Research methods for people-centred health systems: Photovoice

By Jeff Knezovich, FHS Policy Influence and Research Uptake Manager, Institute of Development Studies

In our previous blog post introducing how FHS approached the Third Global Symposium on Health Systems Research, we highlighted the thematic focus of the symposium is 'people-centred health systems'.

FHS has been working for some years to put people first when it comes to health systems, whether it be through understanding how people actually use new technologies, such as in our project on health information seeking behaviour in Bangladesh, or working with communities in Afghanistan to rate and improve their health services through community scorecards.

But putting people at the centre of health systems also means finding different research approaches to studying health systems strengthening. We're profiling a few methods during the symposium. And today's focus is on photovoice.

A bit about photovoice

Photovoice is a visual research methodology through which people can represent, and enhance their community by photographing their daily lives and the lives of those around them. It is a qualitative and participatory research method that aims to capture what occurs when researchers are not necessarily present. 

Following a range of trainings – on how to use digital cameras, how to approach a picture subject, and getting people’s consent – study participants use the cameras provided to them to capture photographs and moments that are relevant to the research study. These photos are then discussed, often in a group, to highlight particular photos and to explain their particular relevance to the topic at hand. In many cases, these photographs then also serve as a key part of the communication strategy of the research project.

How FHS has employed photovoice

Although this is a relatively new approach for us, The Future Health Systems consortium has already used the photovoice technique in two of our focus countries: Uganda and India.

In Uganda, as part of the FHS young researcher grant, David Musoke worked with select youth in a community in rural Uganda to document issues related to maternal and childhood health in the community. Study participants used the cameras provided to them to capture aspects and situations in their community where youth can contribute to improving maternal health for a period of five months. Monthly meetings were held between the youth and research team to discuss the photos and to identify collectively emerging themes and areas for action. See the Uganda photovoice slideshow below, or download the booklet, to see some of the results.

Health facilities in rural areas do exist

FHS Uganda Photovoice: EriaMdidde

OK, maybe it sounds obvious. But the problem isn't necessarily that there are no health care facilities for women. While a considerable number of women in Uganda do choose to give birth in their homes, it isn't necessarily because of a lack of facilities.

Despite stories of limited numbers of qualified health workers and the poor attitudes these workers can take towards pregnant women, they manage to serve many women and children.

Pictured here is a pregnant woman who is smiling after having received adequate care at a local health facility.

But that doesn't mean they're easy to get to!

FHS Uganda Photovoice: Denis Mpiima Mukooza

To reach health facilities and trained health workers, women from this particular village in Central Uganda must travel over 7 kilometres (5 miles). It takes both time and money to travel there, which limits the number of antenatal and post-natal visits expectant and new mothers make.

A common way to get to the health facilities is on a hired motorcycle, known as a bodaboda. These motorcycles are convenient, and they're one of the few means of transportation that can navigate the rugged terrain, but they're not a particularly safe way to transport pregnant women. But there is little choice.

In this picture a mother takes her young child to a health centre for an immunisation.

Getting there is half the challenge, getting seen might be just as difficult

FHS Uganda Photovoice: John Ssewadda 

After walking or taking a bodaboda to get to a facility, many would think that the hard part is over. But getting to a facility is just the first problem an expecting mother might face: often pregnant women must wait several hours for a consultation.

Here, two pregnant women lay on the grass outside the health centre waiting for the health workers to arrive.

'Free' doesn't really mean 'free'

FHS Uganda Photovoice: Annet Nakayima

There are costs associated with getting to a health facility, but the Ugandan government says that health services provided at government facilities should be free. Apparently the Ugandan government doesn't define 'free' the way the rest of the world does.

Because of limited funding from the government and from international sources, many facilities are forced to charge for basic materials like latex gloves. In cases where women were expecting that they wouldn't need to pay, or who are simply too poor to pay, this can result in death.

In this picture, a woman counts money collected in a local savings group which can assist members when in need particularly pregnant women during time of delivery.

Many don't know about the risks of early pregnancy

FHS Uganda Photovoice: Anthony Mpanga

Teenage pregnancy is associated with greater complications for both the mother and child, which can often result in death. But in Uganda, the median age for a mother at first birth is 18.6 years.

