Over the last several decades, family scholars and other researchers have utilized community-based participatory action research (CBPR) to assess the needs of individuals and communities. Photovoice (PV) is one of the many CBPR approaches used to understand and prevent complex health issues. PV is designed to gather information, foster understanding of participants’ experiences with particular health issues, and stimulate social action regarding the unmet needs of marginalized and oppressed individuals and communities (Wang, 1999; Wang & Burris, 1997). At the core of Photovoice is participatory action research (PAR), as the method is based on the premise that people are the experts of their own lives. When empowered to do so, participants of PV can use the method to communicate a lived experience with health or justice issues in a way that stimulates critical, social action (Wang & Burris, 1997).

Theoretical Foundation of Photovoice

Photovoice is informed by theories of critical consciousness (Freire, 1973), feminist theory (Maguire, 1987), and principles of documentary photography (Wang & Burris, 1997). These theoretical underpinnings suggest that individuals are experts in their own lives (Freire, 1973; Wang & Burris, 1997). When given the opportunity to identify and reflect on issues that affect them, they are better able to play active roles in their community and/or their healthcare.

The original PV project sought to explore the daily realities and lived experiences of women living in China, uncovering political and social constructs that contribute to systemic oppression and marginalization of women in their community (Liebenberg, 2018). Documentary photography sheds light on the notion that individuals can communicate their lived experience with a health issue via visual imagery, and that we can all learn from these experiences through bearing witness to the images and the stories participants tell about them (Stryker & Johnstone, 1940). Wang and Burris (1994) utilized the principles of documentary photography in their early work, by entrusting cameras in the hands of their participants to capture images that revealed their daily realities, which empowered participants to then use these visual representations of their experiences as a means for advocacy and social action (Liebenberg, 2018).

Photovoice and photo-elicitation are distinctly different research methodologies that are sometimes used interchangeably in the literature, which can lead to confusion about the role and purpose of PV. The Photovoice method is a research strategy that engages researchers and community members in the exploration of an unmet need or health issue, with an end goal of stimulating social action. Photo-elicitation involves the use of photos to elicit new perspectives or ideas (Gomez, 2020) and has been used as a health intervention (Rolbiecki et al., 2018) and a qualitative interview technique (Church & Quilter, 2021; Oliffe & Bottorff, 2007).

Goals and Typical Elements of Photovoice

There are three main goals of Photovoice: (1) to capture and reflect community strengths and concerns from the perspective of community members themselves; (2) to promote critical dialogue of the needs of the participants and community via group discussion of the photos; and (3) to create social action (Wang & Burris, 1997). Social action could be in the form of new programs and policies, raised awareness of health issues (Evans-Agnew & Rosemberg, 2016), shared understandings of community and stakeholder experiences, or productive working relationships between community members and stakeholders (Catalani & Minkler, 2010; Sutton-Brown, 2014). Even though the method is regarded as flexible and is widely used across many disciplines, a common goal of creating social action regarding the unmet health needs of a population remains (Liebenberg, 2018).

In PV, participants are given cameras and asked to photograph images that best represent their experiences. They then meet together as a group to critically discuss the photos, and the meeting is facilitated by a researcher using the SHOWeD methodology – asking the group to reflect on the pictures via the questions (Wang & Burris, 1997): (a) What do you See here? (b) What is really Happening here? (c) How does this relate to Our lives? (d) Why does this situation, concern, or strength exist? (e) What do we Do about it? A process of participatory analysis then occurs, wherein participants and researchers play an equal role in analyzing and discussing the photos to identify key themes. This active engagement of participants in each phase of the PV process, including analysis, emphasizes that they are valuable members of the research team and, thus, their input is important (Wang & Burris, 1997). According to Wang and Burris (1997), there are three ways to engage in participatory analysis: (1) mutually agreeing on photographs to analyze, (2) contextualizing the photos (i.e., what stories do the photos tell?), and (3) codifying the data, wherein participants and investigators identify potential themes.

Once participants and researchers have mutually agreed upon themes coming from the data, a discussion about how to present these data in a way that meets the original goals and intentions of the project should occur. For example, participants may decide to display photos in an exhibit. The exhibit plays a critical role in validating the stories and voices of participants, and not exhibiting the photos can be viewed as silencing participants (Delgado, 2015). Participants may choose to invite key stakeholders to come and bear witness to the stories as a way to stimulate critical dialogue about the meaning of the photos. In its simplest explanation, to bear witness means to show that something exists, or is true (Cody, 2001). In the context of Photovoice methods, to bear witness to one’s experience with the health issue via their photo-stories is to validate, or assure that their stories are heard, and understood.

