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research-article2016
QHRXXX10.1177/1049732315624223Qualitative Health ResearchEvans-Agnew and Rosemberg

Photovoice
Qualitative Health Research

Questioning Photovoice Research:

2016, Vol. 26(8) 1019­–1030
© The Author(s) 2016
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DOI: 10.1177/1049732315624223
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Robin A. Evans-Agnew, PhD, RN,1

and Marie-Anne S. Rosemberg, PhD, RN2

Abstract
Photovoice is an important participatory research tool for advancing health equity. Our purpose is to critically review
how participant voice is promoted through the photovoice process of taking and discussing photos and adding text/
captions. PubMed, Scopus, PsycINFO, and Web of Science databases were searched from the years 2008 to 2014
using the keywords photovoice, photonovella, photovoice and social justice, and photovoice and participatory action
research. Research articles were reviewed for how participant voice was (a) analyzed, (b) exhibited in community
forums, and (c) disseminated through published manuscripts. Of 21 studies, 13 described participant voice in the data
analysis, 14 described participants’ control over exhibiting photo-texts, seven manuscripts included a comprehensive
set of photo-texts, and none described participant input on choice of manuscript photo-texts. Photovoice designs
vary in the advancement of participant voice, with the least advancement occurring in manuscript publication. Future
photovoice researchers should expand approaches to advancing participant voice.

Keywords
North America; Africa; photography / photovoice; participatory action research, research, qualitative, research design,
health care disparities, review

Photovoice is an important participatory visual research
method that was developed to promote empowerment and
give voice to populations experiencing a variety of health
and health care contexts. Building on the work of docu-
mentary and other visual research traditions, the goal of
this method was first advanced by Wang and Burris (1994)
in women’s health research in Yunnan, China (Wang &
Burris, 1994, 1997; Wang, Burris, & Ping, 1996). They
argued that photovoice could address social change
through participant photography, critical reflection, and
participant-derived text/title/caption to accompany the
photos (hereafter referred to as photo-texts). Photovoice as
a data collection tool has been heralded as marking an
important turn in engaging communities in a deeper
examination of social conditions and structural inequities
for advancing the health of communities through partici-
patory action (Carlson, Engebretson, & Chamberlain,
2006; Israel, Eng, Schultz, & Parker, 2010; Wang &
Burris, 1997). Most important, such a visual examination
of these social conditions might mitigate the social deter-
minants of health and promote social justice through
reversing structures of political, social, and research-based
exploitation (Carlson et al., 2006; Haque & Eng, 2011).
With this underlying goal, photovoice has been used to
reprivilege the authority of participant voice in research
(Palibroda, Krieg, Murdock, & Havelock, 2009).
Such a repositioning of participant voice inside
research designs suggests a need for a closer examination
of participant-researcher power relations, participant
knowledge development, and participant authorship
(Wallerstein & Duran, 2010). Recognition of participants
as co-researchers in knowledge enables the deeper explo-
ration of emic (i.e., exploration from within the commu-
nity) perspectives and representations (Palibroda et al.,
2009; Strack, Magill, & McDonagh, 2004). Yet the inter-
ests of socially just research, as suggested by Boutain
(2005), in moving audiences across a continuum from
awareness, to mitigation, and ultimately to transformation
of a social injustice might not be fully realized in photo-
voice designs that inadequately advance participant voice.
Reviews suggest that occurrences of concrete changes in
social policy resulting from photovoice research are rare,
and that most studies only succeed in raising awareness
1
University of Washington Tacoma, Tacoma, Washington, USA
2
University of Michigan, Ann Arbor, Michigan, USA
Corresponding Author:
Robin A. Evans-Agnew, Assistant Professor, Nursing and Healthcare
Leadership Program, University of Washington Tacoma, Box 358421,
1900 Commerce street, Tacoma, WA 98402, USA.
Email: robagnew@uw.edu
1020 Qualitative Health Research 26(8)
(Evans-Agnew, Sanon, & Boutain, 2014; Prins, 2010;
Sanon, Evans-Agnew, & Boutain, 2014).
Wang and Burris (1997) used the term “photovoice,”
combining the word “photo” with the initials “VOICE” as
standing for “Voicing Our Individual and Collective
Experience” (p. 381), yet they did not further define voice.
Other visual researchers have defined voice as both the
ability to speak on a topic and the right to be heard
(Thomson, 2008) or as the emancipatory act of describing
one’s own reality in stories in a way that clarifies oppres-
sion (Knaus, 2009). Socially just research methodologies
such as critical-feminist, critical-ethnography, and indig-
enous methodologies have included the photovoice
method in seeking ways to privilege the voice of those
previously marginalized by research through the employ-
ment of an epistemology grounded in the co-construction
of meaning and the desire for social change (Foster-
Fishman, Nowell, Deacon, Nievar, & McCann, 2005;
Moosa-Mitha, 2005; Poudrier & Mac-Lean, 2009).
