Using Photovoice With Undergraduate Interprofessional Health Sciences Students to Facilitate Understanding of and Dialogue About Health Disparities Within Communities

Abstract

Overview. It is important that future health care providers be made aware of the health disparities affecting their communities and the populations they will serve. Photovoice is an example of an interactive teaching and research tool used to depict health disparities through the use of images within a community. Purpose. The purpose of the study was to assess the views of undergraduate interprofessional health sciences students after their use of photovoice to understand health disparities. Method. The photovoice project was implemented as part of a learning unit on health disparities within an undergraduate Health Literacy and Culture Care course with 12 class sections over 2 years. Purposive sampling was used to survey the students who completed the course during this 2-year period in order to assess how the assignment increased their understanding of and ability to address health disparities within the communities that they live and serve. Results. A majority of the participants (N = 48) strongly agreed/agreed that the photovoice assignment increased their understanding of health disparities, health disparities within their community, factors contributing to these health disparities, and ways to address health disparities. In addition, most participants strongly agreed/agreed that the photovoice assignment was a valuable learning activity related to health disparities and should continue to be used as an assignment. Although beyond the scope of the assignment, 26% of the respondents indicated that they took action within their community to address the health disparity identified. Conclusion. This study demonstrates that photovoice can be used as a pedagogical tool to extend student learning about health disparities beyond the classroom into the community.

Keywords

college students health disparities photovoice

There are many factors that can influence one’s health. Barriers to accessing health care and the differences in the quality of care received contribute to health disparities among individuals and groups. In addition, factors such as income and poverty status, education, housing quality, environment, employment, and working conditions all contribute to one’s health status. According to the World Health Organization (2015), these factors such as living conditions and environment all have considerable impact on our health, and those more commonly considered factors such as access and use of health care services often have less of an impact. Health starts in our homes, schools, workplaces, neighborhoods, and communities. The conditions that we live in explain a lot about why some people are healthier than others and why health disparities exist. As defined in Healthy People 2020 (U.S. Department of Health and Human Services, 2008), a health disparity is

a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.

It is important that future health care providers become aware of the health disparities affecting their communities and the populations they will serve. As a result, many graduate programs in the health professions are incorporating training on cultural competence, health literacy, and health disparities into their curricula (Kripalani, Bussey-Jones, Katz, & Genao, 2006; Onyoni & Ives, 2007; Shaya & Gbarayor, 2006). This type of training is also becoming increasingly popular and necessary for undergraduate students pursuing various health care professions (Betancourt, Green, Carrillo, & Park, 2005; Cuellar, Brennan, Vito, & de Leon Siantz, 2008; Rapp, 2006). It is important to supplement the training with methods that enhance student understanding of community assets and needs (Smith et al., 2007). Photovoice is a powerful and interactive teaching tool being used to depict health disparities and health inequity through the use of images within a community. Since its development in the mid-1990s by Caroline Wang and her colleagues (Wang & Burris, 1994, 1997; Wang, Yi, Tao, & Carovano, 1998), the community-based participatory research method known as photovoice has received growing attention in community health education. Concisely defined as “a process by which people can identify, represent, and enhance their community through a specific photographic technique” (Wang, Cash, & Powers, 2000, p. 82), photovoice has three main goals: to allow participants to record and reflect on the strengths and issues affecting their community, to promote critical dialogue and increase knowledge about important issues through discussion of photographs, and to reach policymakers to initiate change (Wang & Burris, 1997).

During the past 20 years, photovoice has been successfully implemented in many settings with various populations to raise awareness about and address health disparities. Photovoice has been used to address a range of health issues from chronic health problems (Allotey, Reidpath, Kouame, & Cummins, 2003; Oliffe & Bottorff, 2007) to communicable diseases (Grosselink & Myllykangas, 2007; Mamary, McCright, & Roe, 2007). It has been implemented with various age-groups ranging from children and youth (Brazg, Bekemeier, Spigner, & Huebner, 2011; Thomas & Irwin, 2013; Wang, 2006; Wilson et al., 2007) to older adults (Baker & Wang, 2006; Fitzpatrick et al., 2012). Photovoice has been utilized on college campuses to advocate for things such as changes to campus smoking policies (Seitz et al., 2012; Strack & Wyrick, 2012), creation of healthier campus communities (Budgen et al., 2011), and improvement of green spaces (Seitz, Reese, Strack, Frantz, & West, 2014). It has also been used extensively with various minority populations to depict health perceptions and to advocate for change (Teti, Pichon, Kabel, Farnan, & Binson, 2013; Torres, Meetze, & Smithwick-Leone, 2013; Vaughn, Rojas-Guyler, & Howell, 2008). These studies demonstrate the power of using visual images to engage people in critical thought and discussion about their communities.

