Use of Photovoice in sub-Saharan Africa: Illustrations and Reflections From Research in Uganda

Abstract

Photovoice is a qualitative, participatory research method with great potential for increased use across settings and disciplines in sub-Saharan Africa. The method originated over 30 years ago with two women researchers in reproductive health and has since been used across disciplines in diverse settings globally. Despite its origin within the social and cultural contexts of China in 1992, the method has been used predominantly in settings in the global North and West. There is ample opportunity to employ the method in sub-Saharan African contexts as a powerful, versatile research method. This paper highlights the current use of the photovoice research method in sub-Saharan Africa, with a specific focus on Uganda. We aim to demystify photovoice and advocate for more use of the method as a participatory approach in tackling major current transdisciplinary challenges across the globe. We introduce the method, describe the historical and philosophical underpinnings, illustrate use of the method through two examples of our photovoice research in Uganda, and discuss its challenges and benefits.

Keywords

photovoice qualitative research participatory research empowerment global health sub-Saharan Africa Uganda

The purpose of this manuscript is to introduce, illustrate, and advocate for use of photovoice as an innovative qualitative approach in sub-Saharan Africa (SSA). We start by introducing the method to ensure readers unfamiliar with photovoice understand the basics. We also describe the history of the method, including the philosophical and conceptual underpinnings, as a crucial foundation for researchers considering the use of photovoice in SSA. We then offer practical illustration of the method through two examples of implementation of our own, respective photovoice studies in Uganda. Finally, we discuss challenges and benefits, and conclude with practical recommendations for future applications of photovoice in SSA and other emerging economy settings.

The Photovoice Method

Photovoice is a qualitative research method and simultaneously a tool to promote health and empowerment (Wang, 1999; Wang & Burris, 1994, 1997; Wang et al., 1996; Wang et al., 1998). As an action research approach, it entails researchers facilitating a process whereby a designated study population is viewed as co-researchers and guided through a process including training in ethics and safety, taking photos in their community, and then intentional, specific discussions of the photos facilitated in a group setting. As with other participatory, action research approaches, photovoice most commonly uses purposive sampling with the goal of including participants from communities who experience inequities or who experience a particular social or health issue (Breny & McMorrow, 2021).

Wang & Burris developed photovoice as an action research method with an explicit focus on advocacy, delineating three core goals of; (1) enabling people to record and reflect their community’s strengths and concerns, (2) promoting critical dialogue and knowledge about important issues through discussions of photos, and (3) reaching policy makers (Wang & Burris, 1997). Within that structure, the method of data gathering usually involves participants taking photos to meet the first goal, a series of modified focus group discussions to meet the second goal, and some sort of public sharing and advocacy of the results to meet the third goal. However, as a participatory method and as with other qualitative research approaches and designs, photovoice is intended to be conducted with deep understanding of the contexts where it is being conducted, which in turn leads to variation in implementation of photovoice projects such that no two photovoice studies are ever the same.

The focus of the photos taken by participant co-researchers may be decided in an iterative process by researchers and participant co-researchers and other times is focused on one specific issue such as maternal health (Musoke et al., 2015), experiences of a specific population such as refugees (McMorrow & Saksena, 2021) or community health workers (Musoke et al., 2018, 2020), or more generally in a geographic region of interest such as an urban slum (Ssemugabo et al., 2020). The analysis process starts in a participatory manner during the modified focus group discussions of photos whereby participants make the decisions about which photos they want to share and discuss with the group (or do not want to share). From there, a variety of approaches to qualitative data analysis techniques may be used such as thematic analysis (Braun & Clarke, 2022) or qualitative content analysis (Bradley et al., 2007).

Origins and Theoretical Foundations of Photovoice

Photovoice originated in 1992 as “photo novella” when Caroline Wang, a public health researcher and Mary Ann Burris, an international development educator used the approach of giving women in rural China cameras to take photos of their everyday lives and discuss them. Wang & Burris were pioneers of developing photovoice for use within global health and international development as one component of the Women’s Reproductive Health and Development Program they were leading in Yunnan Province, China. Photo novella was incorporated as one portion of a large, four-part needs assessment to understand the needs of rural women (Wang & Burris, 1994).