Ultimately, the notion of voice in photovoice may dif-
fer from more generic understandings of voice that ema-
nate from other participatory methods such as
community-based participatory research (CBPR) simply
because photovoice is a method that can be strategically
employed in CBPR studies. The voice of participants is
anchored specifically within the co-construction of the
photo-text and the subsequent “right to be heard” through
dissemination of this photo-text. Participant voice in
CBPR is more global than this, addressing participant
choice within the research design, such as determining
goals, methods, or recruitment (Israel et al., 2010). In
photovoice, the responsibility for design lies more
squarely with the researcher. The purpose of this review
is to examine the processes researchers use in photovoice
studies to empower participant voice, specifically through
their analysis and dissemination of photo-texts. In the fol-
lowing section, we briefly describe the background of
photovoice research and discuss the ethical implications
concerning the empowerment of participant voice through
this method.
Background of the Photovoice
Method
Over the last two decades, the term photovoice has
become associated with a variety of research designs and
methodologies that utilize participant photography for
knowledge development. A distinction has grown
between those photovoice researchers that utilize phe-
nomenological and grounded theory designs as photo-
elicitation, a way to describe lived-experiences (see, for
example, Plunkett, Leipert, & Ray, 2013, or Padgett,
Smith, Derejko, Henwood, & Tiderington, 2013), or
develop theory concerning experiences (see, for example,
Teti, Pichon, Kabel, Farnan, & Binson, 2013, or Lopez,
Eng, Randall-David, & Robinson, 2005); and those pho-
tovoice researchers who take a participatory action
research (PAR) approach seeking social change through
the use of photo-texts (Catalani & Minkler, 2010; Hansen-
Ketchum & Myrick, 2008). This latter group of research
studies is the focus of the review.
Much of the “photovoice as PAR” literature is replete
with discussions of participant empowerment through
what Wang and Burris (1994) describe as a process of
self-development, problem analysis, and communicating
identified needs to policymakers (Duffy, 2011; Teti et al.,
2013). Photovoice has often been used in ethnographic
exploration, whereby the researcher uses participant pho-
tography to document participant’s unique experiences
and perspectives in relation to a particular question or
environmental condition (Fleming, Mahoney, Carlson, &
Engebretson, 2009; Stevens, 2006). In other instances,
the utilization of photovoice has been guided by CBPR,
which emphasizes a grassroots mobilization of the
research process, the involvement of community stake-
holders, and an objective of going beyond exploring/
understanding the phenomenon toward promoting social
change (Carlson et al., 2006; Hansen-Ketchum & Myrick,
2008; Hergenrather, Rhodes, Cowan, Bardhoshi, & Pula,
2009; Peterson, Antony, & Thomas, 2012; Streng et al.,
2004).
Wang and Burris’s germinal work putting cameras in
the hands of Chinese women in 1997 proposed photo-
voice as a strategy for participant empowerment and
enlightenment through three outcomes: an awareness of
community needs, a reflection on the structural con-
straints imposed on achieving those needs, and an
empowered desire to act on this knowledge for political
and social change (referred by Freire as conscientização,
or critical consciousness; Foster-Fishman et al., 2005;
Freire, 1973). To achieve these outcomes, Wang and
Burris (1997) suggested a questioning strategy based on
Freirian empowerment-education techniques suggested
by Shaffer (1979) for the discussion and construction of
photo and text as units of data called “SHOWeD”: (a)
What do you See here, (b) what is really Happening, (c)
how does this relate to Our lives, (d) Why does this situ-
ation exist, and (e) what can we Do about it? It is within
this discussion and construction of photo-texts that the
voices of participants become the most important.
Researchers and participants use tools such as the
SHOWeD method, for example, either through group or
individual work, to describe the images, and annotate
them with captions and sometimes titles (Wang, Morrel-
Samuels, Hutchison, Bell, & Pestronk, 2004). These
types of participant voice are what are explored in this
article: voice in terms of the opportunity participants
have to collect, discuss, and represent images relevant to
Evans-Agnew and Rosemberg 1021
Table 1.  Ethical Concerns Regarding Voice in Photovoice
Research.
Issue Ethical Concern
Privacy Individuals and private property may
be identifiable and made public.
Safety The choices made to protect
participants from using images that
might harm them such as implicating
them in an illegal activity.
Photo selection, Researchers may or may not report
presentation, and whether and how participants
publication selected the photos to present at
forums and other forms of exhibits
to community members and
policymakers.
Researcher Participants may take photos of things
influence over that they believe the researchers
subject matter for would most likely be interested in,
participant photos which may not be reflective of their
actual experience with a particular
context.
Photo ownership Participant release of ownership rights
in standard consent forms gives
the researchers the freedom to
represent the data in a manner of
their choosing, vs. the right of the
participants to have their voices be
heard they way they choose.