Process/Framework

The photovoice project was implemented as part of a learning unit on Health Disparities within a Health Literacy and Culture Care course, which was a requirement for undergraduate Health Sciences students at this university. The undergraduate Health Sciences program was designed to provide an interdisciplinary foundation in health care through exploration of opportunities in health professions, preparation for entry-level employment in health care settings, qualification for entry into various health professional graduate programs, and acquisition of real-world experience through service learning. Over the course of 2 years, the project was incorporated into 12 sections of this course, with approximately 30 to 35 students per section. Of the 12 sections, half were on-site and the other half were online, web-based courses. For the online courses, in particular, students were located throughout the United States. The course was delivered over 15 weeks during the fall and spring semesters and over 12 weeks during the summer semester. The learning unit on health disparities consisted of three modules to include an overview of, current issues in, and strategies for addressing health disparities. The photovoice project was introduced at the beginning of the unit and was not due until the conclusion of the third module within the unit. Throughout the unit, a plethora of resources were shared with students to help them identify and address health disparities. In addition, examples of how photovoice has been utilized to address health disparities across the United States were addressed, and samples of previous photovoice projects were shared.

Students were asked to examine health-based data about their community or a community of their choice. Most students chose to cover a community they were currently living in, as that made it easier for them to take the pictures. Some chose to cover a community they had lived in at some point in time in the past. For the scope of this assignment, community was defined by the geographical region; it could consist of a small town or a section of a city. Next, they had to identify a health disparity of interest to them for their review. They were tasked with using the SHOWeD technique (Wang, 1999) as a guide to display the photos of the local community in order to develop a collective understanding of what each image represents. The SHOWeD technique consists of addressing the following: what do you SEE here, what is really HAPPENING here, how does this relate to OUR lives, WHY does this situation exist, and what can we DO about it (Wang, 1999). They were reminded that once this process was complete, those viewing their photovoice should be able to identify the significance of the image to the health disparity.

The assignment was divided into two parts, and both were conducted via the Discussion Board through the university’s Learning Management System. Part I was the photovoice presentation. Most students utilized PowerPoint or Prezi for their presentation. The first part of their presentation consisted of slides that contained information and data that substantiated what health disparity they decided to address within their chosen community. Students were encouraged to start with national data pertaining to that health issue and then narrow their focus to depict state and local data if available; this process was utilized to demonstrate that an actual disparity existed. Next, they needed to provide original pictures depicting the health disparity. As the intent was to allow the images to tell the story, only brief captions for the photos were permitted. The final section of the presentation needed to contain slides that detailed potential solutions or ways to address the disparity. Their proposed strategies needed to align with the five overarching strategies to address health disparities as outlined by the U.S. Department of Health and Human Services National Partnership for Action to End Health Disparities (2010), which included increasing awareness about health disparities, becoming a leader for addressing health disparities, supporting health and safe behaviors in one’s community, improving access to health care, and creating healthy neighborhoods.

Part II of the assignment consisted of reviewing the presentations submitted by other students and providing feedback. Specifically, the students were asked to interpret from the images what the author of the photovoice was trying to communicate about the population and existing health disparities. They were also asked to provide feedback on the health disparity identified and what additional solutions they thought could be implemented to address that disparity.

During the course of the 2 years, many of the students provided positive feedback via the course evaluations and informal emails to the instructors about how the photovoice assignment significantly enhanced their understanding of the health disparities within their community. Furthermore, many students shared stories about how the assignment motivated them to initiate change within their communities, ranging from getting involved with nonprofit organizations to writing grants to organizing service learning projects in order to address the identified disparities. As a result, the course instructors decided to conduct a formal survey to further assess the impact of the photovoice assignment on the awareness of health disparities and motivation to implement strategies to address these disparities. The purpose of the study was to assess students’ views related to using photovoice to understand and address health disparities within their community. The primary research questions consisted of the following:

Question 1: Did the photovoice project increase their awareness of health disparities within their community of study?