Their seminal paper encapsulated the ethos, theoretical underpinnings, philosophy, and details about implementation of the work in Yunnan (Wang & Burris, 1994). More specifically, the philosophical and conceptual underpinnings are explicitly detailed as the three foundations of the method. These are: (1) empowerment education derived from Brazilian educator Paolo Freire’s teachings and adapted within the field of public health education (Wallerstein & Bernstein, 1988); (2) feminist theory and research that views women as authorities of their own lives and advocates for an inclusive approaches of knowledge construction (Linton, 1989); and (3) documentary photography that historically focused on “social and mental wellness of both its subjects and the society of which they are a part.” (p. 175, Wang & Burris). This quote elucidates the vision Wang & Burris had for photovoice:

Photo novella provides participants the opportunities to spin tales about their everyday lives...Most importantly, photo novella is a process. From the outset, we envisioned (it) as a method that would not only contribute to the needs assessment, but also enable women to document, discuss and organize around their collective health interests, with the shared aim of improving life conditions in their communities (p. 179, Wang & Burris, 1994)

In addition, they emphasized that while their photo novella process was conceived as a needs assessment approach to collect information, it was simultaneously and intentionally designed as a means of empowerment education with the goal of enabling community members, often those who are marginalized, to communicate and advocate for change to policy makers and those with more power (Wang & Burris, 1994). This is important for researchers considering the use of photovoice in SSA to understand and incorporate in their study designs.

A central aim of photo novella was to contribute to an environment where rural women’s self-defined concerns entered programmatic and policy discussions. Although many programs have been promulgated on behalf of rural women, it was almost unheard of to seek out, systematically and deliberately, their point of view...(p. 180, Wang & Burris, 1994)

Wang and Burris collaborated with a colleague in China to bring the vision into even sharper focus as a “participatory approach to reaching policy makers” (Wang et al., 1996). They introduced this article with a clear emphasis on rural women in developing countries:

In developing countries, rural women are often seen nor heard, despite their extraordinary contribution to the labor force. Photo novella is an innovative methodology that puts cameras in the hands of rural women and other constituents who seldom have access to show who make decisions over their lives (Wang, Burris, & Ping p. 1391)

This statement is still relevant today, over 30 years later. Additionally, it applies to women and other communities across SSA who also offer “extraordinary contributions” to the labor force and continue not to be seen or heard. Today, photovoice has indeed evolved as a method broadly used with the “other constituents” mentioned by Wang et al. (1996). The evolution has extended so far into diverse disciplines, populations, and settings that Wang & Burris likely never conceived of when initiating the method (Seitz & Orsini, 2022). However, there are two points to note about these early origins of photo novella prior to the evolution to photovoice. First, the creators of the method conceived of it as women researchers applying a solidly feminist and theoretical perspective and Freirean approach to building empowerment and critical consciousness into their work with rural women (Wang & Burris, 1994, 1997). Second, the approach was developed in the context of international development in a Ford Foundation funded project to promote reproductive health in an emerging economy setting. These points of history are key for researchers who might want assurance or more clarity about the applicability of the method for use in SSA or similar contexts.

Wang & Burris described their photovoice work in another seminal publication with a concrete description on how to use Photovoice for qualitative, participatory needs assessment that has been cited by nearly 6000 authors. This manuscript has served as a road map for thousands of researchers as it offered a detailed rationale and practicalities for using photovoice. It includes photovoice elements, facilitators, ideal participants, participatory analysis, adaptations, disadvantages, and implications for public health promotion practice and more (Wang & Burris, 1997). It is worth noting that by this time, they largely deemphasized the women’s health and developing country origins of the method. Citations of the 1994 and 1996 articles are a fraction of the 1997 article with 29% and 12% respectively, offering one possible reason that these important origins of the photovoice method within an emerging economy context, and potential uses, are less known or overlooked.