Advocacy The extent to which participants have
autonomy in their advancing their
interests in policy change.
their lives (i.e., their ability to speak) and in influencing
social change through the dissemination of their ideas
(i.e., their right to be heard).
In their general discussion of ethical concerns regard-
ing participation in photovoice, Wang and Redwood-
Jones (2001) noted that photovoice is anchored within the
code of ethics that encompasses appreciation for auton-
omy, advancement toward social justice, promotion of
benevolence, and avoidance of maleficence. Researchers
have proposed several categories of ethical concerns for
photovoice designs (explicated in Table 1): (a) privacy;
(b) safety; (c) ownership; (d) photo selection, presenta-
tion, and publications; (d) researcher influence over sub-
ject matter for participant photos; and (e) advocacy
(Allen, 2012; Joanou, 2009; Martin, Garcia, & Leipert,
2010; Teti et al., 2013; Wang & Redwood-Jones, 2001).
Although such concerns have received adequate discus-
sion in the literature as they pertain to the protection of
participants, less attention has been directed at how such
concerns influence the advancement of participant voice.
The issues of advancing participant voice through pho-
tovoice then revolve around issues of empowerment and
representation of participant voice through the photographs
discussed and the photo-texts that are disseminated. This
requires much conscientização/reflexivity on the part of
the researchers to ensure that they both encourage the par-
ticipant to choose the message and to represent that voice
throughout the analysis and dissemination of findings
(Harris & Steyn, 2014). Thus, the dissemination of photos
without participant text may seriously compromise the
photovoice method. As Wang and Burris (1997) suggested,
“photographs alone considered outside the context of [par-
ticipants’] own voices and stories would contradict the
essence of photovoice” (p. 381).
In summary, a conscientious effort is needed on the
part of the photovoice researcher to produce an ethical
research design that enables in participants (a) the ability
to speak through training in technique, privacy, safety, and
through the fair facilitation of photo-text development;
and (b) the right to be heard through the representation of
photo-texts and the advancement of participant-driven
advocacy. Thus, an examination of the development and
dissemination of photo-texts might be a way to investigate
the advancement of participant voice in photovoice
designs. Such designs must necessarily be involved with
ethical decisions concerning both the nature and outcomes
of participation and in the choice and selection of photo-
texts to disseminate.
While photovoice as a participatory method has
become increasingly accepted, what is still not under-
stood is how researchers make decisions regarding the
development and dissemination of participant voice.
These decisions regarding participant involvement occur
in four principal areas: (a) the analysis of the data, (b) the
exhibition of photo-texts at community events or exhibi-
tions, (c) the choice of which photo-texts to include in
any manuscript, and (d) the degree to which the photo-
texts used in manuscripts align with the results of the
analysis. In this review, we examined recent research
articles that utilized the photovoice method to determine
how participant voice was privileged in the analysis and
dissemination of data.
Method
Our method is outlined using the “preferred reporting
items for systematic reviews and meta-analyses”
(PRISMA) as a guide (Moher, Liberati, Tetzlaff, &
Altman, 2010). We searched for journal articles published
in English in PubMed, Scopus, PsycINFO, and Web of
Science between 2008 and 2013. Our electronic strategy
included the following keywords: [Photovoice OR photo-
novella] AND [CBPR OR “Community based participa-
tory research” OR PAR OR “participatory action
research”]. The search produced 163 articles after remov-
ing duplicates (Figure 1). Abstracts were reviewed and
articles were excluded if they were (a) not available in
1022 Qualitative Health Research 26(8)
Figure 1.  Review flowsheet.
full text; (b) only evaluated the photovoice method with
no description of a research study; (c) focused on photo-
elicitation, phenomenology, or grounded theory method-
ologies; and (d) did not report the photovoice findings in
the form of a public display or community event. Of the
remaining 37 articles that were downloaded, another 16
were excluded because they did not publish any photos,
leaving a remaining 21 articles for analysis.
To analyze the studies, we first reviewed and recorded
the study purpose, guiding methodology, participant
characteristics, and public dissemination strategies.
Second, we reread the articles and asked the following
questions to develop our summary measures: (a) Were
participants involved in thematic coding of the data? (b)
How did participants select photo-texts to display at com-
munity forums and exhibitions? (c) Were participants
involved in the selection of photo-texts for journal publi-
cation? and (d) How were the photos, titles, and accom-
panying texts linked to the themes identified in the
analysis? The results of our analysis are summarized
below.
Results
Of the 21 studies reviewed (Table 2), the sample size
ranged between seven (Markus, 2012) to 49 participants
 Table 2.  Participant Voice in Photovoice Studies 2008–2014.
