The authors have declared that no competing interests exist.
The purpose of this scoping review was to examine the use of Photovoice in caring research. The review assessed the existing literature using the Arksey and O’Malley scoping review methodology. Database searches of relevant literature published worldwide between 1997–2019 yielded 25 articles in the English language that were included in this review. The authors summarized thematic findings. Three themes emerged from data analysis: 1) strengths of using Photovoice; 2) challenges of using Photovoice, and; 3) methodological complexities in Photovoice studies. The small number of studies included in the review (n=25) indicate the limited use of Photovoice in caring research, reflecting missed opportunities for action-oriented research. The scoping review recommends ways that researchers can better address the needs of carers using Photovoice, particularly as a tool for knowledge translation, advocacy, and empowerment.
The reconstruction of the health care system towards community and home care has shifted the responsibilities for care from the public system onto unpaid, informal and familial carers
While governments may benefit from reduced costs, the costs for carers who provide care at home increases. Specifically, negative consequences arise from the multiple roles and responsibilities expected of carers
Many of the studies examining carers employ quantitative methods. While quantitative studies provide valuable information, such as the number of carers, types of tasks, and the measure or degree of burden, such studies fail to encapsulate the unique and personal experiences of caring
Photovoice is an image-based research method that seeks to examine and understand issues through the everyday experiences of people whose voices are often unheard, forgotten or silenced
1. To enable people to record and reflect their community’s strengths and concerns;
2. To promote critical dialogue and knowledge about important issues through large and small group discussion of photographs, and;
3. To reach policymakers.
Using a camera, participants record visual evidence of their experiences which allows them to share their unique knowledge and expertise. Photovoice involves participants going out into their community to take pictures that will be used to guide further discussion with the researchers, and in so doing, identifying, representing, and enhancing the visibility of issues within their communities
Since its development by Wang and Burris in the mid 1990s, Photovoice has been used in a wide array of research areas to gather information on community strengths and challenges
This scoping review will synthesize existing literature to analyze the utility and limitations of Photovoice in examining the caring experience and will likely be of interest to following groups: researchers who have performed Photovoice studies; carers who have participated in these studies, and; policy makers who have the potential to respond to issues found as the result of research. A total of 25 articles written in the English language were included in this review, comprised of peer-reviewed journal articles, government reports and dissertations. All articles examined were published between 1997 and June of 2019.
Scoping reviews seek to “map rapidly the key concepts underpinning a research area and the main sources and types of evidence available”
The purpose of this study was to determine the current state of Photovoice methods in caring research. The review was guided by the following research question:
At the onset of the scoping review, the authors defined the scope, parameters and implications of the research question. In some older Photovoice studies, the term “Photovoice” was used interchangeably with terms such as “photo novella” or “photonovel”
A set of articles that was already familiar to the authors was used as a starting point. To ensure an extensive search of all relevant articles, the authors consulted with a university research librarian who provided guidance for the scoping review methodology, forming Boolean search strings, and searching relevant databases. The scoping review included articles published since the inception of Photovoice by Wang and Burris in 1997, through to June 2019. Articles were curated from any geographic location internationally but were limited to those in the English language. An initial and unstructured search was performed using Google Scholar, producing a small but relevant set of articles (n=22). Next, the authors searched databases using search strings as suggested by the university librarian. The following search phrases and keywords were used: informal or unpaid or family or familial or parent or grandparent or spouse or spousal AND carer or carer or caregiv* AND Photovoice or participatory research or photo* method*. The asterisk indicates other possible endings for the root words. Most of the databases had a focus on health and included: Web of Science, Sociological Abstracts, Embase, CINAHL Complete, Factiva, and PyscInfo. Generally, the articles contained a Western bias with many originating from North America. The initial search yielded 418 articles; duplicates were then removed. The remaining abstracts were read and then searched through their reference lists to find other relevant articles. While it is recommended to hand search relevant journals, this was not done due to the large number of journals in health disciplines; it was deemed more productive to go through the reference list of articles that were already identified
To filter relevant articles based on the research question, the authors determined inclusion and exclusion criteria. Articles were included in the sample if they addressed each of the following four criteria:1) publication between 1997 and June of 2019; 2) inclusion of Photovoice as a method for data collection; 3) explored the experiences of informal and unpaid carers, and; 4) the carer was caring for a care recipient above the age of 18 years suffering from age or health-related conditions. The authors chose to include studies that also included the following groups in the study sample: care recipients, other family members, and formal health care providers.
Exclusion criteria included: 1) no use of Photovoice as a method of research; 2) care was only provided by formal or paid carers, or did not distinguish between formal and informal carers; 3) the care recipients within the sample included children below 18 years of age. After applying the criteria, 25 articles remained that were then incorporated into the Mendeley database management system. The articles were printed and read in full by the authors.
