Photovoice: method experiment research with adolescent mothers

Photovoice: experiencia del método en investigación con madres adolescentes

Abstract

Objective:

To report on the development of the phases of the photovoice method in qualitative research with adolescent mothers who were experiencing or experienced breastfeeding and/or weaning.

Method:

Twelve individual interviews and one focus group were conducted.

Results:

The photovoice was developed in the phases: Identification of the political decision makers in the community with some community leadership profile; Recruitment of participants; Introduction of the methodology to the participants; Obtaining informed consent; Identification of the theme (s) for the photographs; Distribution of cameras and review of their handling; Provision of time for the registration of photographs; Meeting (s) for discussion on photographs and identification of community resources and issues; Shared planning of the dissemination formats of the images and stories produced.

Final considerations and implications for the practice:

Photovoice stands out as a way to approach health professionals with the life circumstances of adolescent mothers, in order to promote and support breastfeeding.

Keywords:
Adolescent; Breastfeeding; Nursing; Methods

Resumen

Objetivo:

Informar la experiencia del desarrollo de las fases del método photovoice en investigación cualitativa junto a madres adolescentes que estaban vivenciando o vivenciaron el proceso de lactancia y/o de destete.

Método:

Se realizaron 12 entrevistas individuales y un grupo focal.

Resultados:

El photovoice fue desarrollado en las fases: Identificación de los responsables políticos en la comunidad con algún perfil de liderazgo comunitario; Reclutamiento de las participantes; Introducción de la metodología a las participantes; Obtención del consentimiento informado; Identificación de tema(s) para las fotografías; Distribución de las cámaras y revisión de sus manipulaciones; Ofrecimiento de tiempo para el registro de las fotografías; Encuentro(s) para discusión sobre las fotografías e identificación de los recursos y problemáticas comunitarias; Planificación compartida de los formatos de diseminación de las imágenes e historias producidas.

Consideraciones finales e implicaciones para la práctica:

Se destaca el photovoice como medio para acercamiento de los profesionales de salud con las circunstancias de vida de las madres adolescentes, para actuar en la promoción y apoyo a la lactancia.

Palabras-clave:
Adolescente; Lactancia Materna; Enfermería; Métodos

Resumo

Objetivo:

Relatar experiência do desenvolvimento das fases do método photovoice em pesquisa qualitativa junto a mães adolescentes que estavam vivenciando ou vivenciaram o processo de amamentação e/ou de desmame.

Método:

Realizaram-se 12 entrevistas individuais e um grupo focal.

Resultados:

O photovoice foi desenvolvido nas fases: Identificação dos decisores políticos na comunidade com algum perfil de liderança comunitária; Recrutamento das participantes; Introdução da metodologia às participantes; Obtenção do consentimento informado; Identificação de tema(s) para as fotografias; Distribuição das câmeras e revisão de seus manuseios; Oferecimento de tempo para o registro das fotografias; Encontro(s) para discussão sobre as fotografias e identificação dos recursos e problemáticas comunitárias; Planejamento partilhado dos formatos de disseminação das imagens e histórias produzidas.

Considerações finais e implicações para a prática:

Destaca-se o photovoice como meio para aproximação dos profissionais de saúde com as circunstâncias de vida das mães adolescentes, para atuarem na promoção e apoio à amamentação.

Palavras-chave:
Adolescente; Amamentação; Enfermagem; Métodos

INTRODUCTION

Scientific research on adolescents is increasing, and this exposure is often paradoxical, as it is sometimes highlighted by social exclusion, proclaimed marginality and criminality, and sometimes by the transformative potential, social participation, in the family, in the school and community.¹

Considering that many adolescents experience problems of inequality, exclusion, discrimination and situations of vulnerability, understanding and reflecting on adolescents' perceptions and their social context is a challenge and exercise in order to understand and transform health practices, especially nursing ones, seeking to observe, through and beyond their interfaces, their meanings, proposals for intervention and prevention. These processes require new knowledge and proactive actions that are capable of generating collective awareness and commitment to adolescent health.²

