Toi Te Ora Public Health is a public health department on the north island of Aotearoa/New Zealand. We provide health protection and health promotion services much like public health units in Ontario.
When health promoters at Toi Te Ora Public Health were looking for a way to revive a struggling health promoting school project, they pinned their hopes on a research technique called Photovoice. The results were dramatic. When the project was over, the school's attitude to health promoting schools had completely turned around. Teachers, students and trustees began working together to make their school environment a healthier one.
The result confirmed our earlier Photovoice experiences with schools and community groups. When used appropriately, it is one of the most effective ways we can support communities to name and act upon their own health concerns.
I What Is Photovoice?
Photovoice is a process whereby segments of the population are given cameras and asked to take photographs to answer a question. In the above example, the questions were as simple as "What do you like about being a student here and what would you like to see improved?" Once the photographs are developed, the photographers are interviewed and asked to tell a story about each of their favourite photos. The images and the stories behind them are then used as a catalyst for change.
According to Carolyn Wang (http://www.photovoice.com), the goals of Photovoice are
1) to enable people to record and reflect on their community's strengths and concerns,
2) to promote critical dialogue and knowledge about important community issues through large and small group discussions of photographs, and
3) to reach policymakers.
Like Carolyn Wang, we found that the most powerful aspect of Photovoice is that it provides a voice to segments of the population who are sometimes silent and not involved with decision-making. In our experience, it has worked particularly well with children and adolescents who may not be as comfortable in articulating their views through other mediums such as questionnaires and focus groups.
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II What Is The Process?
The stages of our Photovoice projects are as follows:
Stage 1: Recruitment of between 8 to 12 participants. Like any needs assessment approach, we try to ensure that all members of the community have an opportunity to participate.
Stage 2: A workshop with participants describes Photovoice and outlines the process. The question(s) that photographers will address is discussed. In addition possible answers are brainstormed. Participants also receive instruction on the use of the disposable cameras provided, as well as basic information on effective photography.
An integral part of the workshop is a discussion on ethics. Participants or their parents/guardians should provide written informed consent that acknowledges their right to withdraw from the process at any time, as well as their ownership of the photographs. In addition, the rights of the people being photographed need to be considered. Either written or verbal consent should be obtained.
Stage 3: Participants are given a set period of time to take photographs. They are asked to record their thoughts at the time of taking each photograph in a notebook. Two sets of photographs are developed -- one for the project and another for the photographer.
Stage 4: Individual interviews are conducted with participants to discuss a selection of their own photographs (approximately 10 photographs each). An explanatory quotation is then attached to the photograph.
Stage 5: A group discussion with participants is conducted in order to group photos by theme. The group also discusses ways the results can be used and potential solutions to issues.
Stage 6: Results of the Photovoice project are presented to decision-makers and other groups. This can be done in many ways. For example, our projects in schools have included PowerPoint presentations to teachers and trustees, foyer displays for parents during parent-teacher meetings and a competition for students to match photographs and captions.
Stage 7: The results are used to create change.
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III What Are Some Lessons We've Learned
One of the objectives of Toi Te Ora's health promotion work is to build capacity in communities. To this end, we have conducted 'Train-the-Trainer' sessions so that members of community organisations gain the skills to conduct Photovoice projects. Our role seems to be more effective when we are there to provide the technical support but are not seen as driving the project.
As mentioned above, one of the strengths of Photovoice is that it can provide a voice for people who normally do not have a lot of say in how things operate. We have tried different ways to recruit participants. In some schools, the teachers have selected the students. In others, we have looked for volunteers. While one could argue that all students are relatively powerless in the school environment, one could argue equally that there are segments of the student body who have less say than others. Students who are not involved in extra-curricular activities or student council, students who are not academic high achievers and students who simply do not readily identify with any of the informal groups are examples of less powerful students. By allowing the students to be selected by the teachers for this project, we may have unintentionally eliminated many segments of the student body. While no criteria were given to the teachers, participating students were invariably high achievers both academically and in terms extra-curricular activities.
It is important to spend time with the photographers during the workshop to discuss the question(s), possible answers and ways to photograph abstract concepts. Some participants have expressed frustration because they didn't know how to take pictures of abstract things like lack of shade, lack of respect, inability to leave school grounds, and feelings like pride, sadness or boredom. The more time we have spent discussing these issues and the importance of the interviews afterwards, the more diverse and meaningful the photographs are.
Like any research technique, Photovoice is more effective when combined with other methods. For example, for a healthy community project we displayed photographs taken by local children alongside statistics from the local hospital, and findings from a questionnaire completed by home owners and business leaders.
Finally, a major criticism of community research is that the findings don't lead to meaningful change. Photovoice is like any technique -- identifying needs is the "easy part." There must be commitment to translate the images and stories into significant action so that participants know they've been heard. To emphasise this point we often take photos after changes have been made and display them with photographs taken as part of the research. These "before and after snippets" lend credibility to the project because they clearly illustrate that the participants' input has been acknowledged and acted upon.