Abstract
Photovoice is used widely for engaging community members in action research aimed at reducing health inequities. Photovoice methodology can help to raise participants’ critical awareness regarding the root causes of community health problems, thereby encouraging them to take action to address these root causes. We report on our experiences using photovoice as part of a tobacco prevention project with multiethnic youths in an underresourced Northern California community. Through an iterative cycle of action and reflection, facilitated by staff from academic and community partner agencies, photovoice activities enabled the youths to connect smoking behaviors they observed at their school with low student morale and student officials’ lack of engagement regarding students’ tobacco use. The photovoice process helped youth participants to develop an action plan, which involved raising critical awareness among their peers and school staff through workshops and strategic meetings. Despite challenges, photovoice was an effective way to engage youths in community-based research and to foster their sense of collective efficacy in addressing structural determinants of inequities.
Introduction
Photovoice is a participatory research method for engaging community members in research activities. In photovoice projects, community members conduct qualitative research on their own communities by taking and analyzing photographs (or videos, in videovoice) (Carlson, Engebretson, & Chamberlain, 2006; Catalani & Minkler, 2010; McIntyre, 2008; Wang & Burris, 1997). Photovoice projects have been initiated with populations around the globe on issues as diverse as homelessness (Bukowski & Buetow, 2011), forced migration (Green & Kloos, 2009), food security (Lardeau, Healey, & Ford, 2011), Alzheimer’s disease (Wiersma, 2011), and spinal cord injury (Newman, 2010).
Many photovoice projects aim to “give voice” to marginalized populations while generating community-originated visual materials for use in advocacy and education campaigns. Photovoice was originally developed to facilitate what Brazilian popular educator Paulo Freire called “conscientization”: a transformative and emancipatory process through which marginalized people analyze (“decode”) the social structural elements which constitute the terms of their oppression (Freire, 1970/2000; Wallerstein & Bernstein, 1988). This process produces critical consciousness, which includes both awareness and a sense of responsibility to take action (Carlson et al., 2006). In photovoice, photography is less an end in itself and more a means to develop this critical consciousness, providing a medium through which community members assess and analyze specific elements of their social environment in an iterative cycle of reflection and action. Participants use the SHOWeD framework to guide their discussion of their photographs: What do you 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 to improve the situation, or to enhance these strengths? (Wallerstein & Sanchez-Merki, 1994; Wallerstein, Sanchez-Merki, & Dow, 1999; Wang, 1999).
Although many studies have reported findings from photovoice projects, few have investigated the process through which participants develop this critical awareness. Likewise, participants’ self-assessment of their own transformative experiences is seldom included in research reports (Evans-Agnew & Rosemberg, 2016). Here, we report findings from a youth photovoice project, focusing on the processes through which the youth participants developed critical consciousness and assessed their experiences. This project engaged youths in critical analysis of how tobacco use impacts their underresourced San Francisco Bay Area community. It emerged from a research partnership between Pacific Institute for Research and Evaluation (PIRE), and Southeast Asian Young Leaders (SEAYL), a youth development program of the nonprofit organization Community Health for Asian Americans based in the San Francisco Bay Area.
The project was motivated by our understandings that (1) tobacco retailers are disproportionately located in low-income communities of color (Hyland et al., 2003; Peterson, Lowe, & Reid, 2005; Schneider, Reid, Peterson, Lowe, & Hughey, 2005; Yu, Peterson, Sheffer, Reid, & Schnieder, 2010); (2) tobacco use has remained entrenched in these communities, despite overall reduction in California (California Department of Public Health, 2015); (3) community engagement is a key strategy for promoting well-being within underresourced communities (Minkler & Wallerstein, 2008; Wallerstein & Duran, 2006); and (4) youth leadership is valued and supported by communities, especially in tobacco prevention efforts (Lee, Lipperman-Kreda, Saephan, & Kirkpatrick, 2012; Madrigal et al., 2014; Mendenhall, Harper, Stephenson, & Haas, 2010; Ross, 2010).
Our study used a culturally centered approach, in which analyses were generated by “engaging in meaning-making with cultural participants” (Dutta, 2007, p. 311). This is different from a cultural sensitivity approach (also referred to as “cultural tailoring” by Peterson, 2010), which engages community members in data collection but not in data analysis. Prior research and our own two-year pilot study showed us that photovoice was an effective means by which our youth participants could engage in research on tobacco influences (Lee, Lipperman-Kreda, Saephan, & Kirkpatrick, 2013; Tanjasiri et al., 2013; Tanjasiri, Lew, Kuratani, Wong, & Fu, 2011). To assess the participants’ process of conscientization, we conducted content analysis of the artifacts generated by the photovoice process—photographs and accompanying texts—together with qualitative process evaluation materials collected during the course of the project.