The process of adolescence under the systemic and constructivist view is in focus, in which the adolescent is considered the subject of this process and seen within its singularities and needs, and also in its interrelationships with its family and social environment, in a given historical and social time/moment.²

The theoretical and methodological basis was based on the photovoice method, conceived as a flexible research method that can be adapted to different research themes and has been used with several marginalized populations, such as refugees, homeless children,³ underrepresented or stigmatized oppressed groups, because it offers the opportunity for individuals to reveal their concerns⁴ and gives the researchers greater understanding of the subject under study.⁵

The term photovoice was originally proposed by Wang and Burris in the early 1990s.³ This method was proposed in order to describe the narrative-photography approach to explore community issues; however, this methodology has been deepened and is also used to express needs, history, culture, problems and desires.^4,5Photovoice is a qualitative research method that allows the visualization of individuals' perceptions about their everyday realities.^3,5

Participants are invited to present their point of view through photographs, providing a mechanism to see and understand the perceptions of health or the social problem that must be addressed, discussing and often identifying innovative solutions to problems. Stories from photographs can provoke intuitive reactions that can promote action on community issues.⁵

Photovoice also incorporates fun, creativity and collaboration in a way that encourages the participation of adolescents.⁴ In the case of adolescents, this method can be a stimulus in the sense that they can express questions about their life circumstances. In the context of photovoice, this experience report privileges them as creators and not only as recipients of images.

Considering that conception, the meaning that adolescence historically acquires, is certainly determining its actions in relation to breastfeeding. It is fundamental to understand their experiences, so that it is possible to deal with the subjective issues of this process. These depend on their own particular experiences and their socio-cultural reality, in order to transform the relations established with the adolescents, in the sense of including them as active partners and conducive to changes necessary to our society.

The use of the photovoice method in this experience report is intended to give support for a better understanding of the subject under study and for health professionals practices, so that they can act in a significant way in the promotion and support to breastfeeding, extending the duration of breastfeeding and the satisfaction of the mother-child binomial.

Society attributes an underestimated capacity of the adolescent to care for a child. Regardless of age, pregnancy involves interpersonal and social readjustments in order to adapt to motherhood, especially in adolescence,⁶ which implies developing abilities to care for the child, including feeding.

Breastfeeding is an important feeding strategy for the reduction of infant morbidity and mortality, and the World Health Organization recommends exclusive breastfeeding for up to the first six months of life and then supplemented up to two years or more. Among the benefits brought by the practice of breastfeeding, include: lower incidence or severity of infectious and diarrheal diseases; improvement of intellectual, educational and income levels in adulthood; economic benefits for the family and advantages for the mother, such as less possibilities of developing breast and ovarian cancer. It also contributes to: equity, which enables all children to have a nutritional advantage for success in life; reduction of welfare expenditures, and the social and economic development of a country by increasing the educational and intellectual level and, consequently, productivity.⁷

The objective of this study was to report the experience of developing the phases of the photovoice method in a qualitative research with adolescent mothers who were experiencing or had experienced the process of breastfeeding and/or weaning.

METHOD

This is an experience report that occurred during a Nursing Post-Graduation, Doctorate course, addressing the development of the phases of the photovoice method with adolescent mothers, which was approved by the Research Ethics Committee of the Nursing School of Ribeirão Preto, University of São Paulo and by the Health Department of the city of Ribeirão Preto, by means of the Certificate of Presentation for Ethical Approval Protocol CAAE No. 50437515.2.0000.5393, on February 5, 2016.

Two fields were used as the study scenario: the adolescent mothers' residence and two health units, located in the southern district of the municipal health network in the city of Ribeirão Preto, SP, Brazil. Twelve teenage mothers between 13 and 19 years of age participated in the study. For the most part, the research was developed, in the participants' residence.