Participant
Participatory Participant Participant Choice: Research Journal Representation of
Author Purpose Method Participants Exhibit Description Choice: Coding Choice: Exhibits Monograph Participant Voicea

Andonian and To explore social
MacRae (2011) participation among older
adults while living alone
Bharmal et al. To identify and prioritize
(2012) factors associated with
the transition to manhood
among African American
men
Brazg, Bekemeier, To assess adolescent
Spigner, and substance use and abuse
Huebner (2011)
Chilton, To record single mothers’
Rabinowich, stories on poverty and
Council, and hunger to inform social
Breaux (2009) welfare policy
Denov, Doucet, To explore the postwar and
and Kamara reintegration experiences
(2012) of former child soldiers
Downey, Ireson, To explore the
and Scutchfield empowerment-education
(2009) model and community
health assessment
Duffy (2010) To record, reflect, and act on PAR
community influences on
health; to promote critical
dialogue; and to reach
policymakers
Flum, Siqueira, To explore hazards for
DeCaro, and workplace injury
Redway (2010)
Foster-Fishman, To learn about young people
Law, Lichty, and involvement, support in
Aoun (2010) neighborhoods, schools,
and community
Green and Kloos To document youths’ life in
(2009) community
Grieb et al. (2013) Previously incarcerated
housing residents
perspectives on housing/
health
Halifax, Yurichuk, To document and
Meeks, and make changes in the
Khandor (2008) homelessness community
Action research N = 7 Adults who live alone Exhibit: City Hall: Legislators, Yes Not clear No Participant title, embedded
(55+ years). San Francisco, providers, educators and caption, 1/8 themes
California, USA others displayed
CBPR N = 12 Youth and adult Exhibit: Website; Community Yes Yes (collective) No (website) Researcher title, photo
African American males forums: Secondary school caption, 2/4 themes
(16–26 years). Los Angeles, members displayed
California, USA
CBPR N = 12 Youth (15–19 years). Exhibit: Community Yes Yes (collective) No No title, photo caption, 2/4
Washington, USA forum: Alcohol and drug themes displayed
intervention specialists,
youth and family services
director, city attorney, and
local police
Human rights N = 42 Adult mothers of Exhibit: Website; forums for No Yes No (website) No title, photo caption, 8/8
framework. young children. Philadelphia, government officials (U.S. themes displayed
Participatory Pennsylvania, USA Senate/House)
advocacy
CBPR N = 11 Youth (18–23 years). Exhibit: Community forums; No Yes Nob No title, photo caption, 5/5
Bedelu slum, Freetown, government, local, and themes displayed
Sierra Leone international NGOs, youths,
and local media
PAR N = 18 Youth (15–18 years). Exhibit: Community forums; No Yes No Researcher title, no captions,
Appalachia, USA community leaders, and 0/4 themes displayed
stakeholders
N = 7 Adult single mothers Exhibits: Partner agency board; Yes Yes (collective) No No title, photo caption, 4/8
(18+ years). Moncton, New an open house; a 3-day themes displayed
Brunswick, Canada event: Mayor and media
PAR N = 16 Adults, male Exhibit: Forum: Custodians Yes Yes (collective) No Researcher title, no captions,
and female University and occupational health 3/4 themes displayed
Custodians. Massachusetts, stakeholders
USA
PAR N = 19 Youth male, female, Exhibit: Retreat for local Yes Yes (collective) Nob No title, photo caption, 2/5
African American, organizations and residents themes displayed
Caucasian, (12–13 years).
Urban Midwest, USA
PAR N = 12 Youth, migrants from Exhibit: Website; Neighborhood No Yes (individual) No (website) Researcher title, no captions,
Uganda (12–16 years) cafes in NC and SC 0/0 themes displayed
CBPR N = 9 Adult men in transitional Exhibit: Website; Community Yes Yes No (website)b Researcher title, embedded
housing. Baltimore, forums: CBOs and caption, 2/4 themes
Maryland, USA Government workers displayed
CBPR N = 12 Adult homeless male Exhibit: Community forums No Yes (collective) Nob Participant title, embedded
and female (ages 20–60). and events; politicians and caption, 3/4 themes
Toronto, Canada other stakeholders displayed

1023
(continued)
1024
Table 2. (continued)
Participant
Participatory Participant Participant Choice: Research Journal Representation of
Author Purpose Method Participants Exhibit Description Choice: Coding Choice: Exhibits Monograph Participant Voicea

Hannay, Dudley, To identify barriers to CBPR N = 25 Youth and adult Exhibit: At a national Yes Yes (collective) Nob Researcher title, photo
Milan, and physical activity and Latinos. New Britain, conference: Health caption, 2/3 themes
Leibovitz (2013) initiating policy change Connecticut, USA providers, educators, displayed
actions policymakers, and
community members
Kramer et al. To enable policymakers CBPR N = 44 Adults and youth. Exhibit: Policymaker Yes Not clear Nob No title, photo caption, 4/4
(2010) to be actively involved Colorado, USA roundtable and Community themes displayed
