Amanda Braswell is a nurse and was awarded the 2018-2019 Fulbright Research Award to research food access, eating habits and diet of Bangalore’s urban poor. She used community participatory methods to actively engage her research participants in the data collection. In this post, Amanda presents the process of using Photovoice methods and provides resources for others interested in using Photovoice methods. You can learn more about Amanda’s Fulbright experience at https://amandasfulbright.com/

My Fulbright study is titled Perceptions About Food, Dietary Habits, and Prevention of Cardiovascular Disease in an Urban Slum in Bangalore. Cardiovascular disease (CVD) is one of the major noncommunicable diseases claiming the lives of Indians, but with changes to diet and exercise, CVD can be prevented or controlled.

There is a lack of adequate research of nutritional habits of India’s urban poor. As a nurse, I wanted to study nutritional habits of people living in urban slums. I used photovoice as my research methodology, asking my participants to photograph everything pertaining to their diet over a four-week period. Additionally, I assessed their knowledge of nutrition and what they consider to be healthy or not healthy before the study started and again after the study. I incorporated education about diet, nutrition and CVD at the end of the project.

What is Photovoice?

Photovoice is a qualitative community-based participatory action research methodology that uses photographs to elicit perceptions and lived experiences of a population. Photovoice is participant-driven and the researcher acts as a facilitator.

Photovoice involves providing cameras to participants and asking them to take photographs that represent their lived experiences about a topic. The Photovoice process often culminates in an art exhibit; participants actively select and analyze the images used. Sometimes participants give presentations on the images if anonymity is not required.

Why did I choose the Photovoice method?

Photovoice empowers participants because it’s members lead the study; they’re not passive subjects. Community members have a sense of pride and ownership when they are able to talk about what they photographed. I worked with a sensitive community in one of Bangalore’s largest urban slums, where most lack formal education. Studying their diet through photographs taken by them on their own terms, was a wonderful way to study the community’s dietary habits.

Connecting with research participants

Amand, a nurse, teaching about hand hygiene, breast and cervical cancer, and self-examinations for breast cancer.

Connecting and building trust with a community is important for using any community participatory research method. The host institution for my Fulbright has a community health clinic in the slum where I wanted to conduct my study, which enabled me access to participants. People are protective of their community and wary of outsiders because they have been exploited in the past.

Before selecting participants, I traveled with the local health department to the clinic almost every day for a month. I needed to be in the community to learn about its dynamics and have people become familiar with me. I walked the streets of the neighborhood with the home health nurse, went with the healthcare staff to various childcare centers, and spent days in the community clinic. Eventually I met with interested families that the clinic identified and found ten families to participate.

I arrived with 4 cameras donated to me and I purchased 6 used point-and-shoot cameras locally. The cameras were easy to use, and I held a training session with everyone during the first week. The community health nurses served as translators.

Facilitating the Photovoice Photography Process

Amanda teaching participants how to use the digital cameras

While preparing for this study, I read through several photovoice studies. They showed that the more the facilitator was involved, the more successful the study outcome would be. When presenting my proposal to the IRB at my host institution, they were concerned that participants would not be responsible with the cameras.

Knowing the concerns of the IRB, I made myself 100% accessible to my study participants. Every week, I dropped by their homes to check in, offer support, download photos, and inquire about any challenges. When I stopped by, they were always happy to see me. They all insisted on serving me chai, biscuits, and sometimes breakfast or lunch. Some of them needed camera batteries, some of them had already taken 50+ photos, and a few of them needed encouragement because they had not taken any photos.

At the end of the four weeks, the 10 participant families had taken 404 photos. Their images were insightful! The community health department at my host institution was pleased because for the first time, they were seeing what the families were eating.

Analyzing the Photos and Community Perception

Often the facilitator will meet with all participants in a group setting, giving each participant an allotted amount of time to discuss what is in the photos. I had all of the photos printed and divided them up into the individual family participant groups. I did the first round of discussions with each participant individually to protect privacy and respect cultural norms. For example, if the participants had problems acquiring food (food insecurity), I wanted them to speak freely about this and not feel ashamed or embarrassed in front of other people.

Individual discussion about photos taken with a participant

During the first discussion, I asked them to name the items in the photos and describe details about food preparation. One key question I asked was if the participant feels the food in the photo is healthy or not for people in general and people with hypertension and diabetes and why/why not.

My second discussion with the participants was in a group setting and used for understanding health perceptions and included diet education for preventing cardiovascular disease. I had the participants choose between three and five of their favorite photos that represented what they eat the most. Each person told a story about their selected photo. Some of the perceptions of nutrition and dietary habits and how these can cause disease were correct, but there were a lot of misconceptions about nutrition and the attribution of cardiovascular disease.

Participant photos of their daily eating routines

Sharing the results

Community exhibition with participant photos and stories

The final part of my photovoice study was a community exhibition where the photos and stories would be on display to the public. Since my participants are from a sensitive community, I did not have them present. I had the photos enlarged to 12’’-by-18’’ size and mounted them. I typed up the stories for each photo and mounted them beneath the photo. More than 200 people attended the exhibition and asked engaging questions. I plan on having two more community exhibitions during the last six weeks of my time in India.

Photovoice Recommended Resources

To prepare, I read through several past studies, literature reviews, and various guides and manuals on using Photovoice. I read many publications by Caroline Wang and Mary Ann Burris who developed the photovoice method in 1992 while studying village women in China. This gave me insight into the process and helped me identify challenges I might encounter. Photovoice has been used in many fields, not just health. Every study is different and there are no set guidelines to how a study can go – it is common for the facilitator to adapt strategies throughout the project.

Resources I used and recommend:

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Case Study: Fulbright Research Using the Photovoice Participatory Research Methodology

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