Revisiting the Roots and Aims of Photovoice

Leveraging local knowledge to contextualize the opioid epidemic within HEALing Communities Study communities: A Photovoice protocol

Since its inception 30 years ago, Photovoice has gained increasing popularity as a research method and more recently has been incorporated within randomized controlled trial (RCT) designs. Photovoice is a participatory action research method that pairs photography with focus group discussions to record community strengths and concerns, build critical consciousness, and reach policymakers. Adherence of Photovoice implementation to these original tenets of Photovoice varies. This article provides the Photovoice protocol developed by the authors to improve the methodological rigor of Photovoice integration into RCTs and help contextualize the landscape for the HEALing Communities Study (HCS: NCT04111939), a greater than $350 million investment by the National Institute on Drug Abuse along with the Substance Abuse and Mental Health Services Administration to reduce opioid overdose deaths in 67 of the hardest-hit communities in four states (Kentucky, Massachusetts, New York, and Ohio). The product of a cross-state collaboration, this HCS Photovoice protocol provides ethical and methodological tools for incorporating Photovoice into RCT designs to enhance community engagement, communication campaigns, and data-driven decision-making about evidence-based practice selection and implementation.

Profound Love and Dialogue: Paulo Freire and Liberation Education

Paulo Freire, Brazilian philosopher and educator, proposed an educational method for adults based on what he called "the problem posing method." This method was based on dialogue that he deemed necessary for education and was not oppressive and controlling. Freire argued that traditional educational methods were inherently oppressive because they served the interest of the elite, instituted what he called "the banking method" in hopes to turn people into better workers. In contrast to this, Freire advocated for an education that was liberating and required dialogue. Dialogue, however, could only take place with profound love. This article reflects on Freire's call for profound love and dialogue within his pedagogical framework, and its necessity for social and political change. Further, this article explores what Freire meant by profound love and dialogue, and explores how love and dialogue are applicable to current and future health literacy and health education efforts. [HLRP: Health Literacy Research and Practice. 2024;8(3):e118-e120.].

Using Photovoice to Explore Determinants of Health among Homeless and Unstably Housed Women

The lived experiences of homeless and unstably housed women, including their health-related priorities, are understudied in smaller metropolitan and rural communities. In this study, we partnered with a day center for women who experience homelessness in Spokane, Washington. We used Photovoice, a community-based participatory action research method, to explore the health-related concerns, needs, and behavior of women who are homeless or unstably housed. Participant-generated photographs and group interview data were analyzed using thematic analysis. Three themes were generated: "These are my supports", "I'm trying to make my health better", and "[My] choices are very limited". The themes illustrated individual, interpersonal, community, and societal strengths and vulnerabilities aligned with the social ecological model. Participants demonstrated resourcefulness, creativity, and hope as they strived toward health improvement. Trauma-informed, strengths-based approaches that respect the autonomy of homeless and unstably housed women and that amplify their voices are needed to minimize power imbalances in research, policy, and practice. This includes an imperative for healthcare and social work programs to ready graduates to deliver effective, empathic services by increasing their knowledge of social determinants of health and of the stigma faced by marginalized communities. Moreover, collaborating with these communities when designing, implementing, and evaluating services is critical.

Evaluating the effect of a behavioural intervention bundle on antibiotic use, quality of care, and household transmission of resistant Enterobacteriaceae in intervention versus control clusters in rural Burkina Faso and DR Congo (CABU-EICO)

BACKGROUND

Antimicrobial resistance (AMR) is a rising threat in low-resource settings, largely driven by transmission in the community, outside health facilities. Inappropriate antibiotic use is one of the main modifiable drivers of AMR. Its risk is especially high in poor resource settings, with limited diagnostic and surveillance capacities, and many informal medicine vendors determining community use. We hypothesise that to optimise community antibiotic use, especially Watch antibiotics (recommended only as first-choice for more severe clinical presentations or for causative pathogens likely to be resistant to Access antibiotics), both the supply side (medicine vendors) and the demand side (communities) should be pro-actively involved in any intervention.

