1019978

research-article2021
HPPXXX10.1177/15248399211019978JOURNAL OF HOSPITALITY & TOURISM RESEARCHFountain et al. / PHOTOVOICE PROJECTS WITH YOUTH

Review Article

A 10-Year Systematic Review of Photovoice Projects

With Youth in the United States
Sarah Fountain, BS1
Rachel Hale, MA1
Nicola Spencer, MA1
Jinger Morgan1
Laura James, MD1
M. Kathryn Stewart, MD, MPH1

Introduction. Photovoice is a method used in commu- the needs and assets of their community. Through criti-
nity-based participatory research that places cameras in cal reflection and dialogue, youth can become change
the hands of people and invites them to record their agents in their communities. No single set of strategies
lives, engage in critical dialogue, and advocate for will work best for every project.
changes needed in their communities. This article pre-
sents a review of the literature from 2010 to 2019 on Keywords: community-based participatory research;
photovoice projects implemented with U.S. youth health research; health disparities; pho-
informed by an emancipatory research conceptual tovoice
framework. Method. Information on 30 project elements
was extracted from each of the 47 publications, repre-

senting 39 unique projects that met our inclusion criteria.
Projects were also assessed for whether they met the goals
of photovoice as originally conceptualized by Wang and
Burris in 1997. Results. Participants, policy makers, and
community members were affected by photovoice pro-
jects. Outcomes ranged from researcher specific needs to
community change and policy awareness and changes.
Common outcomes included (1) gaining knowledge, (2)
participant empowerment, (3) community change/
action, (4) new partnerships, and (5) reaching policy
makers. Of the 39 unique projects, 17 addressed all three
photovoice goals, 12 addressed two, and 10 addressed
only one. All the projects met the goal of enabling par-
ticipants to record and reflect their community’s strengths
and concerns. Twenty-four were aligned with all three
principles of emancipatory research. Discussion.
Photovoice is a valuable, flexible tool that can enable
participants to play an active, guiding role in assessing
Health Promotion Practice
November 2021 Vol. 22, No. (6) 767­–777
DOI: 10.1177/15248399211019978
https://doi.org/
Article reuse guidelines: sagepub.com/journals-permissions
© 2021 Society for Public Health Education
P
hotovoice is a method used in community-based
participatory research that places cameras in the
hands of people and invites them to record their
1
University of Arkansas for Medical Sciences, Little Rock, AR,
USA
Authors’ Note: The authors would like to thank the Little Rock
School District EXCEL program students for being a part of our pilot
Photovoice project. We are deeply indebted to the Little Rock School
District EXCEL program teachers, Cynthia Booker and Hillary
McCree, for sharing this opportunity with us. No conflict to report.
This work was supported by the U.S. National Institutes of Health
(NIH) National Center for Advancing Translational Sciences: UL1
TR003107, by the Stead Scholar program funded by the University
of Arkansas for Medical Sciences Fay W. Boozman College of Public
Health, the Arkansas Department of Health, and by the NIH National
Center for Minority Health and Health Disparities through the
Arkansas Center for Health Disparities (ARCHD): 5U54MD002329.
The information contained in this publication does not necessarily
reflect the opinions of NIH, the University of Arkansas for Medical
Sciences College of Public Health, the Arkansas Department of
Health, or ARCHD. Address correspondence to Sarah Fountain,
Program Coordinator, University of Arkansas for Medical Sciences,
4301 West Markham Street, Little Rock, AR 72205-7101, USA;
e-mail: sbfountain@uams.edu.

767
lives, engage in critical dialogue with one another, and
advocate for change in their communities (Wang &
Burris, 1997). Due to these features—participatory pro-
cess, reflective inquiry and discussion, and social
action—photovoice is a valuable approach for identify-
ing inequities and steps needed for health promotion
efforts to succeed (Wang et al., 1996; World Health
Organization, 2016). Photovoice typically engages and
empowers groups of individuals whose voices have
been marginalized to visually express their experiences
and perceptions in the broader context of their lives
(Seedat et al., 2015). It is often used with youth, whose
expertise and knowledge are frequently disregarded or
undervalued. This is especially true for youth affected
by poverty, racism, and/or other discrimination. Such
youth may not have opportunities to have discussions
with adults about issues of meaning related to their
lives and experiences or to engage substantively in
community activities addressing issues of social con-
cern. These conditions may contribute to apathy, dis-
satisfaction, and loss of agency and can increase the
likelihood of struggles with school, substance use, and
other harms (Suffla et al., 2012). Such risks and nega-
tive outcomes can be mitigated through experiences
that empower youth and increase their community
involvement (Pancer et al., 2007). Photovoice can serve
this purpose by creating opportunities for these young
people to represent their own realities, which may run
counter to how they are presented within majority cul-
ture (Goessling, 2018). When used in this context, pho-
tovoice is an emancipatory research process, as it seeks
to equalize the power imbalance between the researcher
and those often viewed as “other” who are the “sub-
jects” of their inquiry (Petersen, 2011).