in identifying community summit, policymakers, State
needs Governor, and media
Lardeau, Healey, To explore determinants of CBPR N = 8 Adult, First Nations, Exhibit: Community museum Yes Not clear Nob Researcher title, embedded
and Ford (2011) food insecurity among food Iqaluit. Nunavut, Canada caption, 2/4 themes
program users displayed
Markus (2012) To empower healthy PAR N = 6 Youth American Indian Exhibit: University symposium: No Yes (individual) No Participant title, participant
relationships and (18–19 years). Wind River, Parents, grandparents, Tribal text, 0/4 themes displayed
prevention of HIV Wyoming, USA leaders, college counselors, (photo-poster examples
unintended pregnancy teachers, youths, and mental produced at the end of the
health providers article)
Newman (2010) To record the environmental CBPR N = 10 Adults with spinal cord Exhibit: Written testimony: No No No Researcher title, photo
barriers and facilitators to injury. Charleston, South South Carolina Senate caption, 2/2 themes
community participation Carolina, USA Transportation Committee. displayed
Newspaper published stories
Poudrier and Mac- To explore and make visible Decolonizing N = 12 Adult Aboriginal Exhibit: Community forum: Yes Not clear Nob Researcher title, embedded
Lean (2009) experiences with breast Methodologies women (42–75 years). Key stakeholders, advocacy caption, 2/2 themes
cancer (Feminist Saskatchewan, Canada groups displayed
Epistemology)
Seitz et al. (2012) To empower students to CBPR N = 49 Adults, undergraduate Exhibit: University’s student Yes Yes (collective) No No title, photo caption, 4/4
advocate for change of a college students, USA union building: Faculty, staff, themes displayed
campus smoking policy students, and community
member
Tanjasiri, Lew, To identify and understand CBPR N = 32 Youths (14–18 years). Exhibit: Formal meeting of No Not clear Nob No title, photo caption, 4/5
Kuratani, Wong, environmental Washington and California, tobacco control advocates, themes displayed
and Fu (2011) characteristics associated USA and City Council
with tobacco use
Valera, Gallin, To document challenges PAR N = 9 Adults, low income Exhibit: College conference, Yes Not clear Nob Participant title, embedded
Schuk, and accessing healthy food in women (20–45 years). New and letters to policymakers caption, 3/3 themes
Davis (2009) New York City York City, New York, USA displayed

Note. PAR = participatory action research; CBPR = community-based participatory action research; CBO = Community Based Organization; NGO = nongovernmental organization.
a
Photo-text title, caption (embedded in text/under photo), display of photo-texts to illustrate themes (n)/number of themes.
b
Acknowledged participants in the text.
Evans-Agnew and Rosemberg 1025
(Seitz et al., 2012). Participants in the studies included
youth (n = 7), adults (n = 13), and those that mixed youth
and adults (n = 2). Studies were conducted in North
America (n = 19) and Africa (n = 2). Researchers used
photovoice to explore a variety of health and social jus-
tice issues including community health in general (Duffy,
2010; Foster-Fishman, Law, Lichty, & Aoun, 2010;
Green & Kloos, 2009; Kramer et al., 2010), participation
(Andonian & MacRae, 2011; Newman, 2010), transition
to manhood (Bharmal et al., 2012), substance use (Brazg,
Bekemeier, Spigner, & Huebner, 2011), poverty and hun-
ger (Chilton, Rabinowich, Council, & Breaux, 2009;
Lardeau, Healey, & Ford, 2011; Valera, Gallin, Schuk, &
Davis, 2009), reintegration of child soldiers (Denov,
Doucet, & Kamara, 2012), empowerment education
(Downey, Ireson, & Scutchfield, 2009), workplace haz-
ards (Flum, Siqueira, DeCaro, & Redway, 2010), housing
(Grieb et al., 2013), homelessness (Halifax, Yurichuk,
Meeks, & Khandor, 2008), physical activity (Hannay,
Dudley, Milan, & Leibovitz, 2013), HIV (Markus, 2012),
breast cancer (Poudrier & Mac-Lean, 2009), and tobacco
use (Seitz et al., 2012; Tanjasiri, Lew, Kuratani, Wong, &
Fu, 2011).
Were Participants Involved in the Thematic
Coding of Data?
Twelve of the studies reported that participants were
involved in the coding of data (Andonian & MacRae,
2011; Bharmal et al., 2012; Brazg et al., 2011; Duffy,
2010; Foster-Fishman et al., 2010; Flum et al., 2010;
Grieb et al., 2013; Hannay et al., 2013; Kramer et al.,
2010; Lardeau et al., 2011; Poudrier & Mac-Lean, 2009;
Seitz et al., 2012). Participant participation included
review of slides individually or as a group, and active
discussion to perform selection identification of the main
themes (sometimes accompanied by representative pho-
tos). In four of the 12 studies, researchers coded and sum-
marized transcripts from the photovoice sessions and
then did member checking with the participants (Bharmal
et al., 2012; Grieb et al., 2013; Hannay et al., 2013;
Poudrier & Mac-Lean, 2009). In five studies, participants
were actively involved in coding and analyzing the data
(Brazg et al., 2011; Duffy, 2010; Flum et al., 2010;
Kramer et al., 2010; Seitz et al., 2012).