Power, Ethics, and Potential as an Anti-Colonial Research Method

A comprehensive review of the literature and discussion of power and ethical considerations of photovoice research is beyond the scope of this paper. There is a notable gap in the literature delving into ethics of photovoice within SSA settings and to a lesser extent, a gap in examination of ethical considerations with photovoice across all global settings. A few scholars have offered important contributions focusing specifically on the nuances and important questions on the multitude of complex, ethical considerations for photovoice research beyond simply securing Institutional Review Board (IRB) approvals (Breny & McMorrow, 2021; Creighton et al., 2018; Groot et al., 2023; Harley, 2012; McMorrow, 2022; Teti, 2019; Wang & Redwood-Jones, 2001). However, in alignment with the aims of this article, we want to emphasize that there are myriad ethical considerations to be considered from the outset with photovoice implementation. These include safety of participants when taking photos, consent of people to have their photos taken, consent of people to use photos in which they appear for dissemination, who owns the images, shared power and decision making between the lead researcher and participant co-researchers, and compensation of participant co-researchers.

Additionally, adding yet another layer of nuance to photovoice research, we suggest that discussion of research within the context of SSA must include acknowledgement and continued reflexivity regarding the abuses and impact of colonization and ideally, more concrete steps for designing research as an anti-colonial endeavor and possible tool in the greater movement to “decolonise global health”. We embrace the definition and perspectives offered by Chaudhuri et al. who advocate for dismantling the structural roots of colonisation including white supremacy, racism, and sexism and in a circle back to the theoretical roots of photovoice, call for the decolonisation of global health to align more to social theories from scholars such as Paulo Freire and Achille Mbembe (2021).

In relation to photovoice specifically, there is a growing chorus of scholars’ voices, including those in SSA, both sharing their work in implementing photovoice with an anticolonial approach and advocating for fellow photovoice researchers to adopt anticolonial frameworks (Castledon et al., 2008; Cornell et al., 2019; Fricas, 2022; Harley, 2012; Kessi, 2018). Fricas offers critical reflections and specific, practical recommendations for implementing each phase of photovoice. Here, she summarizes her goal for researchers considering photovoice research that we find particularly salient to highlight for researchers engaging in photovoice research in contexts of SSA (2022, p. 2–3)

My goal is to bring photovoice methodology and scholarly work on anticoloniality into conversation in a way that may further increase photovoice researchers’' care in applying the method and decrease the harm which can arise from an application of photovoice that does not adequately adjust for colonialism and its intersecting oppressions.

Photovoice in sub-Saharan Africa

Photovoice has evolved for use globally, in diverse disciplines including health, education, community development, social sciences and beyond. The method has been used in Southern, Eastern and West African regions in countries including, but not limited to Ethiopia (Malherbe et al., 2016), Ghana (Kabore et al., 2019), Kenya (Mtuy et al., 2021), Malawi (Lofton et al., 2021), Mozambique (Powelson et al., 2022), Nigeria (Olumide et al., 2016), Rwanda (Umurungi et al., 2008), South Africa (Cornell et al., 2019; Kessi, 2018; Kessi et al., 2022), Tanzania (Johnson et al., 2019), Zambia (Harris, 2018 and Zimbabwe (Chidarikire et al., 2021). However, though over 3600 articles have been published on photovoice, the number of articles describing photovoice within the SSA context dwindles to below 300, roughly 8% of all articles published. More in depth examination to discern whether the first authors of publications on photovoice in SSA are African and affiliated with institutions of higher education in Africa reveals even less representation.

There are scholars consistently publishing on photovoice research in SSA (Cornell et al., 2019; Kessi et al., 2019; Molestane, 2023; Musoke et al., 2022; Ngidi &). Yet, ample opportunity remains for expanding and deepening the use of photovoice in SSA. It is a versatile research method with power to truly engage people in participatory processes to elevate voices of oppressed, vulnerable, or marginalised communities. Such participatory research methods are touted and given lip service in medical, health, education, and development in SSA. However, they are not always implemented in practice. Photovoice offers the space for participants and researchers to engage in important, critical reflections on the deep roots of colonisation and their ongoing role as determinants of inequities in SSA today (Cornell et al., 2019).