Methods
Study participants and recruitment
SEAYL originated in 2004 as a youth development program for children of Southeast Asian (particularly Lao, Mien, and Khmu from Laos, as well as Cambodian, Filipino, and Vietnamese) refugees and immigrants living in a Northern California city who were experiencing a community crisis in inter-Southeast Asian gang- and drug-related violence but with no dedicated youth services. However, SEAYL was open to any youths living in the area, and over the years had attracted youths of Latino, African American, and mixed-ethnic heritage.
In our three-year Youth Participatory Action Research intervention study, we attempted to recruit a cohort of approximately 15 youths who participated in SEAYL, but who had not participated in our pilot study. A multi-ethnic subgroup of youths agreed to participate in our intervention study, and voluntarily formed the SEAYL Tobacco Team. A total of nine youths participated on the Tobacco Team, with five of these youths participating as a core group across all three years (four phased in and out due to demands of work and school). At the beginning of our study, they were aged 15–24, with the majority being high school freshman. Half of the Tobacco Team members were female.
During the school year, the entire SEAYL group met after school once a week, and the Tobacco Team members met an additional day after school. All SEAYL Tobacco Team members received a modest stipend to support their participation. All research activities were approved for protection of human subjects by the PIRE Institutional Review Board.
Photovoice process
We conducted an intensive six-week photovoice project during the summer months following year 1 of the study. During an initial discussion, the youths chose their high school as the primary aspect of their lived environment on which to focus their research and action, due to their sense of connection to their school and potential ability to cause change there. Before the photo sessions took place, the youths received intensive training on basic photography techniques, photovoice, and the SHOWeD analysis method. Subsequently, the youths took photographs in and around their local high school and, for comparison, at three other high schools in better resourced and less impoverished neighboring communities. The youth participants documented tobacco advertising and sales in tobacco outlets near these schools. Participants also photographed locations where they had witnessed frequent tobacco use before, during, and after school hours.
Process data: Photos, captions, and discussion notes
After each photography session, the youths participated in a 30- to 45-minute discussion to reflect on what they had documented. During these discussions, each youth chose two photographs and interpreted them using the SHOWeD criteria, first in writing, then through oral presentations to the rest of the group. Their observations were recorded and the youth later transformed them into captions for each photo.
Focus group data
After the completion of the photovoice project, the youths participated in a focus group to elicit their perspectives on the photovoice process. They were asked open-ended questions regarding their experiences using photovoice; the advantages and disadvantages of photovoice and SHOWeD; the ways in which photovoice and SHOWeD could serve as tools for other youth-led environmental prevention efforts; what they had learned about their community and themselves through the photovoice project; and how they felt about their ability to take action to address tobacco use in their community or high school. The focus group was facilitated by the project staff, digitally recorded, and professionally transcribed.
Thematic content analysis
Due to our small participant sample and diverse data sources, we conducted thematic content analysis (Elo & Kyngäs, 2008) of photographic images, captions, and transcripts from group meetings and our focus group. The first stage of analysis was conducted by the Tobacco Team with support from the project staff. The youth participants selected key photographs which they then organized into a slide show presentation, a scientific conference poster, and finally a curated photographic exhibit. In the second stage of analysis, the adult program and scientific staff analyzed (1) the youths’ selected photographs and accompanying captions and (2) the focus group transcript. Staff members reviewed these textual and visual materials several times and then “open-coded” them by assigning descriptive themes to photographs or text passages. Themes were developed through an inductive, or grounded theory-informed, analytic process; that is, they emerged during the review of the materials rather than being determined a priori (Charmaz, 2006). The themes reported below represent the complete set of perspectives related to conscientization that arose in conversation with the youth participants, which the analysts have aggregated within topical domain. Due to the structure of the focus group, it was not feasible to assess within-group accordance with each statement. These themes are presented, alongside representative photographs and quotes, below.
Findings: Photovoice process
The main themes that emerged from the youths’ photographs and project staff’s analysis of the photographs were negative environments, lack of no-smoking enforcement at school, lack of signage, negative perceptions and attitudes, and positive environments (Figures 1 to 5).