Question 2: Did the photovoice project increase their understanding of health disparities?

Question 3: Did their photovoice project increase their ability to identify determinants of health and/or items contributing to the health disparities in the community of study?

Question 4: Did the photovoice project activate them to address the health disparities?

Question 5: Was the photovoice project an effective teaching tool?

Method

After receiving approval from the university’s institutional review board, the online survey was created through PsychData. The link to the survey was disseminated through an email sent to all of the students who took the Culture Care and Health Literacy course between summer semester 2013 and fall 2014; students who did not take the course during that period were excluded from the study. Around 200 students were contacted with an invitation to participate in the study through their university e-mail address in January 2015. Two reminders were sent via email in January and February. The mixed methods survey consisted of 19 questions, all of which were optional. Seven of the questions utilized a 5-point Likert-type scale ranging from “Strongly agree” to “Strongly disagree” options to assess how the photovoice assignment increased their understanding of health disparities, awareness of health disparities within their community, understanding of factors contributing to health disparities within their community, and understanding of ways to address the health disparities. Participants also assessed whether the assignment should be used with future classes and indicated if they took action within their community as a result of the assignment. Open-ended questions were also administered to allow the participants to describe the actions they took (if any) within their community as a result of the assignment and to provide overall feedback on the assignment.

Results

Participants (N = 48) were 90% non-Hispanic Caucasian, 2% Hispanic, 2% African American, 2% Native American, 2% Asian/Pacific Islander, and 2% Other; 67% were 18 to 24 years old, 21% 25 to 34 years old, 10% 35 to 44 years old, and 2% 45 to 54 years old. Thirty-six percent had never worked in health care, 17% less than 1 year, 23% 1 to 5 years, 13% 6 to 10 years, 6% 11 to 15 years, 2% 16 to 20 years, and 2% 21 to 30 years. Sixty-three percent of the respondents completed the course on-site and 37% online (Table 1).

Table 1.

Assessment of Photovoice Assignment.

Item	Strongly agree	Agree	Neutral	Disagree	Strongly disagree
Increased my understanding of health disparities	24	20	2	0	1
Increased my awareness of health disparities within my community	33	12	1	0	1
Increased my understanding of factors contributing to health disparities within my community	27	17	2	1	0
Increased my understanding of ways to address health disparities	27	12	5	1	1
Was a valuable learning activity related to health disparities	26	18	2	1	0
Should continue to be used as an assignment in future classes	26	19	1	0	1
I took action within my community to address the health disparity identified as a result of the photovoice assignment	8	4	18	11	5

A majority of the participants strongly agreed or agreed that the photovoice assignment increased their understanding of health disparities (strongly agreed: 51.1% and agreed: 42.6%), health disparities within their community (strongly agreed: 70.2% and agreed: 25.5%), factors contributing to health disparities within their community (strongly agreed: 57.4% and agreed: 36.2%), and ways to address health disparities (strongly agreed: 58.7% and agreed: 26.1%). In addition, a majority strongly agreed or agreed that the photovoice assignment was a valuable learning activity related to health disparities (strongly agreed: 55.3% and agreed: 38.3%). According to Student 47, “It gives you a better understanding of your community and helps you strive to do better things for the community that you care so deeply about. When you care about a topic it makes you fight for it even harder.” Student 15 expressed,

This assignment made me realize how different geographical locations suffer from different disparities. Because the assignment is presented through photos, it forces students to look deeper into the disparities to find visual proof among the community of their choosing—making him or her think harder about the issue. It is a good assignment and taught me a lot about health disparities in general, as well as how they impact my community.

Student 14 stated, “It was a creative and a very unique way to teach and learn. It was great to see my classmates work as well!” Several students expressed that it was a fun and unique approach to learning about health disparities as opposed to writing a paper. Student 30 indicated that it is a “great project for students to get more involved with their communities and is more effective then writing a paper.”