Pictured here is a pregnant teenager who is also carrying her first child in her arms.

And there is still limited use of contraception

FHS Uganda Photovoice: Roger Mubiru

Although several methods for contraception are available in Uganda, many couples do nothing to space their children. This is partly due to lack of awareness and availability of contraceptive services at many health facilities particularly in rural areas. The country’s unmet need for family planning among married women is currently 34%.

In this picture are two siblings who can be mistaken to be twins, which is an indication of lack of use of family planning methods. As the older is only learning how to crawl, the young one is starting to sit.

There remains low male involvement

FHS Uganda Photovoice: Annet Nakayima

The Ministry of health has made efforts of increasing male involvement in maternal and child health issues. Indeed, pregnant women who are accompanied by their spouses to public health facilities for antenatal care are attended to first before those who are alone. However, male involvement is still very low.

Here, a pregnant woman not accompanied by their spouse for antenatal care waits to be seen by a health worker at a government health centre. 

Being pregnant doesn't mean there's relief from household chores

FHS Uganda Photovoice: Roger Mubiru

Women in rural Uganda do a lot of domestic work. This includes cultivation, washing clothes, cooking, fetching water and other household chores. One would imagine that when these women are in their final weeks of pregnancy and soon after delivery, they are relieved of some of these strenuous duties. However, this is not the case in most households.

In this picture is a pregnant woman a few weeks from delivery as she was from collecting water from a distant water source for household use.

In India, researchers worked with women's groups in the Indian Sundarbans of West Bengal to document the interplay between climate, health and resilience there. The focus remained mainly on maternal and newborn health. The participants mainly sought to capture images that explain how a changing climate affects their daily livelihoods, barriers that exist to accessing health services, and ways that locals are adapting to these challenges. The results are available for download in our FHS India photovoice booklet and for viewing in the slideshow below.

Meen dhara: A costly way to make a living?

Meen dhara, or prawn seed collection, is a traditional way of making a living in the community. But dirty water is becoming more of a problem, especially for women collectors. The dirty water can get inside women, causing uterine infections.

Photographer: Bandana Haldar, (Binodhpur, Kultali)

Crab catching

Crab catching is one of the few livelihoods remaining in one community,  but it’s very strenuous, risky and time-consuming.

‘Sometimes you get wounded, causing heavy bleeding... then you have sit quietly, waiting for your body to absorb the shock... then you can start working again.’

Photographer: Parul Bhakta (Satyadaspur, G-Plot)

A broken ferry ghat

This ferry landing (ghat) has been broken for last three months. This is the only way to cross the river. The mainland, where the nearest Public Health Centre is located, is on the other side.

Photographer: Sita Das (Jayasree Colony, G-plot)

The cost of medicine adds up quickly for those with chronic conditions

‘I am suffering from a chronic disease... Medicines are very costly and not always available here. I have shifted to a rural medical practitioner (RMP) who gave me medicines on credit.’

Photographer: Lakkhana Debnath (Jayasree Colony, G-Plot)

Teenage mother coddles a baby born at a low birth weight

‘The girls in our community often get married at the age of 13 or 14. The girl in the picture gave birth to a low-weight baby at the age of 16. Parents often marry off their daughters at an early age to reduce the number of family members. It’s a way of managing resource constraints.’

Photographer: Sipra Haldar (Binodhpur, Kultali)

Older children as caretakers

‘I leave my younger child with the older one. I know it is very risky but we have to sustain.’

Photographer: Bornali Giri (Nogenabad, Kultali)

Discussing findings with decision makers

FHS India photovoice participants meet with the local self-government (panchayat) to discuss health issues highlighted through the photovoice process.

Giving photovoice a try at HSR2014

On Thursday, 2 October 2014, FHS invited participants at the Symposium to take pictures with Instagram and Twitter and to tag them with #HSG2014PV, #HSR2014PV or #HSR2014. These were collected via Evenstagram to form our own snapshot of the Symposium for the day.

You can review the photos below or online. Let us know which ones are your favourite and why!