Photovoice in Action

The PV methodology was first used by Wang and Burris (1994) as a tool to empower women who lived in the rural Yunnan Province of China to inform policies and programs that affect them and their community. Since then, there have been many modern adaptations of PV by researchers and community activists across many settings and with various populations, and the outcomes vary depending on project goals and community needs. Despite the growing popularity of the PV method, however, there is concern for methodological rigor, as the flexible and “user-friendly” nature of the method creates opportunity for misuse (Liebenberg, 2018).

Photovoice methods have been used to address a variety of social justice and public health concerns (Catalani & Minkler, 2010), including health literacy (Ardiles et al., 2019), experiences of disenfranchisement of women who are living with HIV/AIDS (Teti et al., 2013, 2015), and HIV/AIDS stigma (Teti et al., 2016). The first author used PV as a tool for exploring the experiences of sexual assault survivors who sought justice within university and community justice systems (Rolbiecki et al., 2016). This study emphasized the therapeutic nature of PV, and was foundational to her idea that PV and photo-elicitation methods can facilitate posttraumatic growth (Rolbiecki et al., 2016) and meaning-making (Rolbiecki et al., 2018) among those who have experienced adverse life events like trauma, caregiving, or the death of a family member.

Photovoice and Families

Honoring Family Diversity Through Visibility

PV methods also can be used to help promote inclusivity in families and educate the public about diversity in family life (Garcia et al., 2013). In this way, families serve as participants in the PV project and become the focal point for social action. For example, lesbian, gay, and bisexual (LGB) parent families experience considerable stigma and discrimination in society despite the fact that ample research demonstrates these families function quite well, and children raised by LGB parents experience few or no differences from heterosexual families on psychosocial or educational outcomes (Goldberg, Gartrell, & Gates, 2014). PV could be used to amplify the voices of these families by revealing the stigmatic challenges LGB families face when interacting in various social contexts, illuminating their resilience, and revealing the diversity of experience that exists within their families.

Challenges or Ethical Concerns with Families

Some PV researchers have pointed out a number of challenges and potential ethical concerns that may arise when using PV methods with multiple family members. Logistically, recruiting family dyads or larger family units to participate in a PV project may be difficult due to family members’ conflicting schedules or a member’s reluctance to take part in the project. If the number of family members in each participating family unit varies, or if a family member is unable or unwilling to attend all phases of the project, the group dynamics may shift such that a real or perceived power imbalance manifests within the group (Garcia et al., 2013). Moreover, families are comprised of multiple generations, so younger members of the family may find it difficult to verbalize their thoughts and feelings alongside older family members, especially if their point of view is at odds with the older family member. Facilitators will need to be flexible with the PV method (e.g., allowing for separate discussions or smaller group work) and be diligent about ensuring communication is balanced, giving all family members opportunities to vocalize their perceptions and experiences (Garcia et al., 2013).

Finally, it is important to acknowledge that bringing multiple family members together to discuss sensitive topics may generate conflict or bring forward relationship problems, which not only presents challenges for the facilitator but raises ethical dilemmas that have been posed about visual methods in general, including concerns about family members’ safety via personal disclosures of family trauma, problematic misinterpretations of photos by other family members, or potential burden of representation. Providing validation while also preventing the group from shifting into a therapy session would be an important skillset of any facilitator working on a PV project. Moreover, facilitators need to have a plan if mediation is needed and information regarding therapeutic resources that can be shared with all participating family members. Although PV as intervention has been successfully used in therapeutic settings by mental health professionals (Christensen, 2018; Mizock et al., 2014; Werremeyer et al., 2020), PV as intervention with family units is a new frontier requiring further investigation.

Conclusion

Photovoice is increasingly lauded as a relatively new visual research methodology designed to create social action by the nature of its reliance on participant inclusion throughout the process, empowerment through voice, meaning making, and engaging key stakeholders. Most of the published research utilizing PV methods includes individuals as participants and health policy change as the desired outcome. However, recent applications of this method suggest PV has great potential as a therapeutic intervention in mental health (Buchan, 2020) and as a strategy for collecting and analyzing family-level data (Yi & Zebrack, 2010). Although PV methods can introduce unique challenges in data collection and analysis and raise specific ethical concerns, we believe these challenges can be tempered with proper training and by committing to ongoing and evolving evaluation of ethics vis-à-vis PV procedures and outcomes.