METHODS

In two existing demographic health surveillance sites (HDSS) in Burkina Faso and in the Democratic Republic of Congo, behavioural intervention bundles were co-created in a participatory approach, aiming to rationalise (Watch) antibiotic use and improve hygiene and sanitation practices. Bundles consisted of interactive interventions, including theatre, posters, discussions, etc. To evaluate impact, 11 of 22 clusters (a HDSS community with at least one (in)formal medicine vendor) were randomly assigned to this intervention, which will run over a year. The effect of the intervention will be evaluated by comparing outcomes before and after in intervention and control villages from a) exit interviews of clients from vendors, b) mystery patients presenting to vendors with a set of predefined symptoms, c) household interviews to assess behavioural changes related to antibiotic use, health literacy and water-sanitation-hygiene indicators. Long-term impact on AMR will be estimated by modelling changes in resistant Enterobacteriaceae carriage from repeated household surveys before, during and after the intervention in both arms.

DISCUSSION

Most existing interventions aimed at improving antibiotic use focus on health care use, but in resource-limited settings, community use is highly prevalent. Previous studies targeting only providers failed to show an effect on antibiotic use. Evaluation will be done with before-after epidemiological measurements of actual prescriptions and use. If effective in reducing (Watch) antibiotic use, this would be an empowering methodology for communities, which has significant promise for long-term impact.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05378880 . 13 May 2022.

"How does your residential environment positively or negatively influence your well-being?": A multicase photovoice study with public housing tenants

Public housing aims to reduce social inequalities by providing affordable dwellings as a social policy. Anchored in an ecological perspective, the paper reports on a multicase photovoice study documenting public housing tenants' perceptions of how their residential environment influences their well-being. This design can provide a deeper understanding of the public housing environment to inform change at a programmatic level. To this end, 303 captioned photos were collected by 59 tenant-researchers at six sites in Québec (Canada). An in-depth cross-case analysis of the material led to two key themes with five subthemes each. In the Residential environment perceived as mostly positive theme, the subthemes were access to nature, community resources and services, positive relations among tenants, opportunities for participation, and specific aspects of their home. In the Negative aspects focused on life in public housing theme, the subthemes were strict regulations, lack of respect for tenants' needs, lack of intimacy, lack of proper maintenance, and conflicts between tenants. Findings highlight the dynamic interplay between the residential environment and public housing tenants' well-being. Two recurring programmatic issues are highlighted: problematic maintenance and limited opportunities for tenants' empowerment. Changes to address these concerns at the programmatic level of public housing could potentially increase tenants' well-being.

Nuestra Recuperación [Our Recovery]: using photovoice to understand the factors that influence recovery in Latinx populations

BACKGROUND

Photovoice is a form of visual ethnography intended to engage impacted communities in research followed by action to ameliorate the injustices under study. Photovoice has increased in use, especially in collaboration with Latinx communities addressing health inequities. The Latinx population comprises nearly 18% of the overall United States population and according to the census is projected to reach just under 30% by 2060. This diverse panethnic community faces significant structural barriers in accessing services. Racism and the resulting marginalization, specifically, contributes to limited access to recovery services and treatment. Making meaningful advances in substance use disorder training, intervention and policy necessitates learning alongside the Latinx community.

METHODS

We partnered with a Latinx serving integrated behavioral health and primary care setting in Boston Massachusetts to explore barriers and facilitators to recovery using photovoice. Spanish-speaking Latinx adults with a substance use disorder participated. The group met for three photovoice sessions over a six-week period. Together group members critically analyzed photographs using the SHOWeD method.

RESULTS

Findings indicate a sense of purpose and meaning, security, faith and housing are important elements of recovery. The results illustrated the importance of sources of connection in maintaining sobriety. Through this photovoice project, Latinx Spanish speaking participants highlighted barriers and facilitators to their substance use disorder recovery which spanned individual, community, and structural levels.

CONCLUSIONS

The experiences and voices of the Latinx community are crucial to drive discussions that advance policy (e.g., housing stability and access), enhance providers' understanding of Latinx Spanish-speakers' substance use disorder recovery, and inform culturally and linguistically appropriate services. This study demonstrated that photovoice is highly acceptable and feasible among Latinx clients receiving substance use disorder services. Visual images related to housing, faith, etc. communicate challenges, power structures, as well as hopes to policymakers at multiple levels (e.g., institution/ agency, state).