary research using photovoice and to suggest how to advance photovoice by improving methodology-method congruence for phenomenology, GT, and critical theory. Our implications included novel templates for questioning strategies within each of the methodologies. In revisiting the 20 years of photovoice research, including the contributions made by authors in ANS, we highlighted the importance of a methodology and method pairing in the various components of the photovoice process. The photovoice method when used in congruence with the methodology could be a powerful tool for nursing research in addressing power relations, promoting voice, and seeking transformative change.

Participants using the photovoice method cannot be viewed as neutral constructors of images and texts. Wang and Burris1 called for a reflection about the import of what participants communicated through their photographs and phototexts. Calling upon emancipatory forms of discourse for the iterative construction of these photographs and phototexts, they viewed participants as social actors voicing their concerns. What we have presented in this article is a deeper understanding of this voice in relation to the various methodological opportunities for participants to select, frame, and display their photographs and phototexts to those in power in order to move them to transform situations. Those with marginalized voices can only move audiences if their voice is accurately used.

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critical theory; grounded theory; hermeneutics; methodology; nursing research; participant photography; phenomenology; photovoice; social justice

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