Twelve individual interviews and one focus group session (with three of these participants) were conducted, together with adolescent mothers of infants or children up to two years of age, living in the city of Ribeirão Preto, SP, Brazil, and were experiencing or had experienced the process of breastfeeding and/or weaning. Participants were included in the study according to the attendance at routine primary health care level medical or nursing (childcare and post-natal) appointments.

The number of participating mothers was determined by the data saturation. The saturation or recurrence of the data is characterized by the "The knowledge formed by the researcher in the field, which he/she was able to understand the internal logic of the group or of the collectivity under study."^8:197-8 According to the same author, the configuration of the group of participants is ideal when it reflects the totality of the multiple dimensions of the object of study. Therefore, the data collection was concluded when sufficient and consistent data for the work was attained. The data collection period occurred from March to December 2016, and the focus group was held in February 2017.

This study was developed using the photovoice method, with the production of photographs by adolescent mothers, followed by reflection on the images produced.

DEVELOPMENT OF PHOTOVOICE WITH ADOLESCENT MOTHERS

The development of the phases of the photovoice method with adolescent mothers is based on nine phases, which were adapted^3,9 for this study, as described below:

1. Identify political decision makers in the community with some community leadership profile

In this first phase, it is important to build a connection between the researcher and the community in order to obtain the data and a solid basis for developing the project. The researcher can share ideas, offer feedback and answer questions, in order to establish a trusting relationship between the researcher and the community, generating a more meaningful participation.⁹ The community, in this case, refers to adolescent mothers and to the health team of the southern district of the municipality of Ribeirão Preto, SP.

The most participative photovoice projects tend to be associated with long-standing relationships between researchers and the community.¹⁰ The development of a connection between the adolescent mothers and the researcher was facilitated, since the researcher already carries out work activities with the Health Units approved for this search. A meeting was held with the researcher and the studied community (adolescent mothers residing in the southern district of the city of Ribeirão Preto, SP) and the health team (managers, nursing technicians, nursing assistants, nurses, pediatricians and gynecologists) of the various Health Units (pediatrics, gynecology, nurses' clinic and vaccination rooms), in order to generate a relationship and improve ties.

2. Recruit participants for photovoice

At this stage, the specific details of the photovoice are planned. The researcher takes the lead in the activities, selects the place for the development of the research, develops the activity schedule, organizes equipment and the location for the group meeting, estimates possible problems and establishes the research financial budget.⁹

The researcher selects the type of camera to be used in photovoice. Disposable cameras that come with film and a flash are a good option.⁴ Researchers purchased single-use flash cameras and already had a portable device (Media Players - MP3) for audio recording of sessions. The possibility of using more films, if the participant desired was also explained. No participant requested a new camera.

3. Recruiting the participants for photovoice, introduce the photovoice methodology to the participants and facilitate a group discussion on image, power and ethics

At this stage, the researcher recruits the participants to the study, which involves attracting people from the studied community, inviting them to participate in the photovoice and explaining the research objectives, the details of each step of the photovoice method, identification issues and ethical aspects.⁴ This information was provided to the study participants at the first meeting.

Participants have the responsibility to record photographs that can educate others according to the social theme of the research.⁴

At this stage, some questions are discussed, such as: What is the acceptable way to approach someone who you wish to photograph? Should photographs be obtained from people without their consent? When would you like to be photographed? To whom can you show your pictures? What impacts are caused?³

Photovoice is a method in which cameras are entrusted to people who can act as photographers in order to help people see the world through their eyes. At the end of the first meeting, a camera was provided to study participants who were instructed to take photographs for ten days, according to the theme: "What can facilitate and what can disrupt the breastfeeding of your child?". They were also instructed on the handling and basic techniques of obtaining the images with the photographic camera.⁴

Ethical issues were explained to the participants regarding the responsibility and authority assigned to them as photographers in possession of a camera.