Illustrations of Photovoice in Uganda

We provide illustrating concrete examples and details of photovoice implementation within SSA. More specifically, this section describes details of our respective photovoice research implementation in Uganda. We begin by providing more general examples of photovoice results to offer concrete imagery and ideas of photovoice data. Then, we detail the design and implementation of two distinct photovoice studies that were recently carried out independently in Uganda.

Examples of Photovoice Results

Results from photovoice research can be compiled for in a variety of ways, but a common approach is to have the photos matched with accompanying narrative text illustrating the stories and discussions of participants about each photo. The narrative texts can be adapted from transcriptions or can be written as captions by participant co-researchers. Figures 1 through 3 offer visual examples of how photovoice results from research in Uganda might be shared, primarily in academic presentations, publications, or other forums where reading is possible and a normative way of communicating. For greater community dissemination of photovoice, the accompanying stories can be voiced aloud verbally by the participants. Figures 1 –3 are from a photovoice study on maternal health among youth in Wakiso district, Uganda (Musoke et al., 2016). Figure 1. Figure 2. Figure 3.

To reach health facilities and trained health workers, women from this village in Central Uganda had to travel over 7 kilometres. It takes both time and money to travel there, which limits the number of antenatal and post-natal visits expectant and new mothers make. A common way to get to the health facilities is on a hired motorcycle, known as a bodaboda. These motorcycles are convenient, and they are one of the few means of transportation that can navigate the rugged terrain. However, motorcycles are not a particularly safe way to transport pregnant women, although there is normally little choice.

In Figure 2, a mother takes her young child to a health centre for an immunisation.

The Ministry of Health in Uganda has made efforts of increasing male involvement in maternal and child health issues. Indeed, pregnant women who are accompanied by their spouses to public health facilities for antenatal care are attended to first before those who are alone. However, male involvement is still very low. Here, a pregnant woman not accompanied by their spouse for antenatal care waits to be seen by a health worker at a government health centre.

Poor water and sanitation can lead to diarrhoeal diseases which can greatly affect women during pregnancy. It is therefore recommended that women have access to safe water and sanitation facilities during pregnancy. In Uganda, access to safe water is generally low particularly in rural settings. It is therefore common to find use of inappropriate water sources in various parts of the country. Figure 3 shows a pregnant woman bending to avoid stepping in the accumulated wastewater during the process of collecting water from a source which was in a bad state.

Key elements of photovoice as it was conceived by its originators, Caroline Wang, and Mary Ann Burris, were designing the method to empower participants, working with them in a participatory manner, and importantly, ensuring that process culminates in efforts to publicly disseminate the work to advocate for change (Wang & Burris, 1994, 1997). Photovoice researchers approach the public dissemination and empowerment aspects differently depending on the population, context, choices of the participants and resources. Figure 4 shares one example of community dissemination of the photovoice research on maternal health in a rural setting in Uganda. In the dissemination, the photovoice participants who were youth shared selected photos from the study and presented the accompanying narrative stories to several stakeholders including local leaders. Then, Figure 5 illustrates a photo and accompanying narrative shared by one photovoice participant, a woman who is a refugee from the Democratic Republic of Congo living in the United States. This describes her perspective about the experience of empowerment through participating in photovoice study (McMorrow & Saksena, 2017).

…the first time you told us about this, I am going to be honest, I was a little scared or nervous or I (didn’t) know what to expect. But as we are doing this, you (made) me so happy because you (got) us together and it gives us power in this country and the love that you put in between us...I want you guys to continue doing stuff like this, gathering together, it's something they are not able to do a lot here and it is something very, very nice to warm hearts…

Figure 4.

Figure 5.

Design and Implementation of Two Photovoice Studies in Uganda

As a qualitative, participatory, action research method, no two photovoice projects are ever the same. Here we offer more in-depth description of the design and implementation of two distinct photovoice studies that we respectively implemented in Uganda recently. The emphasis is on the design, implementation, and reflections on the use of the method with the specific populations and settings described in Uganda. We conceived these studies in adherence to the underlying and intersecting conceptual frameworks recommended by Wang & Burris, hence the work is rooted in empowerment theory, feminist theory, and documentary photography (1994; 1997).