For the nine studies that did not include participants in
the analysis and coding of data, some used participants
for confirmation of themes (Chilton et al., 2009; Denov
et al., 2012), while others used other methodological
approaches (Downey et al., 2009; Green & Kloos, 2009),
or did not specify a particular process for coding the data
(Halifax et al., 2008). In these studies, it was impossible
to determine whether there was any development of
themes. For example, in their work with homeless adults
in Toronto, Halifax and others (2008) in the beginning of
a section titled “The Homeless Community’s Voice”
stated that “the group painted a comprehensive picture of
what homelessness is like” (p. 131). However, they did
not describe how they arrived at this comprehensive pic-
ture other than using the photovoice discussions.
How Did Participants Select Photo-Texts
to Display at Community Forums and
Exhibitions?
We were able to identify 14 out of the 21 studies where
the researchers described how participants selected
photo-texts for display at community forums and exhibi-
tions. Participants were involved in some sort of selection
process for their photo-texts either individually (n = 4;
Chilton et al., 2009; Denov et al., 2012; Downey et al.,
2009; Markus, 2012), or collectively (n = 10; Bharmal
et al., 2012; Brazg et al., 2011; Duffy, 2010; Flum et al.,
2010; Foster-Fishman et al., 2010; Green & Kloos, 2009;
Grieb et al., 2013; Halifax et al., 2008; Hannay et al.,
2013; Seitz et al., 2012). Researchers that described indi-
vidual choice typically encouraged individual participant
autonomy over selection of their own photographs to dis-
play at the conclusion of the focus groups, for example,
Denov et al. (2012) required each youth to review their
photographs and select two for publication prior to com-
ing to the group sessions. Researchers more commonly
described the collective choices made by participants for
presentation of photo-texts (n = 10). Most of these collec-
tive groups’ decisions were also mediated in part (and
depending on researcher description of such) by partici-
pant agency in determining which text to align with their
photo. The common characteristic among research
designs that encouraged either individual or collective
decisions regarding the exhibiting of photo-texts were the
explicit descriptions of participant choice. We found that
in the remaining seven studies, the authors did not involve
participants or were not explicit enough for us to deter-
mine how participants were involved in choosing which
photo-texts to display at community events (Andonian &
MacRae, 2011; Kramer et al., 2010; Lardeau et al., 2011;
Newman, 2010; Poudrier & Mac-Lean, 2009; Tanjasiri
et al., 2011; Valera et al., 2009).
Were Participants Involved in the Selection of
Photo-Texts for Journal Publication?
None of the articles described participants as having a
choice over which photographs would be published.
Some (n = 10) researchers used the acknowledgment sec-
tions of the article to recognize the contributions of par-
ticipants. Instead, the photo-texts appeared placed by
researchers to be representative of particular themes
1026 Qualitative Health Research 26(8)
discussed by participants, although there were no explicit
descriptions of how researchers ultimately made their
selections. Some researchers (n = 4) provided a link to a
website that they had developed for the display of all the
photo-texts. Out of these four sites, we found three that
were currently maintained (Bharmal et al., 2012; Chilton
et al., 2009; Halifax et al., 2008).
How Were the Photos, Titles, and
Accompanying Texts Linked to the Themes
Identified in the Analysis?
Of the 21 articles reviewed, four articles attached partici-
pant-derived titles to the photos depicted (Andonian &
MacRae, 2011; Halifax et al., 2008; Markus, 2012; Valera
et al., 2009), researcher-derived titles were used in nine
articles (Bharmal et al., 2012; Downey et al., 2009; Flum
et al., 2010; Green & Kloos, 2009; Grieb et al., 2013;
Hannay et al., 2013; Lardeau et al., 2011; Newman, 2010;
Poudrier & Mac-Lean, 2009), and the remaining eight
articles did not attach any title to participant photos
(Brazg et al., 2011; Chilton et al., 2009; Denov et al.,
2012; Duffy, 2010; Foster-Fishman et al., 2010; Kramer
et al., 2010; Seitz et al., 2012; Tanjasiri et al., 2011).
Participant-derived captions were included in 18 of
the 21 articles. Most of the articles (n = 12) positioned the
participant text directly under the participant photo in a
single figure (Bharmal et al., 2012; Brazg et al., 2011;
Chilton et al., 2009; Denov et al., 2012; Duffy, 2010;
Foster-Fishman et al., 2010; Hannay et al., 2013; Kramer
et al., 2010; Markus, 2012; Newman, 2010; Seitz et al.,
2012; Tanjasiri et al., 2011). The remaining six articles
embedded the participant caption inside the results sec-
tion of the article (Andonian & MacRae, 2011; Grieb
et al., 2013; Halifax et al., 2008; Lardeau et al., 2011;
Poudrier & Mac-Lean, 2009; Valera et  al., 2009).