It is important to highlight that 41 adolescent mothers who were waiting for the doctor or nursing consultation in the waiting room of the Health Units accepted to participate in the research. However, 12 teenage mothers actually composed the group of participants in this study. It is important to highlight the difficulty of this initial phase (recruitment) of the research, in which there was a certain refusal to participate in it. It was noted that those who refused to participate were very concerned about their child and perhaps this is the great reason for refusal to participate in the research. Some of the reasons reported for such refusal were: lack of time, as taking care of the baby and household activities consumed a lot of time; participation in the research would depend on their partner's acceptance; lack of skill and/or creativity to take photographs.

The majority of the study participants declined to use of the camera and preferred to capture the photographs with their own cell phone and send them to the researcher through the WhatsApp cell phone application.

4. Starting photovoice - obtaining informed consent

During this time of photovoice, the implementation of the project plan occurs by establishing the meeting schedule.⁴

Issues such as, safety, authority, and responsibility that participants must possess are emphasized when using a camera to transmit their messages.⁹ Ethical principles should be respected when recording images, such as refraining from infringing individual privacy, as photographs will be a true representation of the problems, which can include photographs of people and they must always be treated ethically.⁴

Researchers should inform participants about the responsibility to respect the privacy and rights of individuals. The researchers followed this recommendation and therefore the adolescent mother was informed that privacy and the rights of the people had to be respected, adding that they could only take photographs of people from the neck down and it was not allowed to photograph the faces of people. Participants complied with this recommendation.⁴

Thus, in order to use photographs that include people, authorization was requested by means of the Image Use Agreement.

Before starting the interview, the researcher presented the appropriate consent form to each type of study participant, these included; the Informed Consent Form for the adolescent under 18 years of age; The Informed Consent Form for those responsible for the adolescent and the Informed Consent for the adolescent over 18 years of age, the researcher then obtained the signed consent forms from all participants.

Also, the telephone number of one of the researchers was made available to the participants, which allowed the participants to contact the researcher as needed, at no cost.

Photovoice is usually performed with socially marginalized individuals. In addition to this vulnerability, examining the problem in question may generate feelings of concern and/or frustration with the individuals' life or with the social issues of their community.⁴ Most of the adolescents who directly or indirectly participated in the research revealed their dissatisfaction with their socioeconomic conditions, and some have revealed that they have no prospects for a better future for themselves and their child/ children. The researcher contacted the social assistance service from the municipal health network for the specific cases of two adolescent mothers. The same authors state that exposing these emotions shows personal growth and change can be painful. It is necessary for the researcher to plan in advance and to know how this situation can be approached and discussed. As, the fact that the adolescent mother is experiencing emotional discontent can have influences on her breastfeeding process.

5. Identify one or more subjects for the photos

At this stage, the participants thought about the research questions and determined what they wanted to photograph. Subjects should be oriented about the focus of the research, the objectives of the study, the role of each individual in the group and informed consent.⁴

Adolescent mothers were encouraged to photograph situations that will be used to educate, sensitize and understand the research theme⁴ (the aspects that facilitate and hinder the breastfeeding process in their daily lives).

Participants must be willing and interested to openly share their experiences with the participating group and eventually with the public.⁹

As the photovoice progresses, participants will improve their skills and confidence as photographers and information creators.⁴ Most of the participants in this study reported initial difficulties in knowing what to photograph. This type of difficulty can occur.⁴ The subject was approached in a sensitive manner by the researcher, the participants were encouraged and examples of potential photographs and methods were given to the participants as well as a discussion about how to overcome this difficulty.

6. Distribute the cameras to the participants and instruct them regarding their handling - collecting the data

This phase portrays the data collection that begins with the execution of the research and continues until the phase of sharing the photographs, followed by the data analysis.⁴

After acquiring the cameras, the researcher made them available to the study participants. After obtaining the images from the participant, the researcher revealed the photographs. If the adolescent wished to obtain the images with their own cell phone, they were informed about this possibility and for this to be permitted, the adolescent signed the Refusal to Use the Photographic Camera Form. In this case, the adolescent sent the images to the researcher through the WhatsApp cell phone application. The majority of study participants declined to use the offered camera and preferred to send the photographs to the researcher through this application.