Photovoice on Maternal Health Among Youth in Wakiso District

The aim of this study was to explore maternal health and youth in rural Wakiso district in central Uganda. Three main publications have emanated from this study. The first paper describes the community level barriers affecting maternal health in the study area (Musoke et al., 2015). The second paper reflects on the experiences of the researchers and participants in the photovoice study (Musoke et al., 2016). The third paper shares the potential role of youth in contributing to maternal health in the community (Musoke et al., 2020).

Research Context and Team

The study conducted in rural Wakiso district in central Uganda was part of the Future Health Systems Research Consortium, with support of the UK Department for International Development. The lead researcher (co-first author) is a male Ugandan public health researcher with vast experience in qualitative and quantitative methodologies particularly among rural communities. He speaks the same language as all of the study participants (Luganda) which is the language in which the research was conducted. The other public health researchers involved in the study were Ugandan working in health systems research (blinded for peer review). The researchers, all working in a leading training institution in Uganda, participated in conceptualization of the study, training of participants, facilitating discussion of photos, manuscript writing, and dissemination of the findings.

Recruitment and Participants

The study involved 10 participants aged between 18 and 29 years who were recruited through local leaders, with guidance from the researchers. Indeed, the researchers met the local leaders to introduce the study to the area, as well as discuss the criteria for identification and selection of participants. The selected participants were diverse in various characteristics including occupation, marital status, and education level. Participants received a transport refund whenever they met the researchers for purposes of the study including training, discussion of photos, and dissemination.

Implementation Stages

A workshop was initially held to train the participants and initiate the study. The training covered various topics such as introduction to research, key issues in maternal health, the photovoice methodology including use of photos in research, use and care of cameras, as well as ethics in photovoice research. Following the training of participants, they were provided with digital cameras and assigned to take photos related to maternal health in their community. Notebooks were also provided to the participants for use in writing any situations related to the study but may not have been captured on camera. The photography period took 5 months which gave the participants ample time to capture various scenarios in their areas.

During the study, monthly meetings were held involving both the participants and researchers during which the photos taken were discussed. Each participant had an opportunity to talk about their photos and how they related to the study. Any issues recorded in the notebooks were also presented and discussed. Other participants provided their perspectives on the photos of others which generated rich qualitative data. The photos were transferred to a laptop and projected on a screen to facilitate the discussion. One of the researchers moderated the sessions, while another supported with note taking and other logistics.

The discussions were audio recorded, and later transcribed verbatim (in Luganda, the common local language used in the area). Once the transcripts had been verified by the researchers, they were translated to English for analysis. Data analysis was done using thematic content analysis with the support of Atlas Ti version 6.0.15 as described in detail in our earlier publication (Musoke et al., 2016).

Following data analysis, a dissemination workshop was held in the community to share the findings with key local stakeholders. These stakeholders included local leaders and other influential people such as religious leaders and community health workers. During the dissemination, selected photos were presented by the participants, explaining the key emerging issues on maternal health to the audience. These photos were printed and displayed on boards to facilitate the dissemination and ensuing discussion.

Photovoice with Urban Refugee Women in Kampala

The aim of this photovoice study was to explore experiences of integration, health, and healthcare for adult women refugees from the Democratic Republic of Congo (DRC) who are currently living in the urban setting of Kampala, the capital city of Uganda. It extends similar co-authored work completed by a co-first author of this current paper examining experiences of integration and health for adult women refugees from DRC resettled in an urban setting in the United States (McMorrow, 2022; McMorrow & Saksena, 2017, 2021; Saksena & McMorrow, 2017, 2020, 2021).