Negative environments. This is a big pile of butts, trash, and more outside of a liquor store across the street from [our high school]. Growing up in [our city], I got used to the environment being dirty, but I was pretty shocked on how much there were. There was way more than I expected. Photo and caption by Sydney Phong. Lack of enforcement. You never would expect that this is one of the main spots for the students of [our high school] to smoke because it’s the front of the school. The administration office knows but still does nothing. You figured going to school would prevent it. You can find the students smoking here before and after school. Photo and caption by Evelyn Munoz. Lack of signage. This is the tobacco sign at [a neighboring high school]. Man, you kidding me, every school except my school has this sign. A sign is not expensive, makes me wonder how the other schools got to like what they are now. Clean and nice neighborhoods, why is [our city] so littered? We have so much potential but it’s filled with cigars and swishers. The environment we live in changes our perspective to do what we need to. Photo and caption by Johnathan Saeteurn. Negative perception/attitude. This is a church in front of [our high school], a place that is supposed to be a good, bright, honest place, has cigars & swishers packs all around it. This church is in front of [our high school] where a lot of kids have to pass by. Kids seeing that every day, they get used to it especially the seniors about to graduate and go to college. They’ll remember the bad things and continue telling their stories of how bad [our city] is, they shouldn’t remember us for that. Photo and caption by Johnathan Saeteurn. Positive environment. Though [our city] has a bad rep, there are good people who will help you out. We were walking by an auto repair shop and the owner of the shop invited us inside. He gave us permission to take this picture, gave us a tour and gave us information on classic muscle cars. He even gave us background information on why he collects old school cars. Photo and caption by Daniel Gracias.
Findings: Focus group
Critical awareness of surroundings
Three focus group participants stated that the photovoice project allowed them to develop a more critical awareness of their surroundings (in the focus group transcript sections below, P indicates Participant, with numbers to identify distinct participants; F indicates Facilitator). P2: It was nice, because you don’t really go and look at all the other schools in your district. You only really know how your school is and what’s around your school. But to go to the different schools and see how it is there and what they have and how nice and clean it is or something, it’s like really different. You can really put your two cents in how they run their school and how we run our school, and the complete difference that there is in between [them]. P5: I just saw how every place is different. Even though they’re in the same community, everybody goes there. You live in [our city], but you go there, and there, and there. But it’s so different—I’m distracted by that too—and I see how it’s so different, but I wonder why. P3: Before, I was—how do you say—I didn’t really look around my surroundings. I just went to school, homework, back home, and lock myself in my room. That’s all I did. But when I started joining SEAYL, instead of staying home and just sitting there in my room, I actually went out and looked around my community to see how messed up and how beautiful it is. So yeah, it really did change [what I see].
Negative perceptions of the community
Several focus group participants expressed concern about negative perceptions of the wider community in relation to their school environment. P2: And then, they really do judge, “they,” meaning community, people. Anybody driving by judges the school on how it looks, because they don’t have the opportunity to go in and get to know the students there. So they judge off the school. And the students leaving the school how it looks and just tossing garbage and cigarette wrappers and Swishers and stuff just on the floor, just makes it look so much worse. And then they complain as to why, “Oh, we have a bad name. Our school looks so dirty.” P5: “It’s so ghetto.” P2: Yeah. “Our school is ghetto. Nobody likes us.” Because they don’t take action and take care of the school. We could be just like [another local high school] if the students chose to help out, but they don’t. And that’s the thing I hate. They jump to conclusions and judge the school and everybody in it by its past or how it looks, when it really shouldn’t be that way.
Appreciation for the community
Through the medium of photovoice, participants described making connections with residents in the community and learning about the community’s strengths and resources. P5: I don’t know. It just felt really cool, just going out, especially when me, [other participant], and [other participant] met that person at the car place. Remember that? It was really cool. He was really nice. He introduced [himself to] us. He likes visits at the shop. I saw new cars, saw old cars, saw vintage cars. It was really cool, and seeing there are really cool people in this community, that felt really good. P4: I learned that what most people don’t see is that [our city] really does have a lot of talent, a lot of hidden people who are nice, talented, down to earth, doing them (sic) down to earth kind of thing. But we got this code as a ghetto community, and this code’s not coming off because the rest of the community doesn’t really care about the name anymore. It’s been tarnished to the point where … you can’t come up from the bottom anymore. That’s how I see it. But in reality, there’s so much in [our city], the diamond hidden in the dirt. P1: I feel like people, like how [P4] says that there are so many talented people. I feel like since they’re in our community, they feel like, they’re too scared to show it, to come out with it. I don’t know. P2: You started from the bottom, then you’re staying there.
