Photovoice is a qualitative, participatory research method, which can simultaneously serve as a health promotion intervention.(1) The three goals when conducting photovoice research are to enable people to record and reflect community strengths and concerns, to promote critical dialogue and knowledge through discussions of photos, and to reach policy makers.(2) Photovoice has great potential for empowerment and advancing health equity due to deep conceptual roots within feminist theory, Brazilian philosopher Paolo Freire's education for critical consciousness, and documentary photography. Developed 30 years ago by public health researcher Caroline Wang, international development educator MaryAnne Burris, and collaborators in China, the essence of Photovoice is collaborating with participants as co-researchers to seek insight into perceptions, experiences, and determinants of health through photos taken and discussed directly by community members themselves.(2–4) Participants take photos of their lives and environments individually. Then, they convene with fellow participant co-researchers to discuss the photos and collaboratively reflect on the root causes and potential solutions to the problems captured. The method is ideal for people with limited literacy since participants simply take photos and discuss them. This links back to the potential power of the method for elevating voices in communities whose voices have been silenced due to inequitable structural determinants of health such as access to education.
Since its conception as a community needs assessment method to better understand reproductive health with women in rural China,(4) photovoice has evolved for use globally, in diverse disciplines including medicine and other clinical health professions. A quick search of the term “photovoice” reveals over 3,600 published articles. Search results include photovoice studies conducted across sub-Saharan Africa with the highest proportion coming from South Africa. However, the total number of publications describing photovoice specifically within the sub-Saharan African context drops to below 300, roughly 8% of all articles published. More in depth examination to discern whether the first authors of publications on photovoice in sub-Saharan Africa are African and affiliated with institutions of higher education in Africa reveals even less representation. There are, however, notable examples of scholars leading the way in using photovoice to investigate health issues of both community and clinical importance across sub-Saharan Africa. Dr. David Musoke who has built a program of Photovoice research in Uganda to examine critical health issues such as community health workers, maternal health, and integrated malaria prevention.(5,6) He also led a collaborative article advocating for photovoice to reach marginalised populations and ultimately support health systems in multiple low and middle-income countries including four sub-Saharan countries.(7)
Turning more specifically to South Africa, Shose Kessi and Josephine Cornell have implemented photovoice in higher education settings.(8) They have published widely on utilisation of and advocacy for more use of photovoice in South African contexts as a key tool for decolonial feminist praxis and overall raising consciousness, community mobilisation, and ultimately social action.(9,10) Other health scholars have used photovoice in South Africa to examine critical societal issues such as sexual violence.(11) Yet, ample opportunity remains for expanding and deepening the use of the Photovoice method in South Africa. Photovoice presents a versatile, revelatory research method with power to truly engage South African citizens in participatory processes to elevate voices of oppressed, vulnerable, or marginalised communities as a critical ingredient to advancing health, gender, and racial equity. Such participatory methods are often touted and given lip service regarding medical, health, and education efforts. However, they are not truly implemented in practice on the ground or are implemented only in a surface level manner which may not only fail to promote empowerment and equity but may perpetuate the ongoing harms and status quo of social injustice. Photovoice offers the space for participants and researchers alike to engage in important, critical reflections to dig into the deep and painful roots of colonisation and apartheid and examine their ongoing role as determinants of health inequities in South Africa today.