When asked if this should continue to be used as an assignment, 95% of the respondents indicated that it should be used with future classes. One of the online students shared,

This was probably the most beneficial learning tool I was provided in any of my online courses especially with the lectures and all of the extra resources given prior to it. I believe this project should set the bar for future changes to the online curriculum as it is engaging and applicable to solving real problems.

Student 12, supportive of utilizing the photovoice assignment with future classes, indicated, “It forces the learner to view their community in a different light; to see the disparities you might not have noticed before.”

Although beyond the scope of the assignment, 26% of the respondents indicated that they did take action within their community to address the health disparity identified as a result of the photovoice assignment. Some students even shared feedback on the actual actions they took. Student 13 said,

I learned a lot from this project and put together a really strong presentation for my home town. I really wish I could fix the flooding problem we have in my home town, but I know after completing this assignment, I can make everyone more aware of the issue.

Student 28 shared,

I did my project on heroin, and since this project I have become extremely passionate about the issue in my community after realizing how prevalent it has become. I used part of my research from this project to build a campaign against heroin use in my Speech Communications class. This assignment was helpful in more ways than one.

Other students utilized posters and social media to raise awareness about the health issues affecting their communities.

Students also provided feedback on improving the assignment. Some expressed that each student in the class should be required to focus on a different health disparity as there was a lot of overlap with people addressing the same issues. Others indicated that they encountered barriers with traveling to collect pictures and that additional time should be provided for the assignment. Students also provided suggestions for using additional tools to present the photovoice project. Major themes emerged related to the value of the assignment and suggestions for future application of the assignment. Table 2 provides additional representative quotes related to those elements and emerging themes from the open-ended survey questions.

Table 2.

Feedback on Photovoice Assignment.

Elements	Themes	Representative quotes
Value of Assignment	Beneficial learning tool	“This was probably the most beneficial learning tool I was provided in any of my online courses. Especially with the lectures and all of the extra resources given prior to it. I believe this project should set the bar for future changes to health care science online courses. Others are less engaging and applicable to solving real problems.”
		“I thought it was a fun, different type of assignment to do, rather than write a paper about disparities.”
		“I really enjoyed this project. I thought it was a creative way to learn and because of that it made me enjoy doing the assignment.”
		“I really enjoyed the photovoice assignment and I would not change a thing about the assignment.”
		“I really enjoyed the challenge of the assignment.”
		“This is hands on allowing you to apply what you learned in class.”
	Increases understanding of health disparities within community	“By doing a photovoice for your community it gives you a better understanding about your community. It helps you strive to do better things for the community that you care so deeply about. When you care strongly about a topic it makes you fight for it even harder.”
		“Was a great and creative tool for the students to do research and get out in the community and involved in the disparity up close!”
		“I think it is a beneficial assignment and should continue because it opened my eyes and made me realize how my community specifically was affected by health disparities.”
		“I think it was a great learning experience and it was nice to see what other communities had for problems as well.”
		“I thought it was a great eye opener and even though it was an online class so every photovoice wasn’t from my community it still showed the issues throughout the country.”
		“This assignment visually shows the need for change in the communities through the United States. It starts with making students aware of their communities.”
		“I believe that it should be used in future classes. In a sense it forces the learner to view their community in a different light; to see the disparities you might not have noticed before.”
		“It helped me to be aware of what was happening around me and see the community in a different light.”
		“Although I chose not to take action in my community, I think that this was a great assignment to physically go out and see why there were issues with health disparities in my community.”
Suggestions for Future Application of Assignment	Encourage variability in health disparities addressed	“One suggestion that I have is to have each student make their health disparity different from others. There was a lot of repeats. For example in my class almost half the class did the difference in price in health food and junk food so maybe only allow two people to do one topic so that way students have to really research and find many of the other health disparities in a community.”
	Encourage variability in health disparities addressed	“In the semester I completed this, I felt that most other students chose obvious disparities. The less mainstream the topic the more the student doing the project and others in the class will learn. If you are hoping to get students to further their scope of thinking and invoke action—reaching toward less common disparities is going to provide a wealth of knowledge and has the potential to promote and inspire action in the communities most impacted by the disparities.”
	Allow use of any community	“It is difficult for some students to travel to take pictures, which is the only downside I see to the assignment.”
	Allow use of any community	“It may be hard for some students to go home, but having the option of the local community makes it easier for those students.”
	Provide more time	“It would have been nice to have more time to get the pictures I needed for this assignment.”
	Provide further instructions	“The description of the assignment should be more instructive, as many of my class mates had very little experience in understanding what it should look like.”
	Incorporate additional presentation options	“Incorporating something like iMovie works well as PowerPoint is a struggle to get what the assignment needs.”