This article presents our review of the literature about
photovoice projects conducted with youth in the United
States over the past 10 years (2010–2019). We found no
other reviews of projects published during this period
focused on U.S. youth. Our interest in learning more
about others’ experiences using photovoice with young
people was stimulated by our early attempts to pilot
such a project among high school students participating
in our Community Scientist Academy (Stewart et al.,
2018). Therefore, one of our goals was to identify com-
mon practices and lessons learned.
We used emancipatory research as a conceptual
framework to inform our review. Many photovoice pro-
jects engaging youth are oriented toward social justice
and empowerment of those at the margins. The prin-
ciples of emancipatory research—reciprocity, gain, and
empowerment—are particularly relevant in this con-
text (Oliver, 1997; Petersen, 2011). These principles are
consistent with the three goals of photovoice as defined
768 HEALTH PROMOTION PRACTICE / November 2021
by its developers: “1) to enable people to record and
reflect their community’s strengths and concerns, 2) to
promote critical dialogue and knowledge about impor-
tant issues through large and small group discussion of
photographs, and 3) to reach policy makers” (Wang &
Burris, 1997, p. 369). Ideally, photovoice creates condi-
tions wherein participants can apply their agency and
empower themselves, and through dialogue and reflec-
tion move to a greater understanding that leads to action.
Our other goal, then, was to examine to what extent pro-
jects conducted with youth and described as photovoice
in the literature were able to address these goals.
>>
The Photovoice Process
Photovoice participants often write the captions
for their photos by using a method called SHOWeD, a
framework adapted from Shaffer’s 1985 work, where
participants are asked questions that guide their cap-
tion development. SHOWeD questions include the fol-
lowing: (1) What do you See here, (2) What is really
Happening here, (3) How does this relate to Our lives,
(4) Why does this situation Exist, and (5) What can we
Do about it? (Shaffer, 1985). This method allows the par-
ticipants to critically think and discuss with the other
participants and the research team about why they took
the photo, how it relates to the given topic, and what can
be changed in order to mitigate the issue.
The process of photovoice includes teaching the par-
ticipants photography skills (ethics, safety, and camera
basics), using SHOWeD or a similar method to construct
the caption for their photo, participating in group discus-
sion to find predominant themes within all the photos,
and holding a forum to display the photos for community
members, city officials, and/or policy makers. Not all pho-
tovoice projects have a community forum to display their
photos but doing so allows dissemination of the findings
about the important issues identified by the community
affected to other members of the community, including
policy makers. Policy makers, city officials, and commu-
nity leaders and other stakeholders are invited to these
events to provide the photovoice participants an audience
with those who have the power to effect policy or other
changes needed to address their concerns.
Photovoice can be used for almost any type of popu-
lation and age group. Most participants in a photovoice
project are individuals society has ignored or oppressed
through systemic discrimination based on their com-
munity’s socioeconomic, demographic, racial, ethnic,
cultural, gender, and/or sexual identities. For exam-
ple, concerns of young people at the intersections
of oppressed identities are often underrepresented in
policies and programs.
 Photovoice involves participants in visual expression
using photography to document the assets and/or needs
of their community. Photovoice is traditionally imple-
mented with digital cameras, but with the decreased cost
of smartphones and 84% of U.S. teenagers now owning
one (Kamenetz, 2019), it is feasible to implement pro-
jects using any phone with a camera. This daily expo-
sure to taking photographs may allow adolescents to be
more comfortable and interested in photovoice projects.
However, only 53% of youth 11 years or younger have
a smartphone (Kamenetz, 2019). Children younger than
10 years may have difficulty using a camera and writ-
ing their caption; Photovoice is not frequently recom-
mended for use with children younger than 10 years
(Heidelberger & Smith, 2015; Schwartz et al., 2015;
Valenzuela et al., 2013).