Research Context and Team

The research team consisted for four women including a white, American public health faculty member as the Principal Investigator (PI), a Ugandan woman who had recently graduated with her bachelor’s in public health as the Research Assistant, a Congolese woman who came to Uganda as a refugee as the Lead Interpreter, and another Congolese woman who came to Uganda as a refugee as the Support Interpreter and Project Assistant. The Principal Investigator (PI) was serving as a U.S. Fulbright Scholar with a Ugandan University at the time of implementation, so the study was approved by the Institutional Review Boards (IRB) of that university, the IRB of the home institution in the U.S. and the Uganda National Council for Science and Technology. Informed consent was initially obtained through written signature or thumbprint and ongoing informed consent was practiced ensuring participants understood they could decide to stop participation or decline to be audio recorded at any point. There was a high level of ethical consideration and intentionality in the study design for protection of the participants and understanding the high potential for trauma exposure due to their background fleeing a highly violent and volatile setting in the DRC.

The study was implemented in close collaboration with a non-governmental organization (NGO) in Kampala with depth and breadth of experience serving urban refugee populations. Collaboration started at the concept stage and continued for the duration of the study whereby staff and leaders served in a valuable advisory role, assisted with access to the population, offered support throughout implementation, and attended the public sharing of the photovoice results.

Recruitment and Participants

Participants were recruited purposefully through an informational meeting conducted at the NGO. Inclusion criteria were age 18 or older, self-identified as female, living in Kampala, and confirmed as a refugee from the Democratic of Congo. After details were provided about the study, attendees of the informational meeting were invited to another meeting where random selection was conducted since we had more potential participants than resources would allow for implementation. The aim was to recruit twenty women for participation in the study. Nearly thirty women expressed interest, so some flexibility was exercised to align with the context and employ a more anticolonial approach and twenty-one women joined the study (Fricas, 2022). Participants were compensated for the time spent both attending photovoice meetings and taking photos over the course of the study and were also offered support to cover the transportation to and from the study site. The sample was diverse in age, education levels, and duration of time living in Kampala.

Procedures

As summarized, photovoice aims to reduce the power gap present in more traditional research approaches where the researcher is the one in control, making all the decisions. Instead, the photovoice approach is to work more collaboratively with the participants as co-researchers to engage in decision making throughout the study such as what to take photos of, what to name the group, which photos to share with the group, or the approach to the public exhibit of photos (Breny & McMorrow, 2021; Wang & Burris, 1997). The photovoice method was well suited for this study in terms of working with a population that is often marginalized and vulnerable living as refugees in Uganda. Participation in the photovoice process offered an opportunity for study participants to join to share knowledge, support, and resources.

Implementation Stages

Again, each photovoice study is unique as researchers follow an iterative, participatory approach that involves engaging participants, once recruited, in study decisions. This study included multiple stages. First, there was an initial meeting to conduct ongoing informed consent and a brief semi-structured interview to gather demographic information. Next, a second meeting of about 3 hr occurred to build rapport, introduce the method, train participants in ethics and safety, and generate ground rules with participants. Between meetings, participants took photos centered on what they defined as their experiences of integration, health, and healthcare in Kampala. Then, a series of four meetings where participants chose photos to share and discuss with the group were conducted and with permission, discussions were audio recorded. About a month later, an additional meeting was held for participants to both validate their responses, which involved them seeing the photos they discussed and hearing the summary of the accompanying story and plan for the exhibit. Finally, an organized event to showcase photos and accompanying narrative stories, which included the participants, at least one family member and stakeholders related to refugee health and support in Kampala. The duration of the study was four months encompassing training, taking photographs, photovoice meetings to discuss studies, participant validation, and public dissemination.

The meetings took place at a meeting space in the same neighborhood as the NGO, which was convenient for most participants. They were scheduled in the morning and included breakfast for participants and the study team. Each meeting started with the research team working to download the photos chosen by each woman to the computer for projecting later in the meeting. Once the formal meeting started, we would review ground rules and generally check in with each other. Participants collectively came up with a name for the photovoice group in Congolese Swahili.

For photo discussions, participants would take turns describing the photo they chose for that day by following an adapted version of the SHOWeD method (Shaffer, 1984; Wallerstein & Bernstein, 1988; Wang et al., 1998) by sharing answers to the questions; What is happening in your photo? Why did you take this photo? What does this photo tell us about your life? How does this photo show things that met the photo missions from these last weeks? (harm your health, help your health, show examples of being welcomed/integrating into Uganda) and, what are some possible solutions to issues present in this photo? After each participant shared their answers, a greater group discussion occurred related to the photo and/or what had been shared about the photo.