In terms of more practical questions and solutions, how do we expose more clinical medicine and other health professionals to the photovoice method? If asked, most physicians and other clinicians would not be familiar with the method. This is true globally, certainly inclusive of the United States (U.S.) where I am based, as well as in South Africa. One way forward is inclusion of photovoice in higher education classrooms where clinicians and community health practitioners are being trained. The literature suggests that health science educators in South Africa have successfully utilized photovoice as a teaching tool. For example, Haffejee used photovoice to advance critical thinking for undergraduate students enrolled in an epidemiology module (2021). Similarly, outside of SA, Loignon at el. designed an innovative photovoice study to facilitate medical residents in Canada to scrutinize their biases about poverty in relation to their future professional role in caring for patients whose health status is inextricably tied to living conditions and economic status.(12) The purpose of these projects wasn’t explicitly to train students in using photovoice in their future careers, but involvement with photovoice as a medical student or resident can certainly plant seeds for potential ways of using the method for community engagement in the future. One example authored by medical students themselves, details twelve tips for medical students to facilitate photovoice. The authors reflect candidly on how using photovoice enabled them to build important skills for community collaboration and advocacy for social change.(13)
A common reaction to learning about photovoice is excitement about the method but feeling overwhelmed and not knowing where to start. My recommendation is to start with the three goals of photovoice: (1) to enable people to record and reflect their community's strengths and concerns; (2) to promote critical knowledge and dialogue about important issues through discussions of photos and (3) to reach policy makers.(2) Next, as a firm believer in the critical role of history in shaping the present and future, I recommend reading the 1994 and 1997 papers by Wang & Burris and the 1996 paper by Wang, Burris & Ping to ground oneself in the deep conceptual and philosophical concepts and ideals set forth as the foundations of photovoice. Then, Photovoice for Social Justice and Visual Representation in Action guides readers through the steps for implementation of photovoice including key ethical considerations and samples of tools such as recruitment flyers and informed consent forms.(14) I authored that text with a colleague in the U.S., mainly providing examples of photovoice implementation within North American contexts, so turning to experts within South Africa who can speak about photovoice in the South African context is vital. The chapter “Photovoice methodologies for Social Justice” by Kessi et al. within the edited volume of Transforming Research Methods in the Social Sciences: Case Studies from South Africa offers insight into the authors’ experiences and recommendations for implementing photovoice in South Africa.(10) Kessi and colleagues are working within the social sciences, so despite the origin of photovoice within the health sciences, it has clearly been adapted across disciplines. If you are faculty teaching clinical medicine or other future health professionals then Jaiswal et al. provide a view of photovoice from the student perspective after completing a photovoice project.(13) After grounding yourself in this general literature, I next recommend searching the literature to find a photovoice study examining the specific health or clinical issue you want to study, ideally in the context of South Africa or at least in other sub-Saharan settings. With over 3600 publications about photovoice, it is likely that someone has utilized the method for your area of interest be it palliative care, cardiovascular health, HIV, or tuberculosis. If possible, reach out to the author(s) to seek insight from their experience. Finally, if you are committed to jumping into the iterative, reflexive process of photovoice then a manual with step-by-step advice can be a practical tool. Malherbe, Cornell, & Suffla from the Institute for Social and Health Sciences at the University of South Africa offer a comprehensive guide from a South African perspective, which includes concrete examples of consent forms and other materials.(16)
Earlier this year, I had the great honor of delivering seminars on photovoice in South Africa at both Wits and Nelson Mandela Universities as a U.S. Fulbright Scholar visiting from Makerere University. By far, the most common concerns from attendees centred on ethics and the processes of securing approval from Research Ethics Committees (RECs). Ethics are undeniably a critical concern when undertaking photovoice research. In my experience, some RECs, and Institutional Review Boards may be surprised about the elements of photovoice research if they are not familiar with the method. Particularly in a medical school or school of health sciences, there may be more familiarity and bias toward quantitative research methods. The fact that photovoice is a qualitative, participatory, action research method may call for diplomatic education of colleagues serving as REC members. Photovoice is often used-and indeed was explicitly intended for- study populations that are historically vulnerable and marginalised. The benefits and power of the method, particularly if you are dedicated to working toward social justice and health equity, are worth the education and advocacy. Practically speaking, I urge two actions when working with RECS for photovoice research approval. First, invest time upfront to identify the precise ethical concerns unique to your photovoice study and explicitly delineate actions to protect and minimise risk for participants. The resources previously mentioned offer detailed ideas for this.(14,15) Second, if REC reviewers express surprise at the method or have not heard of it, I always return to calling on the 30 years’ worth of published research using photovoice. It may be helpful to specifically highlight prior photovoice research conducted by researchers from institutions within South Africa or other sub-Saharan countries or with the same population or health issue you propose to study.
In closing, I revisit the third goal of photovoice, which is to reach policy makers. The ideal is to plan from the outset to reach policy makers in your photovoice process. Often, photovoice projects end in public forums where results are shared to advocate for policy changes. Some projects may involve media coverage such as this one: TV Coverage of Photovoice. The targeted policies for change can range from national or provincial level legislation to institutional policies within universities, hospitals, or schools that impact gender or racial equity. Over decades of iterations of photovoice research, this public sharing and emphasis on policy change has increasingly been lost. Therefore, if you feel passionate and inspired to harness the potential power of photovoice within your sphere of influence in clinical medicine, I urge you to work alongside the participant co-researchers to honor all three original goals of photovoice and culminate with advocacy to improve policies for social justice and health equity in South Africa.