>>
Method
Search Process and Inclusion/Exclusion Criteria
We used the PRISMA ((Preferred Reporting Items for
Systematic Reviews and Meta-Analyses) guidelines to
conduct a systematic review of the literature. The original
search was conducted by the primary author (SF) using
the PubMed database. We used the following search cri-
teria: “photovoice” AND “youth” OR “adolescents” OR
“adolescent” OR “teenager” OR “teenagers” AND “United
States.” These search criteria resulted in 80 articles. Our
exclusion criteria consisted of the articles being published
before 2010 or after 2019, all the participants being older
than age 21, and studies conducted outside the United
States. The last date of our search was February 5, 2020.
We used a PRISMA flow diagram for systematic
reviews to organize the excluded articles. Ten of the
80 articles originally pulled were excluded because
they were published before 2010 leaving 70 articles
for abstract review. Eleven articles were excluded dur-
ing this stage and another 14 were excluded after full-
text assessment. The majority of the articles that were
excluded were not implemented with youth. The next
most common reason for exclusion was that the photo-
voice project took place outside the United States.
Two of the articles that resulted from the PubMed
search referenced other articles that were published
about the same photovoice project. We determined that
the two referenced articles fit within our inclusion cri-
teria and added them for inclusion in the final review.
In summary, we identified 47 articles representing
39 unique projects that met our inclusion criteria since
eight of the projects had multiple articles about the same
project. We included all articles that described their
projects as photovoice, rather than applying a strict
definition such as requiring them to have addressed all
three of Wang and Burris’ original defining goals. We
chose this inclusive approach to incorporate the greatest
diversity of projects, topics, procedures, and outcomes.
Therefore, a number of projects did not necessarily take
their discussion beyond the members involved in the
project and did not reach out to policy makers. Below,
we describe our assessment of which of the three goals
were met by each of the projects.
Content Review and Abstraction
Each article was reviewed by two of the authors (SF
and RH) for the participants’ demographics and location,
study design, project implementation, analysis, project
outcomes, dissemination, challenges, and recommenda-
tions. A table was constructed by the primary author to
extract this information into clearly defined categories
to identify similarities throughout the literature. After
all the data were entered, the primary author organized
the information to group articles referencing the same
project. All articles pulled for review and information
extracted from each article were reviewed again by the
second author (RH) who made recommended revisions
to the categories and presentation of data. The first two
authors then discussed differences in how they had cat-
egorized extracted information to reach consensus on
the final presentation of data in 30 categories. For pur-
poses of readability, the original table was broken into
Supplemental Tables S1 to S3. These tables include 16 of
the original 30 data elements extracted. Information from
the remaining excluded categories is either reported in
text or in the Supplemental Table S4.
Supplemental Table S1 provides project overviews
and describes participants, location, purpose, goals, and
whether the project was strictly for formative research
or intervention. Supplemental Table S2 presents pro-
ject design features including sample size, trainings
provided, project duration and meetings, prompts and
topics, framework (SHOWeD, etc.), assessment, research
team members, whether sessions were recorded and
transcribed, and evaluation. Supplemental Table S3
focuses on project outcomes related to themes identi-
fied, dissemination methods, audience, those affected
and how, challenges and limitations, and recommenda-
tions for future research. These results help define what,
if any, actions were taken to address the issues raised by
participants through the project.
Next, the last author (MKS) constructed another table
(Supplemental Table S5) based on information extracted
from the articles about whether the project enabled par-
ticipants to reflect their community’s strengths and/or
concerns, whether participants were engaged in critical
Fountain et al. / PHOTOVOICE PROJECTS WITH YOUTH 769
dialogue through large and small group discussions, and
whether they reached policy makers. The first two authors
(SF and RH) then reviewed this information and all three
discussed and resolved differences before finalizing the
table. For purposes of our assessment, we defined “policy
makers” broadly to include anyone with some ability to
influence the issues identified by the youth participants,
either directly or indirectly. For example, we identified
a project where providers were engaged in discussions
about changes needed in the way they provide care as
reaching policy makers.
We identified projects that met all three of the goals
of photovoice and also aligned with the three emancipa-
tory research principles of reciprocity, gain, and empow-
erment. Those that only engaged participants in taking
photographs but not in discussions beyond their group
were considered aligned with the reciprocity goal only
unless they described action beyond their own group.
Projects that met the first and second goals of photovoice
were identified as aligned with both the reciprocity and
gain principles because participants were engaged in
both taking photos and in discussing the meaning to
their lives. If they also indicated that participants felt
empowered and/or that they were able to disseminate
their work in a way that positively affected them and/
or their communities, we considered them to be aligned
with the third principle of empowerment, whether or
not they were able to disseminate specifically to policy
makers.