7. Provide participants time to capture the photographs - analyzing the data

The participants who chose to use the camera, used it for one week on average; participants who chose to send the images through the WhatsApp application sent pictures for an average of three days. This enabled the capture of a total of 94 photographs. An average of seven photographs per participant were captured, with two being the minimum amount and nineteen being the maximum amount. Some photographs that were not clear or duplicated were excluded. It was noted that adolescent mothers between 13 and 17 years of age had a tendency to capture fewer photos compared to older adolescent mothers (18 and 19 years of age).

No limit was set for the number of photos, and participants were instructed that only a few photos would be discussed in the interview. Participants were asked to photograph pictures that answered the research questions: What facilitates or facilitated breastfeeding your child? What makes it difficult or made it difficult for you to breastfeed your child?

Next, data analysis begins, in which images are selected that accurately portray the research objectives and are used to guide the interview with the participant and should be categorized for the group discussion.⁴ Asking questions can guide this choice, such as: What did you exemplify here? What really happened in this image? How is this picture related to your life?⁹

This interview aims to obtain the stories about some of the photographs. The researcher started with the photograph that was most significant for the adolescent. The interview continued until the participant verbalized that she would like to finish the interview or until the depth of the questions was reached. In some cases, all the photographs referring to each participant were discussed. The researcher asked a number of questions about the photo, as addressed by Nykiforuk, Vallianatos and Nieuwendyk (2011)⁵ and Wang (1999), for example³: What do you see in this photo? Why is this image important to you? What is really happening in this photo? Why does this problem or concern exist? What can we do to improve or solve this?

For this study, it was noticed that the individual interview allowed a more in-depth exploration of the issues of interest.⁵ This interview aims to get the stories about some of the photographs. The researcher started with the photograph that was most significant to the adolescent. The interview continued until the participant verbalized that she wanted to end the interview or until the depth of the questions was reached. The researcher asked a series of questions about the photo, for example: What do you see in this photo? Why is this image important to you? What is really happening in this photo? Why does this problem or concern exist? What can we do to improve or solve this?^3,5

Next, there was discussion of the photographs in which the participant was questioned about her experiences with her participation in this research and how their participation had an impact.

After the conclusion of the interview, the researcher offered the participants a copy of their photographs, free of charge. One participant accepted the copy of their photos.

8. Encourage a meeting/meeting to discuss photos and to identify community resources and issues

In this phase the participants are gathered in a group and the images are displayed and discussions and exchanges of experiences are carried out on the addressed topics.⁹ The focus group is one of the group techniques most used in qualitative research, which constitutes of a type of interview or conversation based on the interaction between the participants, in small and homogeneous groups.⁸

One of the challenges faced by the researchers in the planning of the development of the research, was whether or not to adopt the focus group technique, as regardless of knowing that it would be a valuable method in data collection, and financially feasible as well the possibility of obtaining valid and reliable data in shortened time, it would be difficult for the participants to join the group sessions.

For this phase of photovoice, the ideal number of participants relative to the group meeting ranges from seven to ten, since they are sufficient for each person to contribute significantly in the exchange of experiences and ideas.³

There was a difficulty in bringing the participants together for the focus group. Initially a meeting with the 12 participants was scheduled, through telephone contact, of which seven were confirmed. On the day of the meeting, only one attended, and then another meeting was scheduled with 11 participants, as it was not possible to contact one participant. From the contact with the adolescents, nine confirmed the participation on the scheduled day and time, however only three adolescent mothers attended and participated in the focus group, which allowed the maximization of the depth of expression of each one of them.