The PI and Research Assistant facilitated the meetings in English and the Lead Interpreter translated to Congolese Swahili, all participants except for one responded and talked with each other in Swahili (one person spoke English), and the Lead Interpreter translated responses to English. The choice of Swahili as the language of data collection was originally recommended by the NGO and confirmed by participants during the initial interviews. While multiple participants spoke several other languages including French, Lingala, and Kinyarwanda, the participants were most comfortable speaking Congolese Swahili.

Discussion

We have systematically introduced the photovoice method, described its origins and theoretical foundations, highlighted considerations with power, ethics, and the potential of photovoice as an anti-colonial method, and illustrated examples of how we implemented photovoice in Uganda. Now, we will discuss the challenges and benefits of using photovoice and conclude with specific tips for implementation of photovoice within SSA contexts based on our experiences.

Challenges of Using Photovoice in Uganda

In this section, we reflect on key challenges collectively experienced during implementation of photovoice studies in Uganda. First, lack of trust of research teams by community members as well as the ability to speak openly is a key issue to consider. Situated within the complex social, cultural, and political contexts of Uganda-both historically with colonization patterns and political dictatorships and in the present day- it is important to understand the impacts of the socio-historical-political context on trust. Not only do photovoice researchers need to be constantly aware and reflexive about the challenge of building rapport with the community to trust research teams, but also, there is need for photovoice researchers to cultivate a high level of trust given to the participant co-researchers. Remnants of colonial approaches to education and the dominance of positivist approaches to research within Uganda and many other settings in SSA must be acknowledged and actively addressed throughout photovoice implementation.

Similarly, another challenge is the power dynamics that exist, despite the best of intentions of photovoice researchers, that need to be overtly and purposefully attended to while implementing such research. This is true for researchers who identify as African but may represent hierarchies and possess privileges such as economic, educational, nationality or more. It particularly requires special attention for researchers who are not African and are clearly outsiders with different nationality, ethnic/racial identity, language, economic status, educational status and more. Not only is working to redress power imbalances an ethical imperative, but one tangible risk for study results is the possibility for social desirability bias (Edwards, 1957), manifested by participants taking only photos they believe the researcher or research team want them to take. Additionally, challenges with both trust and power dynamics may lead to surface level discussion whereby the researchers will need to overcome those challenges to facilitate the deep, meaningful discussions that can grow out of photovoice research.

A third challenge pertains to realities of logistics and infrastructure that might impact for implementation of photovoice in Uganda and other SSA settings. Poor or intermittent access to electricity is a key concern. This challenge could affect the choice of camera in terms of whether participants will be able to keep a mobile phone camera charged. Additionally, if the researcher aims to share electronic photos using a laptop and/or a projector during routine discussion meetings, then a lack of electricity in a particular setting or sudden power outage necessitates a clear backup plan for sharing photos such as printing them or having an external power supply.

Finally, a challenge that we have both faced and would be remiss not to mention is researcher commitment to education and advocacy when approaching IRBs or Research and Ethics Committees (RECs) within African universities. Though the photovoice method has been used extensively for over 30 years around the world, it is still often a new and relatively unknown method for many research ethical review boards members, calling for researchers to ensure they thoroughly know the background and ethical approaches for implementing the method in their respective settings in SSA. However, photovoice research within SSA may require researchers to have a high level of commitment to the method and provide education to REC members who may not be familiar with photovoice. Noting and sharing how concerns about privacy, confidentiality, anonymity, and use of photos have been addressed in previous photovoice research approved by IRBs in SSA is important. In particular, researchers can use prior photovoice research conducted across SSA regions as illustrative examples when working with ethical review boards (Chidarikire et al., 2021; Cornell et al., 2019; Harris, 2018; Johnson et al., 2019; Kabore et al., 2019; Kessi, 2018; Lofton et al., 2021; Malherbe et al., 2016; Mtuy et al., 2021; Olumide et al., 2016; Powelson et al., 2022; Umurungi et al., 2008).