Critical thinking skills
The youths described photovoice as a method that allowed them to develop skills that could be applied to other life contexts, such as critical thinking. P1: It’s real life. It’s real life, like something you’d probably actually maybe use. P4: I feel like photovoice, it uses some of the things we learn in school, like grammar of course. But other than that, it’s more of a, I guess elective kind of thing, where it forces you to think not in an educational way, but more of a … because you have to think outside of your bubble in order to come out with something that you feel deep inside, other than school. P5: I think photovoice, it makes me look at things with a new perspective. In school, it’s just like, “Oh, this is what you’re going to learn. This is how we do it,” right? But in photovoice, it’s like, you take pictures and you look at it, at how you want to, right? There’s not like a way to do it. That’s what I kind of think, how it helps in life. P4: Yeah, like you have your own freedom of where your limit is and how far you could push it. I found it useful because as they say, a picture can hold a thousand words or more. And what you can think this picture means, what it means to you, can mean the complete opposite to someone else, and makes you a combination of anything to anyone else that sees it. They could see the good or the bad, the black or the white, everything, just depending on the mood of the person who’s looking at it.
Self-efficacy versus collective efficacy
The participants described how challenging it was to consider moving from research to action. Much of this conversation centered on their uncertainty as to whether they as young people could effect change in regard to reducing tobacco use in their community and at their school. F: So did photovoice make you want to take action and address tobacco use in your community or high school? P2: Kind of, but the thing is, you want to do it. You’re like, “I’m going to do it.” When you really think hard about it, you’re like … P5: “I don’t want to do it.” P2: “What’s the point?” It’s not going to stop anything. It’s not going to stop anybody. We’re not going to change anybody’s minds. We can, but the way that our community is and how hard-headed and stubborn they are, they’re just going to be like, “Oh, look at these teenagers trying to think they could change us.” P3 and P5: Yeah. P2: “Oh, you youngsters, go back to playing video games,” or something. They’re not going to take us seriously. And that’s a huge disadvantage to us. It shouldn’t be that way, but that’s just the way adults and the older generations think of us. They think that we have no effect and we have nothing to do but just be youngsters. P2: And if you have no one behind your back … like majority of the community smokes, even the teenagers. Us as teenagers trying to prevent it are going to be like with the adults. So it’s going to be more of them against us. And if we really don’t have anything to fall back on, like people supporting us, it’s going to be even harder. It is possible, but the chances of it actually happening are very slim, very slim. P1: I agree with [P2] about how adults see us, but it really depends on who the person … P2: Mm hmm. On the adult. P1: … that you’re talking to. Because some people, if you really bring out the facts and everything, and then you tell them the truth and everything that we say, then they’ll probably say, “Yeah, there are youth in our community that actually care. They’re so educated about it that they would come and try to change our community.” But then again, it would be kind of pretty hard because even if … we’re a small group. They won’t just listen to us. They want more opinions. And it’s kind of hard to get other people to change their opinions, especially at our age, because smoking is “cool.” P5: Well, I want to say something. When people try, kind of like SEAYL and [another community project], it really helps, because even if it’s little by little, people kind of like me. SEAYL will reach into my perspective on things … So I think if we really try, I think if the community really tries, and even though it’s little by little, it changes. Kind of like us. We’re all here. We’re all trying to change. It’s better than doing nothing. Doing anything is better than nothing.
Discussion
These photographic and focus group data suggest that popular education-inspired methods such as photovoice can be useful in promoting community-led knowledge production in participatory research. Over the course of this photovoice project, participants reported developing critical awareness through the documentation and analysis of community issues such as tobacco use at school and the impact of littering on their school’s perception by the wider community. Beyond simply focusing on tobacco use, the youths displayed increasing attentiveness to the social inequities affecting the health of their community and school.
This critical awareness, however, did not immediately translate into a sense of self-efficacy to effect change on their environment. Rather, photovoice served as a catalyst for an initial exploration of the socioeconomic factors contributing to tobacco use. In the focus group interview, several participants described a pervasive sense of community-level despair and socioeconomic depression that they associated with an increased likelihood of smoking. This perception, along with the perception that “the majority” of adults and teenagers in the community smoked, seemed to reduce some participants’ sense of self-efficacy in combating tobacco use. A few respondents also expressed doubt that adults would take them seriously due to their age. In another photovoice project conducted with Latino adolescents, participants had similar concerns (Mejia et al., 2013).