The focus group is a qualitative methodology research that aims to collect information about a specific topic that can provide the exchange of experiences, concepts and opinions among the participants. It gives rise to discussions and elaborates group tactics in order to solve problems and transform realities, based on learning and exchange of experiences on the subject investigated, enhancing the protagonism of the participants as they collectively dialog and construct the results of the research.¹¹ Therefore, the focus group in this study was based on the following theme: what facilitates and what makes the breastfeeding process difficult for adolescent mothers.

For the meeting, the researchers separated the photographs between facilitating factors and factors that hinder the breastfeeding process. The discussion was stimulated from the presented photographs. The researchers acted as moderators and created a favorable environment, so that the discussion provided the expression of different ideas and points of view.

The focus group meeting took place in a room attached to one of the Health Units, in a place that was easily accessible to the participants (close to their residence), safe and comfortable and at a time which was previously scheduled with them. Their statements were recorded on two electronic devices, generating MP3 files. Two digital recorders were used in order to fully record the participants' discourses and also as not to risk losing the material by using only one recording equipment.

The group meeting lasted one hour and thirty-two minutes. Typically, their duration varies from 90 (the minimum time) to 110 minutes (the maximum time) to ensure good use of the technique.¹² To facilitate social interaction among the mothers, a snack was offered with juices and cookies. Toys, diapers and children's clothes were also distributed to participants as a way of thanking them for their contribution to research. The expenses were covered by the researcher.

The focus group allowed the participants to listen to the life history of each participant, share their own history and identify common and divergent aspects, as well as to know the way each participant coped with the research questions.

9. Shared planning of dissemination formats of photographic images and the stories produced

In this last phase, the presentation of the photographs could be carried out through various means and strategies with the objective of disseminating the works, stories and recommendations to local community members, leaders and politicians⁹ in public sessions, local, national and international events, ensuring the anonymity of the participants.

The publication of the data of this work and the presentation in scientific events, as well as in communities, comply with this phase.

FINAL CONSIDERATIONS

Considering that we viewed adolescents as marginalized or socially stigmatized groups, the development of the photovoice method provided benefits to the participants, it gave them the opportunity to express their needs, to reveal their life history, to highlight sociocultural aspects that influence their decisions and life plans, to demonstrate problems that are responsible for the life conditions which they are subjected to and to reveal their future desires, perspectives and plans.

Some difficulties were encountered in the implementation of the method, such as recruitment for research and difficulty in bringing adolescent mothers into the focus group. These barriers were resolved by extending the data collection to another location and having flexible date and time for the next meeting.

In the search for a broader understanding of the context of the adolescent mother's daily life, the photovoice method is a positive component, since it has given us discoveries about important issues from their point of view, especially regarding their singularities and needs. It also provided a greater understanding and involvement with the life context of the adolescent mother, as aspects that hinder and facilitate breastfeeding from the perspective of the mother were revealed.

We consider that the approach of the researcher in the residence of the participants made it possible to understand the life context of the adolescent mother and her family, the knowledge of their practices and beliefs and the evaluation of the environmental and housing conditions, as well as providing a greater connection between researcher and participant. The results of this experience make us reflect on user embracement issues and lack of space for the adolescent mother to express herself.

It is concluded that the photovoice method can be used as a way to approach health professionals with the life circumstances of adolescent mothers, in order to know what they consider important in order to act in a significant way in promoting and supporting breastfeeding. It is suggested that the professionals incorporate the use of photographs of the reality of the adolescents and of their locality in the approach and the interactivity with these young people and that they try to insert real aspects of the life of the adolescent in their work through the use of interactive devices.

This study contributes to the continuity of the development of scientific knowledge in adolescent health and encourages the reflection of society on the integral attention to their needs. For this, a new nurse profile must emerge, capable of transforming the approach with the adolescent mother.

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Publication Dates

• Publication in this collection
  2018

History

• Received
  25 Oct 2017
• Accepted
  17 Jan 2018