Participant captions were not included in three of the arti-
cles (Downey et al., 2009; Flum et al., 2010; Green &
Kloos, 2009).
Photo-texts were used by researchers to depict some or
all of the thematic findings in 19 of the 21 articles. In
seven of these articles, photo-text exemplars were
depicted for all the themes described (Chilton et al., 2009;
Denov et al., 2012; Kramer et al., 2010; Newman, 2010;
Poudrier & Mac-Lean, 2009; Seitz et al., 2012; Valera
et al., 2009). In 11 articles, some of the themes were
depicted with photo-text exemplars (Andonian &
MacRae, 2011; Bharmal et al., 2012; Brazg et al., 2011;
Duffy, 2010; Flum et al., 2010; Foster-Fishman et al.,
2010; Grieb et al., 2013; Halifax et al., 2008; Hannay
et al., 2013; Lardeau et al., 2011; Tanjasiri et al., 2011).
In a further three articles, the photo-texts displayed did
not correspond to themes (Downey et al., 2009; Green &
Kloos, 2009; Markus, 2012). These last three articles
represent the varying purposes of photovoice: Downey
et al. (2009) used photo-texts to produce a community
assessment booklet for rural Appalachia; Green and
Kloos (2009) did not develop themes as such but exhib-
ited the photo-texts to raise awareness of life in rural
Uganda; and Markus (2012) showed three examples of
posters comprising several photo-texts but not in relation
to their developed social justice themes.
Discussion
In this article, we aimed to examine the processes
researchers use to empower participant voice, specifi-
cally through their analysis and dissemination of photo-
texts. We specifically explored participants’ voice in (a)
the analysis of the data, (b) choice of photo-text at com-
munity events, (c) selection of photo-texts in published
articles, and (d) alignment of photo-texts in manuscript
results. A recent review on photovoice included an explo-
ration of methodology fit and outcomes of photovoice on
a social justice continuum of awareness, amelioration,
and transformation (Sanon et al., 2014). Other reviews on
the photovoice method also included an exploration of
individual and community change (Hergenrather et al.,
2009), and the process of the photovoice method itself
with a significant emphasis on rigor and fit between the
method and health concerns (Catalani & Minkler, 2010).
This review is the first to examine how participants’ voice
was facilitated and promoted within the research design
and through the dissemination process.
Our findings show that participant voice is most often
advanced in areas that remain hidden from the direct
experience of the readers of these articles in the develop-
ment of themes and in the exhibition of the photo-texts to
community groups and policymakers. We found the least
advancement of participant voice in the actual publishing
of photo-texts in the articles that we reviewed; both from
the absence of any discussion by researchers on partici-
pant choice of which photo-texts to publish and the small
number (n = 7) of studies that comprehensively used
photo-texts to illustrate themes. This finding was surpris-
ing considering the emphasis within PAR and other forms
of CBPR toward participant involvement and recognition
in the publishing of research monographs (Israel et al.,
2010).
We found that researchers employed a variety of styles
for matching photo-texts to the themes presented in their
findings sections. For example, we found that in only half
of the studies we reviewed, participants’ voice appeared
to influence coding (n = 12) and the selection of photo-
text exhibits at local events (n = 13). These findings con-
trast with an earlier study where a higher level of
participant involvement (i.e., at least one group discus-
sion based on the photos) was reported in the majority
Evans-Agnew and Rosemberg 1027
(85%) of photovoice studies reviewed (Catalani &
Minkler, 2010). However, in that study, the researchers
did not explicitly investigate whether these group discus-
sions were the principal means used by the group to
develop themes. In our review, we had purposely selected
studies that involved participants in discussions, so we
were surprised that just more than half of studies actually
used the discussions as the principal basis for the devel-
opment of themes. This finding reiterates the need for
researchers’ report on how participation discussions con-
tributed toward data analysis.
In our review, we found that just more than half of the
articles (n = 13) had explicit details about participants’
choice of photo-texts for display during exhibits and
community forums. There were inconsistencies across
these articles regarding the number of slides/photos cho-
sen and who was responsible for the printing and produc-
tion of the display. Wang and Burris (1997) gave general
guidance for this but left much open to different interpre-
tations. We further examined whether researchers were
clear about engaging participant choice over which
photo-texts to display. Warren (2005) suggested that this
form of local exhibition that combines printed photo-
texts and the opportunity for participants to speak about
their research is the principal way in which photo-texts
empower participant voice because “the photograph
gives research participants something to talk about that
they actually own in a tangible way” (p. 870). In our
study we found that just over half of the articles were
explicit about participant selection for local display,
therefore we cannot assume that such events were consis-
tently privileging participant voice.
In addition to photo-text display discussed above, we
were most surprised to find that no authors discussed par-
ticipant choice for what photo-texts to display in pub-
lished research. Co-publishing and authorship are
important components of CBPR (Bordeaux et al., 2007;
Horowitz, Robinson, & Seifer, 2009), yet this has not
been the topic of discussion within studies or method-
ological articles using photovoice. Despite the numerous
publications surrounding photovoice, the issue of co-
authorship remains unexplored. Our findings have led us
to reflect more deeply than before on whose voice is,
indeed, being served through the publication of photo-
texts in research monographs.