>>
Results
Project Overview (Supplemental Table S1)
Age Range and Number of Participants. Most articles
reported participants’ ages as an age range rather than
reporting the number of participants by age thus limit-
ing our ability to report a mean age of participants. The
age ranges of participants varied widely among the
projects with the youngest being 8 years (Schwartz
et al., 2015) and the oldest including participants up to
26 years (Bharmal et al., 2012). There were five projects
that included participants outside our initial inclusion
criteria. However, three of those projects categorized
participants into distinct age groups, and all three proj-
ects included one group that fell within our inclusion
criteria for age (Kowitt et al., 2015; Sin et al., 2010;
Valenzuela et al., 2013). The remaining two projects
included participants within our inclusion criteria for
age, and these were categorized as one age group. One
project had participants aged 18 to 24 years (Kubicek
et al., 2012) and the other had participants aged 16 to 26
years (Bharmal et al., 2012).
770 HEALTH PROMOTION PRACTICE / November 2021
Location. Of the 39 projects, 12 included the city and
state where the photovoice project was implemented
while 16 only included the state. An additional six
projects stated the county and state, three only stated a
general description of the area without including the
state, and the remaining two projects did not include
information about where the study was implemented.
The U.S. Census Bureau divides the United States into
four regions and all regions were represented through-
out the projects (Abadi, 2018). There were more proj-
ects completed in the Western and Southern parts than
in the Southeastern and Midwest regions. Only one of
the listed counties is considered rural (population
under 50,000) and all the cities that were listed had a
population over 50,000. For specific locations, refer to
Supplemental Table S1.
Recruitment. Recruitment methods varied across the
projects. These methods included leveraging existing
community relationships and previous project partici-
pants, developing new relationships (e.g., local school
staff, clinicians, youth leaders, project and/or commu-
nity focused community advisory board members) to
personally recruit participants, posting flyers, sending
targeted emails, word of mouth, hosting informal com-
munity meetings, partnering with other organizations,
and visiting venues frequented by potential community
participants.
Also of interest, but not shown in the table, are a few
points regarding relationships and research team com-
position. Twenty-five of the projects had some level of
relationship with the community prior to the project.
Additionally, 14 projects included a nonemployee com-
munity member on the research team, nine employed a
local photographer to facilitate photography basics train-
ing, and two employed community members as facilita-
tors in the group discussions.
Project Design (Supplemental Table S2)
Sample Size. The total number of participants among
the 39 projects was 590. The sample sizes ranged from
four (Vélez-Grau, 2018) to 36 (Kubicek et al., 2012) par-
ticipants and the mean number of participants was ten.
Training Provided. Training was a common element of
the projects including such topics as photography
basics, research ethics, and project-specific education.
Twenty-six projects included photography basics (cam-
era use, composition, etc.) with nine projects employ-
ing either a local photographer or photojournalist to
facilitate the session. In addition, 22 projects included
photography ethics, safety, and consent. Additional
training addressed social determinants of health and
health equity (Petteway et al., 2019), environmental
health (Kovacic et al., 2014; Madrigal et al., 2014), and
introductory research and methods reviews (Irby et al.,
2018; Kovacic et al., 2014; Madrigal et al., 2014; Noone
et al., 2014; Petteway et al., 2019; Schuch et al., 2014;
Stanley et al., 2018).
Project Duration. For the 31 articles that indicated the
project duration, the time period ranged from 1 week
(Mmari et al., 2014) to 1 year (Schwartz et al., 2015).
Most designs involved a variety of schedules from
daily, weekly, monthly, virtually, and sporadically dis-
persed over months, making it difficult to identify a
common practice for meeting frequency.
Use of SHOWeD Framework. Only 22 of the projects
used the SHOWeD framework as a way to assist partici-
pants in writing their captions. Five projects used a
modified version of SHOWeD (Cardarelli et al., 2019;
Findholt et al., 2010; Irby et al., 2018; Mmari et al.,
2014; Petteway et al., 2019) and this modified version
varied for each project. Modifications to SHOWeD
included rewording the questions in order to make
them easier for participants to understand, not asking
the participants all five of the questions, adding ques-
tions to be answered, or making some of the questions
more specific to the project topic. Three projects used
SHOWeD along with another framework to discuss
their photos (Merino et al., 2019; Petteway et al., 2019;
Salerno Valdez et al., 2019). The remaining nine either
used a framework other than SHOWeD or did not state
if they used a framework.