Discussion

This study demonstrates that photovoice can be used as a pedagogical tool to extend student learning beyond the classroom into the community. The results also suggest that the photovoice tool can be used effectively with college students and future health care providers to raise awareness about health disparities. Photovoice provides visual stimulation, allowing the experience of seeing with one’s own eyes. This makes it participatory for the student collecting the information; the student takes the photos while becoming an observer of the information. It gives students as community members an objective reflection of the reality of an identified health disparity. Photovoice crosses generational barriers as everyone can relate to pictures. This enables students to see the cause and effects of the problems contributing to health disparities, so that they can begin finding solutions (Freedman, Pitner, Powers, & Anderson, 2014).

The primary limitation of this study is the small survey response rate from the university students. Although some of those surveyed had just completed the course, a majority of those contacted to complete the survey had taken the course in a previous semester. It is possible that some of those contacted had already graduated and no longer had access to their university email account where the survey was sent. Of the approximate 200 students who received the survey, 48 completed the survey producing a response rate of 24%. In addition, limitations associated with self-reported data, specifically selective memory, existed. As previously noted, many of those surveyed had completed the photovoice activity 6 to 18 months prior to receiving the survey; this gap in time could have affected the extent and accuracy of the recollections related to the photovoice activity. Despite these limitations, the results provide strong implications for the potential use of photovoice by undergraduate college students to give voice to their work.

Extant studies have shown that learning photovoice as a technique for collecting and sharing information provides students an opportunity for civic engagement. It can strengthen community support and involvement. Pictures allow the pairing of the information to personal experiences (Hergenrather, Rhodes, Cowan, & Bardhoshi, 2009). It is important, though, that participants understand how to effectively employ the photovoice technique. The literature has demonstrated that photovoice projects that incorporated training resulted in a higher quality of participation from those involved (Catalani & Minkler, 2010). This project contained assignment instructions, an overview of the SHOWeD method, and access to previous photovoice submissions. However, limited guidance and training were provided on how to actually take the photographs in order to accurately capture and emphasize the issues. Incorporating some form of training on the technical and conceptual operation of a camera and photographic ethics is important.

Beyond the use of photovoice as a pedagogical tool lies the importance of dialogue and communal action to address the identified health disparities. Ensuring that students have an opportunity to share and discuss their experiences and findings is an important part of the dialogue and reflection aspects of the project. Many studies have demonstrated the utilization of the photovoice technique to enhance critical dialogue about important issues (Foster-Fishman, Nowell, Deacon, Nievar, & McCann, 2005; Rania, Migliorini, Rebora, & Cardinali, 2014). The assignment did allow for limited dialogue through the online discussion board where students addressed representational questions such as what do the photos mean, what are the themes from the photos, and what was the photographer’s intention. However, it is also important for additional nonrepresentational dialogue to occur via small group discussion about the dynamic relationships of the photos and the impact on the community, policy makers, and so on. Students should also understand how to utilize this tool to influence policy and instigate change. As the assignment described in this article, many photovoice studies employed in the past have lacked a social action component (Short, 2006; Strack, Magill, & McDonagh, 2000; Streng et al., 2004). Neglecting incorporation of an action component may negatively affect marginalized communities as members may feel objectified by the lack of follow-through to address the issues identified by the photovoice process. It is important that both researchers and the communities assessed benefit from these types of projects.

Future suggestions would be to enhance the dialogue and action components of this project. Photovoice empowers individuals to recognize and take action to improve their communities. Consequently, if important components of the theoretical framework such as social action and group dialogue are missing, participants and communities may not gain as much from the study. It is clear that the benefits of this type of activity for students extend beyond the confines of the course. Further evaluation of these experiences can help inform incorporation of the action component into other courses and service learning opportunities within the curriculum. As we encounter and facilitate learning for digital natives, methodologies such as photovoice promise to be a powerful tool for engaging Generation Y and beyond!

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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