However, as shown in the final set of quotes presented above, two participants in our study articulated a burgeoning conviction in their ability to influence their environment in small but meaningful ways, especially when acting together. This conviction continued to grow over the course of the project as the participants implemented their collective action steps for reducing tobacco use at school. Conscientization thus occurred at two levels in our project, individual and collective. As argued by Freire, individual realization of oppressive conditions is a necessary first step in the conscientization process, followed by individuals’ realization that they share oppressive conditions with others and can therefore act together for change. Individuals become aware that they alone cannot change the conditions of oppression, but that change is possible through collective action. This dual-level conscientization process was borne out among youth participants during our project.
Our findings indicate that photovoice is a useful tool for bringing about shifts in critical consciousness by using observations about the environment to provoke active reflection and discussion among community members. Photovoice helps to initiate a dialogue among participants that can serve as a first step in a larger process of effecting social change. As in our project, the process of critical reflection can also expose limiting beliefs about community members’ ability to change their environment as individuals. For this reason, it is important that photovoice not be the sole component of a participatory action research endeavor, but rather the first step in a sequence of identifying a community health problem, exploring its structural roots and effects through photography, and then using that information to create a feasible plan for advocacy or direct collective action (Wang, 1999). A recent literature review of studies using photovoice similarly found that the social justice impact of these studies was more related to “awareness” rather than “amelioration” or “transformation” (Travers et al., 2013). The authors of this review also argued that photovoice is best used when coupled with a firm plan of action based on photographic findings with attention to the question, “what can we do to make the changes we want a reality?”
The inclusion of a community-based facilitator who can help enlist support and resources to aid the group in accomplishing its goals is key to crafting an action plan. The project described here was facilitated by a staff member at the community partner organization. Once the participants implement and enforce had devised a list of action steps, the facilitator contacted the school administration and enlisted their cooperation in the youth-led initiative. This approach helped to address the youths’ fears of being ignored by adults while also increasing their chances of success by involving stakeholders with the power to policy (Wang & Burris, 1997).
In using photovoice and other methods to evoke conscientization with marginalized groups, however, there are risks which can arise from seeing their situations with “new eyes.” As noted by SEAYL participants, photovoice brought into focus negative aspects of their community and school environments, particularly in comparison with more affluent neighboring communities and schools. In Freirian terms, this rising awareness represents a “limit situation”—an awareness of the circumstances that limit a person or group, which may create a “climate of hopelessness” depending on whether they are perceived as “fetter”—which may be cast off—or “insurmountable barriers” (Freire 1970/2000, p. 80). As a sense of hopelessness in youths is associated with increased risks for poor behavioral health, including depression, sexual risk taking, and suicidality (Horwitz, Berona, Czyz, Yeguez, & King, 2017; Kagan et al., 2012; Wallace, Neilands, & Sanders Phillips, 2017), it is critical that program staff facilitate the photovoice process carefully. Rather than naturalizing and reifying relationships between participants and their circumstances, the photovoice analytic process must be directed toward emancipatory goals that enable participants to objectively perceive their environment and themselves in historical context, and thus subject to transformation.
In conclusion, using the photovoice method and SHOWeD analysis can be important steps toward developing critical awareness and action plans with the goal of reducing health inequalities. They are best deployed as preparatory exercises that precede the implementation of action plans, rather than the action plan itself. Our findings also suggest the potential benefit of shifting the role of the scientist “from director to facilitator and catalyst” (Cornwall & Jewkes, 1995, p. 1670) in participatory-based studies, especially when working with populations that have traditionally been excluded from social and political decision-making processes, such as youths. Youth-led participatory research can promote the inclusion of youth in social change efforts while allowing them to define the sphere of action in which they can make the most substantial change.
Footnotes
Acknowledgements
Photo and captions reproduced by permission of SEAYL youth collaborators. The authors acknowledge the members of the SEAYL Tobacco Team: Andy Lovanpheth, Brandy Fabian, Daniel Gracias, Evelyn Munoz, Johnathan Saeteurn, Kelly Wong, Lydia Solorzano, Randy Rodriguez, and Sydney Phong. They also acknowledge the support of the entire SEAYL group and of staff members Erica Corpuz and Meme Wang. The author(s) would like to thank Dr Alfredo Ortiz for leading the review process of this article. Should there be any comments/reactions you wish to share, please bring them to the interactive portion of our blog on the associated AR+| ActionResearchPlus website: 
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: This work was supported by the University of California Office of the President Tobacco Related Disease Research Program (grant number 21AT-0012).