Cameras (Data Not Shown in Table) and Use of Social
Media. Just less than 80% (79.50%) of the projects pro-
vided the participants with cameras, while 10.25% did
not state if the participants were given a camera, and in
the remaining 10.25% participants used their personal
phone camera. One new modification since publication
of the last review of photovoice projects was the use of
online platforms (Instagram, Tumblr) to replace in-per-
son group discussion and dissemination of photos. Two
projects chose this design with only one conducting an
in-person focus group. One project was entirely imple-
mented using the social media platform Instagram (Yi-
Frazier et al., 2015), allowing participants to upload
their photographs with an optional designated hashtag.
While this project did include a final in-person focus
group, only five of the 25 participants attended the dis-
cussion. Another project that used an online platform
conducted all their meetings virtually with a final
phone interview conducted by the researcher (Riggsbee
et al., 2019). The participants who attended the in-per-
son focus group at the end of the project stated they felt
more comfortable discussing the topic after meeting
with the other participants.
Informed Consent and Incentives to Participate (Data
Not Shown in Table). Thirty-four of the 39 projects
stated that the participants and/or their parents signed
informed consent forms. Three projects did not include
whether or not they used an informed consent form,
and the additional two projects stated that consent was
gained, but the process of gaining consent was not
included. All participation was voluntary, and all were
able to drop out of the projects at any time.
Twenty-two of the projects offered incentives for
their participants. The incentives, provided at the com-
pletion of the project or after each photovoice session,
included money (articles that reported monetary value
ranged from $10 to a $100 stipend), gift cards (those that
reported monetary value ranged from $5 to $150), a lap-
top, cameras used for the project, field trips, class credit,
and community service hours. Five projects provided
food and/or travel reimbursement to the participants.
Research Team, Transcription, and Participant Assess-
ments. Of the 39 projects, 35 assigned a research team
member to take notes during all group sessions and dis-
cussion and of those, 22 projects also audio-recorded
the sessions. Among the 39 projects, only six assessed
the participants’ experiences. Methods to assess par-
ticipant experiences with the photovoice project
included written evaluations from participants (Find-
holt, Michael, & Davis 2011; Tanjasiri et al., 2011), sat-
isfaction surveys completed by the parents and the
participants (Valenzuela et al., 2013), collection of writ-
ten reflections after each in-person session and admin-
istration of a 43-item questionnaire at the completion of
the project and again ten months later (Madrigal et al.,
2014), interviews with participants (Woolford et al.,
2012), and a pre- and postsurvey of participants that
included open-ended questions about their reasons for
participating (Cardarelli et al., 2019).
Evaluation and Identification of Themes. All the proj-
ects had some type of evaluation measure to assess the
project findings. Fourteen projects used the photos
taken by the participants and eight projects used the
captions from the photos to identify themes or similari-
ties. Thirteen projects used verbal discussion, either
between the researchers and the participants or only
between the researchers, while two stated that inter-
views were used to identify the themes. Ten projects
used codes to sort or identify similarities and seventeen
Fountain et al. / PHOTOVOICE PROJECTS WITH YOUTH 771
used software (see Supplemental Table S2 for software
used). Twelve projects used written notes and thirteen
used transcripts and/or audio to evaluate the themes.
Only three projects used surveys or worksheets and
only one stated that they used open-ended questions
for their evaluation.
Only 10 of the projects reported involving youth/ado-
lescents in identifying themes. The most used method
of finding themes was for researchers to review tran-
scripts and audio from group discussion sessions and
then sort the photos into categories. These categories
were then identified as the themes for the project. One
project had a unique focus and was developed to influ-
ence change to the Washington State asthma plan. This
project compared adolescent experiences with the state
asthma plan’s intended focus (Evans-Agnew, 2016).
Topic and Themes. All 39 projects included topics or
themes related to health and social determinants of
health including substance and tobacco use and other
health behaviors, barriers to health care, racism and
other discrimination, obesity/body image, environmen-
tal health, chronic disease, violence, lesbian, gay, bisex-
ual, transgender, and queer issues, mental health and
suicide, influences of health in the community, and the
food environment.
Project Outcomes (Supplemental Table S3)
Dissemination and Audience. Photovoice projects typ-
ically involve the participants showcasing their photos
and captions to members of the community. This is one
mechanism for reaching policy makers and can amplify
the voice of participants among others who might have
influence over the issues depicted in their photos.
Twenty-seven of the projects presented their photos to
the community, and 21 of those held a community
forum that was open to the public. Some studies focused
their findings on specific target audiences, rather than
holding a public exhibit of their photos. The audience
members varied widely including attendees such as
participants’ friends and families, community mem-
bers, local government officials, health care providers,
educators, funders, and academicians.