Where we found the greatest variability in the advance-
ment of participant voice was the use of photo-texts
within the monographs with respect to whether or how
the photograph was anchored to a title, text, or the theme
the authors were trying to illustrate. In Wang and Burris’s
(1997) original text, photographs did not have titles but
included the text next to the photographs. The Hamilton
Photovoice Manual, a commercially available handbook,
includes a SHOWeD question handout for participants
that has a simple prompt for a title at the top of the page
(Dahan et al., 2007, p. 38) but no guidance on how such
questions, or which questions in particular, should lead to
the development of either title or text. We found that only
four manuscripts included participant-derived titles,
whereas researchers either chose to create titles (n = 8) or
leave them out (n = 9). The creation of a title may stimu-
late a deeper level of interpretation for the participant and
viewer than that of the creation of text. We also noticed a
great variation in the way researchers used photo-texts in
publications to represent the themes that the participants
developed. Researchers made decisions about which
photo-texts to include, which themes to depict, and which
themes not to depict through photos.
Implications for Practitioners
There are important structural and theoretical consider-
ations for practitioners considering the advancement and
empowerment of participant voice in photovoice designs.
Practical factors such as funding, publication constraints,
and Internal Review Board (IRB) processes may con-
strain the ability to fully realize the participatory action
research goals of photovoice. In other words, (a) there
may not be the funds to pay for extra analysis and writing
sessions, or for trips to conferences or other venues for
dissemination; (b) publication constraints such as page
and figure limits may diminish the accurate description
and advancement of voice; and (c) IRB requirements
such as not allowing faces to be photographed may limit
the full creative expression of participants. What further
complicates this issue is that the publishers of journals
have unique requirements concerning consent and copy-
right to visual images that identify persons. This may be
a barrier for visual researchers who may not have access
to the participant years later to acquire consent for pub-
lishing in that particular journal.
We propose that researchers concerned with empower-
ing participant voice within photovoice designs use a
checklist to ensure that all appropriate decisions are made
both prior to and during the project (see Supplementary
File.) In designing photovoice projects, health researchers
need to be explicit about the involvement of participant
voice in the design, implementation, and dissemination of
such studies. Otherwise, the opportunity to appraise the
advancement of participant voice is obscured. Consideration
should also be given to encouraging participants to indi-
vidually and/or collectively process, analyze, select, and
design photo-texts for advancing their voice in both com-
munity events, in manuscript publication, and in other
media. In this article, we have suggested that there is no
theoretical justification offered for limiting the involvement
and power participants have in this process. We recommend
that researchers make serious consideration of whether to
1028 Qualitative Health Research 26(8)
include either title and/or caption for participant photo-
graphs and to work to anchor these to the photo in their
display in publications. Reviewers of manuscripts could
then more critically examine the fit between participant
voice as advanced through the photo-text and the thematic
summary provided in the findings of the study.
Limitations
For this review, we did not contact any of these researchers
to elicit any data that may have further characterized their
process for giving voice to participants, nor did we exam-
ine the particular language used in the consent process per-
taining to ownership, recognition, or dissemination. We
did not examine the author guidelines concerning the use
of figures for the journals within which these articles were
published. Given that photo-texts are a primary source of
data in any photovoice study, an arbitrary limiting of the
amount of these texts to be displayed as figures might have
constrained authors in the publication of participant voice.
In conducting this review, we also could have made addi-
tional efforts to consolidate our rigor, such as (a) working
with a research librarian, and (b) keeping a detailed record
of steps taken to adhere to the PRISMA guidelines.
Conclusion
In this review, we have asked whether existing research pro-
cesses for photovoice designs are actually advancing partici-
pant voice in health and health care research. Given the
underlying social justice intent of the photovoice, and the
primacy of privileging participants with the ability to speak
and the right to be heard, we are left to question whether
future photovoice researchers should rethink the fundamen-
tals of their designs, and engineer distinct strategies to
advance participant voice in the analysis and dissemination
of photo-texts. Although there is great promise in the photo-
voice method to develop critical knowledge that has the
opportunity to mitigate and transform social injustices, it is
clear from this review that many research designs are lack-
ing in rigor to successfully harness this opportunity.
Acknowledgment
We gratefully acknowledge the support of Doris Boutain, PhD,
RN, who provided the inspiration for this article.
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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Author Biographies
Robin A. Evans-Agnew, PhD, RN, AEC, is an assistant profes-
sor in the Nursing and Healthcare Leadership Program at the
University of Washington Tacoma, Washington.
Marie-Anne S. Rosemberg, PhD, RN, is an assistant professor
in the School of Nursing at the University of Michigan, Ann
Arbor, Michigan.