During this stage, the authors simultaneously read the articles, applied the inclusion and exclusion criteria, and charted the articles’ themes and concepts. A chart, created using Microsoft Excel, was used to extract and organize the authors’ findings. Charting the data was done through sorting and charting information based on key terms and themes
1. Authors and year;
2. Study sample characteristics (a. sample size; b. relationship to care receiver; c. condition/disease/other inclusion criteria of care recipient);
3. Methods (a. details of research process; b. other qualitative/quantitative methods used with Photovoice);
4. Findings and results, and;
5. Conclusions (implications for carers, researchers, policy makers).
After analyzing articles for relevance and content, the authors determined if the article matched the inclusion criteria. If the authors were unsure, they discussed and jointly decided the article concerned should be included.
Of the 25 articles that were included, 20 (80%) were peer-reviewed primary research articles. Three articles (12%) were dissertations and two articles (8%) were academic/government reports. The geographical distribution of studies included Canada (n=8), the United States (n=8), Australia (n=4), United Kingdom (n=3), Netherlands (n=1), New Zealand (n=1), and Portugal (n=1). The authors collaborated to compare and discuss common findings amongst the articles. The results of the thematic analysis are described in the following section.
The authors identified the following themes: 1) strengths of using Photovoice in research on caring; 2) challenges of using Photovoice in research on caring; and 3) methodological complexities.
The scoping review revealed four strengths of the Photovoice method in caring research: (a) a positive experience for carers; (b) facilitating communication of novel and abstract ideas, (c) participant cohesion, and (d) collaboration in research. Each of these strengths is discussed below as subthemes.
Previous studies have found that the Photovoice process allows researchers to engage fully with participants because of the presence and stimulus of visual cues (Hibberd, Keady, Reed & Lemmer, 2009; Young & Barrett, 2001). A few of the studies noted that carers found the research process enjoyable
Photovoice can allow for the ease of communication between researchers and participants. The Photovoice methodology is useful when collecting data from participants that have low literacy or are not fluent in the language of the researchers
Photovoice allows participants to be in control of the research process; this is especially important when discussing topics that may be difficult to explore. For instance, Horsfall, Leonard, Evans & Armitage (2010) identified and analyzed the social networks of older people and their carers, choosing Photovoice because social networks are often “invisible, not talked about, or are seen as an unremarkable part of people’s everyday lives”
Researchers in three studies noted that Photovoice enabled the emergence of overlooked, ignored, or under conceptualized aspects of the caring role
Many of the articles analyzed (n=18) recruited samples of carers who were caring for recipients that were suffering from a common disease or condition. For instance, Guerra, Rodrigues, Demain, Figueiredo & Sousa (2012) studied family carers of dementia patients. Common characteristics amongst the study sample allowed for a greater sense of community and cohesion due to shared experiences, common needs, and challenges. In LaDonna (2014), some participants had not met other individuals outside of their families who had Myotonic Dystrophy Type 1. Participation in the research study allowed participants to meet, socialize and bond with other affected individuals, which may have contributed to participants’ assessment of the research process as “therapeutic”
Research suggests that carers are given little help from health care professionals when performing tasks and when dealing with the emotional demands of caring
This section addresses the challenges identified in the articles included in the review, including: (a) time and cost demands, (b) memory bias, and (c) photograph selection bias.
Photovoice projects can be costly; all the 25 articles chosen by the authors either provided or lent participants a camera. Additional costs include: using a digital camera as opposed to a disposable camera; film, and processing fees. In additional to financial costs, Photovoice research are very time consuming, which can be problematic given the time constraints already experienced by carers
Another challenge lies in the fact that Photovoice is a retrospective method, which leads to possible memory bias. During the interview or focus group phase, participants are asked to recall how they felt and what their experiences were like when they first took their photographs, opening up the possibility of recall bias
Some of the carers’ experiences may contribute to them being identified as more memorable, and thus more photographed (Guerra, Rodrigues, Demain, Figueiredo, & Sousa, 2013). Participants may choose photographs that highlight positive aspects of caring worth memorializing in photographs. Guerra et al. (2012) also suggested that participants may have a cultural bias towards the photographs they choose to take. As with other qualitative and quantitative research methods, researchers must be mindful of participants providing responses that they believe the researchers are looking for
It should be noted that the challenges outlined above are not limited to research with carers; such challenges have been seen in Photovoice with other participant groups and in other fields of research.
The following section explores the methodological complexities of using Photovoice, as identified from the 25 articles. The following subthemes emerged: (a) methodological challenges, (b) alternate research approaches, and (c) ethical considerations.