Additional means of dissemination involved the pho-
tographs being displayed in various locations around
the community (e.g., city halls, libraries), outside public
events, private meetings with a targeted audience, and at
conferences and universities. A few projects employed
the use of newsletters (Kovacic et al., 2014), magazines
(Noone et al., 2014), and online platforms such as Tumblr
(Madden & Breny, 2016) and Instagram (Yi-Frazier et al.,
2015). The Tumblr blog was established after completion
772 HEALTH PROMOTION PRACTICE / November 2021
of the project to disseminate the results, while photos
posted on Instagram were posted during the project.
Almost a third (30.7%) of the projects did not present
their findings to the community but instead they either
had participants post their photos in an online forum
for all participants to see, texted the photos only to the
researchers, or had focus groups only with participants
and researchers.
Who/What Was the Impact and How? Those affected
by the photovoice projects included researchers, par-
ticipants and their immediate family and friends as
well as the broader community involving community
leaders, policy makers, and representatives of organiza-
tions and academic and clinical institutions. Research-
ers reported gaining valuable knowledge from the
projects that helped them design future research proj-
ects and implement interventions within the commu-
nity (Agaronov et al., 2019; Findholt et al., 2010;
Heidelberger & Smith, 2015; Merino et al., 2019; Mmari
et al., 2014; Riggsbee et al., 2019; Stanley et al., 2018).
Participant capacity was increased through the training
they received, and the experience of implementing
their projects and presenting their findings to the
community.
In addition to increasing the knowledge of research-
ers and participants, the photovoice projects raised
the community and stakeholders’ awareness of issues
(Brazg et al., 2011; Cardarelli et al., 2019; Estrella &
Kelley, 2017; Evans-Agnew, 2016; Findholt, Michael,
& Davis, 2011; Foster-Fishman et al., 2010; Hall et al.,
2018; Irby et al., 2018; Jennings & Lowe, 2013; Kovacic
et al., 2014; Lightfoot et al., 2019; Markus, 2012; Sin et al.,
2010; Valenzuela et al., 2013). Photovoice participants
also indicated increased interest in research careers
(Cardarelli et al., 2019).
Research-related outcomes included future research
projects (Schwartz et al., 2015); new partnerships (Irby
et al., 2018); community research collaborators (Schuch
et al., 2014; Schwartz et al., 2015); culturally appropri-
ate document revisions (Lightfoot et al., 2019); and an
organization guidebook (Foster-Fishman et al., 2010).
Individual and Community Empowerment. Nine of the
projects reported that the participants expressed feel-
ings of empowerment during projects and after dissem-
ination and discussion of their photographs in public
forums such as community events, exhibits, and con-
ference presentations (Cardarelli et al., 2019; Estrella &
Kelley, 2017; Kovacic et al., 2014; Leung et al., 2017;
Noone et al., 2014; Madden & Breny, 2016; Schuch
et al., 2014; Tanjasiri et al., 2011; Tanjasiri et al., 2013;
Vélez-Grau, 2018). Community-level changes reflecting
broader empowerment included creation of youth advi-
sory/advocacy councils or action teams (Balvanz et al.,
2016; Bharmal et al., 2012; Kubicek et al., 2012; Pette-
way et al., 2019; Woods-Jaeger et al., 2013); community
gardens, school recycling programs, walkability assess-
ments (Balvanz et al., 2016; Madrigal et al., 2014; Pette-
way et al., 2019); policy changes/recommendations
(Evans-Agnew, 2018; Petteway et al., 2019; Salerno Val-
dez et al., 2019; Tanjasiri et al., 2011); and photogra-
phy/art installations (Brazg et al., 2011; Foster-Fishman
et al., 2010; Lightfoot et al., 2019).
Limitations/Challenges Reported by Projects (Data
Shown in Supplemental Table S4). Commonly reported
limitations included generalizability, small sample
size, study design limitations, conflicting schedules/
logistics, and having a short time frame. For project
specific limitations, refer to Supplemental Table S3.
Projects’ Recommendations for Future Research (Data
Shown in Supplemental Table S4). Most recommenda-
tions for future research focused on the individual proj-
ect’s research or program area but a few addressed
design and implementation related issues. These rec-
ommendations included addressing participation and
communication challenges by embedding the photo-
voice project within a class or student organization
(Cardarelli et al., 2019), assessing the time commit-
ments of the participants (Foster-Fishman et al., 2010),
and building an atmosphere of trust (Irby et al., 2018).