Benefits of Using Photovoice in Uganda

While there are certainly challenges and significant issues requiring researchers to have a deep understanding of photovoice prior to implementation in SSA, there are key benefits we want to underscore based on our experience with the method. First, it can be used effectively by participant co-researchers who may not be able to read or write. The method of data collection involves taking and discussing photos, thus enabling them to be able to verbally describe the photos and the deeper social and political implications that may surround them. Further, while sharing photos with accompanying written narratives in public forums is one powerful way of advocating for policy change, sharing the photos alone in rural settings where some people have limited literacy can have a powerful and ripple effect on village residents. As we have observed in our photovoice implementation in Uganda, the images convey much more meaning and inspiration to action than sharing the results of logistical regression or other quantitative indicators.

Another benefit is the dual role that photovoice can play as an intervention to empower, educate, and activate participant co-researchers (Wang et al., 1998). Our work has not yet included qualitative investigations explicitly inquiring about the perceived experiences and benefits of engaging in the photovoice process as participant co-researchers. However, our observations and experiences with photovoice implementation in Uganda offer insight into the transformative potential for photovoice. For example, in the study with urban refugee women in Kampala, a photo of a woman experiencing severe menstrual cramps led to a lengthy discussion where the participant co-researchers and the PI were able to share knowledge, dispel myths, and share experiences about how to access better reproductive healthcare and information. In addition, participants of the photovoice study on maternal health in Wakiso district noted being more known in their community after the research which enable some of them get leadership positions after the study. Due to presenting photos during monthly meetings, the participants also gained communication skills and confidence to speak to large gatherings which was beneficial to them beyond the study.

Finally, we offer ten tips for implementation of photovoice research in SSA. Inspired by the ten tips offered by Breny et al. (2017) for conducting photovoice more generally, these are a synopsis of the key points we have examined in more depth throughout this article and are based on our collective and cumulative experiences of using the method in Uganda.

Ten Tips for Implementation of Photovoice Research in Sub-Saharan African Contexts

1. Honor the original ethos and aims of photovoice.

2. Employ anticolonial approaches for equitable partnerships between researchers, participant co-researchers, and communities.

3. Recognize history, politics, and power dynamics.

4. Invest in adequate training of participants.

5. Allow sufficient time for photography.

6. Engage with the community continuously.

7. Be flexible and adaptable.

8. Expect the unexpected.

9. Engage in continual reflexivity with specific attention to anti and decolonial aspects of the research.

10. Learn from and with participants.

Conclusion

Photovoice offers an innovative, versatile qualitative research method for diverse settings in SSA. When researchers engage in learning and reflection regarding ethical considerations prior to undertaking photovoice, it offers a powerful, participatory tool with the potential for contributing evidence to address major current transdisciplinary challenges in SSA and across the globe, including poverty (Loignon et al., 2023; Willson et al., 2007), rapid urbanisation (Ronzi et al., 2016) and climate change (Elum & Meike, 2023). We call for researchers across SSA and in other emerging economy contexts to consider adding the method into their repertoire of qualitative research approaches to reduce historic inequities and contribute to the decolonisation movement.

Footnotes

Acknowledgments

Dr. McMorrow would like to acknowledge the girls and women who committed their valuable time and experience as participants in the various Photovoice projects mentioned. She would also like to acknowledge Dr. Jyotika Saksena who is the co-investigator and co-author on the longitudinal Photovoice work with Congolese refugee women in the U.S. that is mentioned. Dr. Musoke would like to acknowledge the youth and community health workers in Wakiso District, Uganda who have participated in various photovoice studies. He would also like to thank the other researchers with whom he has conducted several studies on photovoice in Uganda including Dr. Asha George, Dr. Rawlance Ndejjo, Dr. Elizabeth Ekirapa-Kiracho, and Dr. Charles Ssemugabo.

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 Dr. Musoke: Future Health Systems Research Consortium funded by UK DFID; Dr. McMorrow: U.S. Fulbright Scholar award and Indiana Minority Health Coalition.

Ethical Statement

ORCID iD

Shannon McMorrow

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