Certain controlled, research-directed settings can create an authoritarian environment which may shift away from a participant-directed research process
Many of the studies in this review used modified aspects of the traditional Photovoice method, originated by Wang and Burris (1994). Although there are no set guidelines in undertaking a Photovoice study, the following steps are generally represented: an orientation meeting, focus groups and/or individual interviews, and a group forum to share findings. The rationale for altering the Photovoice method varied from researcher to researcher. For example, some studies opted to use individual interviews as opposed to focus groups to discuss participant photographs. In Sethi (2014) and Roger, Migliardi, & Mignone (2012), the researchers were concerned with the use of large focus groups as participants may not be comfortable discussing intimate issues in such a format. Other modifications include not involving participants in the data analysis stage even though Photovoice, as stated earlier, is based on the tenets of participatory research.
Our analysis found that some studies used other qualitative methods in conjunction with Photovoice during the data collection phase. The use of other methods in conjunction with Photovoice may offer a richer understanding of participants’ experiences. A scoping review of Photovoice literature in 2012 found that out of 191 studies, 55% used Photovoice as the sole method for data collection and analysis, while the remaining 45% used Photovoice in addition to other methodological approaches
It is of utmost importance for researchers ensure the participants’ confidentiality and anonymity. Ethical issues during the use of Photovoice include the following: invasion of privacy; issues in recruitment; participation; representation, and; advocacy. Methods taken by the researchers to ensure confidentiality included: obtaining ethical approval from research boards; discussing ethical issues that may arise during the photography process; signing consent forms; allowing participants to withdraw at any time point, and; providing pseudonyms. In one of the few studies to directly state ethics concerns that had arisen during the Photovoice studies, Sethi (2014) noted that researchers must be cautious of this innovative methodology; Photovoice may not be suitable for participants whose safety has been a concern due to political issues in their country, for example. In Sethi’s (2014) study, three participants who were refugees shared their stories but did not take photographs. While no studies explicitly mentioned that potential participants decided to not partake or to withdraw from the study due to ethical concerns, researchers must continue to be cognizant, sensitive, and accommodating of these issues.
Some studies in this review fell short in disseminating research findings through knowledge mobilization and knowledge translation strategies. In particular, only 60% (n=15) of articles included some photographs from the data collection phase in the journal article
As outlined by Wang and Burris, one of the goals of Photovoice is to reach policymakers
Although one of the goals of Photovoice is to empower participants, information on evaluating and achieving this goal may be lacking. Few studies mention or allude to ways in which partaking in Photovoice research studies can be advantageous and beneficial for participants. In Sethi (2014), participants had a sense of pride and ownership in the photographs they had taken, such that some were excited to show the researcher their photographs. Given that participants in that study may feel a sense of empowerment after completing the project, future research studies can further explore how Photovoice may be used as an empowerment tool for carers. Some studies mention that carers are better able to make sense of their caring situation
There are a wide range of new research directions in the area of caring that have yet to be tapped when using Photovoice methodology; three will be discussed here. First, immigrants are providing transnational care across international borders in increasing numbers given current trends in globalization and technological advances. Sethi (2014) found that study participants rely on their families abroad for social support through computer and phone message applications, phone and video calls. More research can be done to explore transnational caring and the ties that immigrants have to care recipients in other countries. Photovoice can be used to understand such unique experiences, which can be useful in policy making to help support these carers. Second, exploring the negotiations that double-duty carers have to make when transitioning between their paid caring work, whether in an institutional setting or in the community, and their unpaid/ informal care work, whether in an institutional setting, in the community, or at home. Third, intersectionality theory can be integrated in Photovoice research on carers. Intersectionality theory suggests that the interactions between various social categories, such as race, class, and gender shapes an individual’s personal experiences
There are numerous limitations of this scoping review. Limitations include the lack of inclusion of the literature outside of the English language and regions outside of the Western sphere of influence. Further, all included papers would have been more thoroughly reviewed if all four authors read and discussed each one, thus providing a cross-check. The final limitation is the possibility of missed articles when using the database searching techniques employed.
Employing the scoping review framework offered by Arksey and O’Malley (2005), this paper has synthesized caring research which has employed Photovoice. Through reviewing in detail the 25 articles that met the inclusion criteria, the authors identified the following key themes: strengths and challenges of using Photovoice; methodological complexities; research gaps, and new research directions. Most of the articles analyzed for this review were primary research articles from peer-reviewed journals. The authors found that photographs taken during the research provided a unique lens into the intimate experiences and everyday realities of these carers by bringing to light the rewards and conflicts experienced. In particular, the articles in totality illustrated that carers are critical players who support the health of their recipients. The limited use of Photovoice in caring research may reflect missed opportunities for action-oriented research, which may greatly impact the lives and experiences of carers
CI, ZA, AW: School of Earth, Environment, and Society, McMaster University; BS: School of Social Work, King’s University College, University of Western Ontario
This research was funded by a Canadian Institutes of Health Research‐Institute for Gender and Health, Research Chair in Gender, Work & Health, addressing Caregiver‐Friendly Workplace Policies (MOP-60484).