Additional design recommendations included larger
sample sizes, increasing the project length (Findholt,
Michael, & Davis, 2011), requiring the use of a digital
camera rather than a personal cellphone (Irby et al.,
2018), inclusion of a project orientation that goes beyond
a discussion of photography basics and ethics to help
youth participants understand how the community
context can affect health (Findholt, Michael, & Davis,
2011), replication of photovoice efforts in other diverse
environments (Markus, 2012), and designing a project
utilizing the Wilson et al. (2007) model, which aims to
use photovoice to evaluate what social action issues to
tackle (Valenzuela et al., 2013). Tanjasiri et al. (2011) rec-
ommend encouraging the involvement of policy makers
at the outset of the project to help translate the project’s
findings into policy change.
Further research is recommended to explore the effi-
cacy of using photovoice as a medium to change behav-
ior (Yi-Frazier et al., 2015), as a potential therapeutic
strategy when working with adolescents (Vélez-Grau,
2018), and to examine the longevity of partnerships,
continued roles of youth beyond their initial work, and
the impact on youth and community over time (Balvanz
et al., 2016).
Number of Photovoice Goals Met by Projects and
Alignment With Emancipatory Research Principles
(Supplemental Table S5)
Of the 39 unique projects, 17 addressed all three pho-
tovoice goals, 12 addressed two, and 10 addressed only
one. All the projects met the goal of enabling partici-
pants to record and reflect their community’s strengths
and concerns. While researchers held discussions with
participants about their photographs in almost all pro-
jects, in most of the 11 projects that did not meet the
second goal of engaging large and small groups in criti-
cal dialogue, they did not go beyond these small dis-
cussions. Though we used a very flexible definition for
“policy makers,” the majority (22 of the 39) did not meet
the goal of reaching policy makers. By our assessment,
24 of the unduplicated projects were aligned with all
three of the principles of emancipatory research includ-
ing reciprocity, gain, and empowerment, while five were
aligned with two of these principles.
>>
Discussion
The implementation of photovoice within health-
related research has continued to increase in the past
10 years. The flexibility of this method allows its appli-
cation to different health issues in a variety of groups
and settings (Wang & Burris, 1997). As noted in a previ-
ous literature review conducted by Catalani and Minkler
(2010), the many modifications of photovoice allow for
varying levels of community involvement and engage-
ment on the community-based participatory research
project participatory spectrum. These modifications
meet the unique needs of different research teams but
there are unanswered questions as to how these changes
may have affected and/or hindered the community
members in becoming change advocates in their com-
munities.
This review confirms photovoice as a valuable tool
for health promotion. All the projects focused on issues
related to health and/or its social determinants, with the
majority identifying health equity concerns that would
need to be incorporated into any health promotion inter-
ventions planned. For example, projects found normative
attitudes related to homophobia (Hall et al., 2018), drug
trafficking and substance use (Salerno Valdez et al., 2019),
and teenage drinking (Brazg et al., 2011). Other projects
gained knowledge that will inform future disease pre-
vention activities including the Native Hawaiian model
of drug prevention (Helm et al., 2015), perceptions of
Fountain et al. / PHOTOVOICE PROJECTS WITH YOUTH 773
cardiovascular disease among their African American
adolescent participants (Kowitt et al., 2015), environ-
mental factors affecting their participants’ health (Mmari
et al., 2014), food access (Riggsbee et al., 2019), and
smoking (Tanjasiri et al., 2013), and targets for local HIV
prevention efforts (Woods-Jaeger et al., 2013). All these
findings represent the emancipatory research principle of
“gain” for the researchers, and if they lead to changes in
communities, for the participants also.
Young people need to have a voice when changes that
affect them are being made within their communities,
in policies, or at the system level. Having their voices
represented in research can provide adult researchers
with a better understanding of the real-world issues that
youth are facing, which could otherwise be misunder-
stood or missed entirely (Cunningham & Rious, 2015).
Photovoice projects among youth give these partici-
pants a chance to discuss and bring attention to issues
that directly affect them and potentially lead to needed
change. Indeed, the power of young people to make an
impact when mobilized should not be underestimated.
They have been on the forefront of the climate change
movement and other social movements organizing social
media campaigns, protests, and so on (Panaligan, 2019;
Sengupta, 2019; Stauffer, 2019). Such examples illus-
trate the eagerness and ability of adolescents to be com-
munity advocates and directly counter the stereotypical
descriptions of adolescents being lazy, self-centered, and
complacent (Cunningham & Rious, 2015). In Listening
to the Voices of Young People: Implications for Working
in Diverse Communities, Cunningham and Rious state,
“[the] youth voice has the potential to illuminate condi-
tions and issues that adults may never have considered,
thereby creating avenues for positive structural change.”
