Using Photovoice to stimulate critical thinking: An exploratory study with Nursing students*

Objective: to explore the potentialities of the Photovoice methodology to stimulate critical thinking on Social Determinants of Health. Method: an exploratory and descriptive study with a qualitative approach, using different steps of the Photovoice methodology. Nursing students obtained photographs in their community, showing Social Determinants of Health, analyzed and classified the photographs, and exposed the results in the Nursing school. The students answered a questionnaire writing their perceptions. The data collected from the questionnaires were qualitatively analyzed. Results: 91 students participated in the study. Two main categories emerged from the data: Photovoice is a good methodology to stimulate critical thinking on Social Determinants of Health, and Photovoice is a good methodology to stimulate other skills (expressing beliefs and perceptions, stimulating creativity, developing research skills, strengthening ties with colleagues, and attracting attention). Conclusion: we explore the potentialities of the Photovoice methodology. It can be an original, simple and economical tool to stimulate critical thinking on Social Determinants of Health, and to stimulate other skills. Photovoice can be considered in teaching about aspects related to health/care in Nursing students, in order to promote critical thinking of future agents for a change in health.

The World Health Organization (WHO) asserts that the SDHs are mostly responsible for health inequities, for the unfair and avoidable difference in health status seen within and between countries. The key concepts are employment conditions, social exclusion, public health programs and social determinants, women and gender equity, early child development, globalization, health systems, measurement and evidence or urbanization (15) .
Global initiatives (16)(17) have considered these social factors in their programs, in order to eliminate health disparities.
Regarding the WHO recommendations for health professionals, it seems to be interesting to address SDHs in the Nursing curricula and to promote critical thinking about it. Some researchers have promoted this critical thinking about the importance of the social and cultural dimension of health through the simulation method (18) or service learning (19) , for instance.
In this way, as professors involved in a subject in which SDHs are integrated in its curricula, we proposed to reinforce their contents through community observation, introducing qualitative methodologies to explore their perceptions and to promote critical dialogue.
We wonder if Photovoice will allow the students to narrate their experiences and produce knowledge about their context. The objective of the following research was to explore the potentialities of the Photovoice methodology to stimulate critical thinking on Social Determinants of Health.

Method
Design: An exploratory and descriptive study with a qualitative approach, using different steps of the Photovoice methodology (Photo-documentation, Photoelicitation, and Exhibition in gallery) (12) . In a second session (2 hours), a participatory analysis of the data was carried out (Photo-elicitation).
All the students were divided in 5 classrooms of approximately 20 students per class (91 students = 5 classes). Each classroom with 20 students was divided in groups (5 students per group). Firstly, in each group of 5, each student had to explain the 3 selected photographs to the other 4 students, using their SHOWED-based narratives. A discussion group was established, and they had to select the best 5 photographs that they thought best-reflected the SDHs of their community. Secondly, a discussion group was established between all the students of the classroom. They had to carry out a qualitative analysis of the photographs (8) , classifying them into categories.
In order to identify the categories, the professor provided the students the WHO classification on SDHs.
To ensure saturation of the data and of the categories emerged, the topics were compared and confirmed by all the groups of students. Considering that this research aimed to explore the potentialities of the Photovoice methodology in order to stimulate critical thinking, we created a questionnaire to be filled out by the students (paper). In it, they had to write their perceptions about this Photovoice experience.

Results
All the students enrolled in the subject (a total of ninety-one) participated in the Photovoice experience and answered the questionnaire. They were from 19 to 37 years old, 71 of them were female, and 20 were men.
The results were obtained from a qualitative analysis of the questionnaires, of the notes obtained from the field notes (observation of the participants), and of the photographs.
Two main categories emerged from the data: Photovoice is a good methodology to stimulate critical thinking on SDHs, and Photovoice is a good methodology to stimulate other skills. In Matrix 1 we can see the categories and subcategories emerged from the data.
Moreover, we showed some representative photographs and meaningful units that emerged from the data, as examples (Figure 1).
Following the definition from the WHO, the students classified all the photographs in 10 categories, corresponding to employment conditions, social exclusion, public health programs and social determinants, women and gender equity, early child development, globalization, health systems, measurement, and evidence or urbanization.
In this way, on one hand, they realized which the SDHs are in the communities that interfere in health. Moreover, all of the photographs were placed on an Individual, Community, or Socio-cultural/environmental level. To realize different points of views of the same determinant/situation "It has allowed me to appreciate other ways of seeing the same thing, since, in the sharing, everyone saw a photo with a different nuance" "It has made me reflect on the amount of things that a photograph can tell me, even the amount of things that I can tell the others, an image has a great impact on people" (C79)

Discussion
We found some Nursing research highlighting the use of photography as a valid tool to encourage reflective learning experiences about aspects related to health (7,23) .
Using photographs (not pre-existing photos, but photographs taken by students, as in our study), some authors (6,24)