Only six of the 39 projects reviewed attempted to
assess the participants’ experiences, with only one of
these six conducting a 10-month follow up with partici-
pants. Use of photovoice appears to promote participant
empowerment; however, the literature does not consist-
ently identify how this outcome was measured nor if it
was sustained after the end of the project. Catalani and
Minkler (2010) noted the same concerns in their review,
and this continues to be an area that warrants future
consideration.
Overall, the projects were not prescriptive; they gave
their participants the freedom to take the pictures that
represented the topic or research question from their
perspective. This practice, in addition to the practices
of allowing participants to decide what pictures they
wanted to share and having them take the lead in dis-
seminating their photographs and their stories about
them, exemplify the emancipatory principle of reciproc-
ity. By having participants interpret the topic in their
774 HEALTH PROMOTION PRACTICE / November 2021
own individual way, the researchers also gain a better
understanding of the lives of the participants. On the
other hand, in projects where the researchers identified
themes without participants, they may have misinter-
preted the participant’s photo and narrative and biased
their results.
Photovoice and emancipatory research seek to
empower participants to be change advocates with the
final objective of policy or community change. In the
Mountain Air Project, one participant expressed their
desire for the findings to be shared with their commu-
nity and another said: “I feel proud to have been a part
of something so active. I hope it will result in change”
(Cardarelli et al., 2019). The “Health in my Community”
project participants shared that the project “affected
my perspective of what is my community,” and they
felt they were “helping and doing something good”
(Madrigal et al., 2014). Photovoice has the potential to
activate and amplify youth voices in their communities
resulting in various levels of change from personal to
institutional.
We included documentation of outcomes in our
review. These data provide a strong rationale for the use
of photovoice both as a tool for empowerment of youth
and also for providing data and motivation contributing
to changes in policies, community awareness about an
issue, and individual level empowerment of other youth
and adult community members. The most recognized
outcome of the projects was an increase of community
awareness of the issues identified in their projects. This
finding leaves unanswered questions about how long
this awareness lasted. As previously mentioned, long-
term follow up may provide additional outcomes to the
study and the sustainability of the community momen-
tum toward change.
In fact, the results of the photovoice project raised
stakeholders’ and community members’ awareness
in nine of the projects. Researchers reported that the
knowledge gained would help them in developing and
implementing future interventions in six of the projects.
Community change and/or action was taken in eight
of the projects, while policy change specifically was
taken in four projects. New partnerships were devel-
oped through one project, two projects have the intent to
implement a pilot project using the students as partners
in the future, one project reported changing a hospital
form to become more culturally appropriate, one project
reported the creation of an organization guidebook, and
another reported that the participants were interested in
a career in research. Empowerment, one of the criteria
of emancipatory research, was reported in nine of the
projects and interestingly, only four of these reported
reaching policy makers.
 A limitation commonly mentioned by authors was
their projects’ small sample sizes. However, we believe
the value of photovoice is as a tool for learning about
specific communities and the perspectives and lived
experiences of those participating. In its best form, it
can serve as both an intervention and a qualitative data
collection method that can have value even when small
numbers are involved.
No single set of strategies will work best for every pro-
ject. Projects should be tailored to fit the topic and par-
ticipants. Many of the articles we reviewed did not assess
the participants’ experience, leaving open the question
of the nature and extent of individual level empower-
ment the project achieved. While nine projects stated
that the participants were empowered, we suggest that
future projects include stronger measurement of empow-
erment. Such measures might include qualitative data
on what parts of the project the participants felt were
most empowering, whether their empowerment was long
term, and whether any actions were taken as a result.
Though it was beyond the scope of our review, it would
be interesting to know which of these projects served as
a foundation for longer term interventions and outcomes.
>>
Conclusion
In this review of photovoice projects implemented
with youth, we found a variety of methods of recruitment,
designs, and project outcomes. No one method is suit-
able for all project topics and communities. Photovoice
projects should continue to be designed specifically
to fit the needs of the specified population to enable
the community and participants to achieve the greatest
benefit from the project. Future research is needed to
study measures of empowerment and long-term impact.
Photovoice is an effective tool for identifying needs of
the community, raising awareness of critical issues, and
improving policies and programs affecting youth and
their communities.
ORCID iD
Sarah Fountain https://orcid.org/0000-0003-3504-5535
Supplemental Material
Supplemental material for this article is available at https://
journals.sagepub.com/home/hpp.
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