Whose Voice is It Really? Ethics of Photovoice With Children in Health Promotion

Abstract

Photovoice, a way of conducting research through pictures, is considered a child-friendly method to engage children in participatory research and social change but this practice can raise ethical dilemmas. These dilemmas have rarely been discussed in the literature. The aim of this article is to provide insight into the ethical dilemmas we faced using photovoice with children. It is grounded in a 4-year participatory health research project in two primary schools where we used photovoice alongside other creative and arts-based methods. We reflect critically on pressing ethical tensions and how we dealt with these dilemmas. Our logbooks and reflexive conversations were used as data sources. The findings reveal that everyday ethical dilemmas occurred throughout the project. These were sometimes anticipated but were often unexpected. Questions that arose included: ‘Who controls the outcome?’; ‘Photos to assess needs or to give voice?’; ‘Giving voice or aesthetics?’; ‘Who decides who is visible?’ and ‘Disrespectful and stereotypical representations?’ We conclude that ethical dilemmas in using photovoice with children deserve more attention to sensitize researchers and help them live up to the ideals of voice and empowerment.

Introduction

The popularity of photovoice as a child-friendly method to engage children in participatory research and social change is growing (Clark, 2010; Hennessy et al., 2010; Gibbs et al., 2018; Groundwater-Smith et al.,2015; Phelan & Kinsella, 2011; Sarti et al., 2018). Photovoice was originally developed for Chinese women (Wang & Burris, 1994, 1997), and it holds the promise of giving voice to marginalized groups, such as children. Photovoice gives children the opportunity to take pictures of what is important to them and select the most meaningful pictures to articulate their story. They can then show these pictures to adults as a prompt for further dialogue. These photographs act as tangible representations of the children’s interests and in this way, they can serve as reminders of important topics that may warrant ongoing discussions (Cook & Hess, 2007).

Photovoice is considered to be child-friendly because it is less verbally oriented than traditional research methods and thereby enhances a child’s potential to express their perspective and participate more fully in research. It is also considered an accessible method because in our visual culture children are often eager to use their smartphones or (digital) cameras and the assumption is that they are familiar with these technologies. This method is potentially powerful and empowering because children hold the camera and control what is seen and unseen, instead of being the subject of research (Cook & Hess, 2007; Groundwater-Smith et al., 2015). We define empowerment here as ‘people assuming control and mastery over their lives in the context of their social and political environment; they gain a sense of control and purposefulness to exert power as they participate in the democratic life of their community for social change’ (Wallerstein, 1992, p. 198). We agree that photovoice may be potentially empowering for children, but we also note the possibility of unintentionally disempowering effects as the notion of empowerment is a complex, relational and multi-layered (Groot & Abma, 2019; 2020).

Photovoice is driven by an agenda that emphasizes inclusion and social justice and aims to honour participants’ rights to express their voices and include their perspectives in processes of democratic decision-making (Wang & Burris, 1994, 1997). However, as Evans-Agnew and Rosemberg highlight, it often remains unclear how researchers make decisions regarding the development and dissemination of participants’ voices (2016, p. 1021). Liebenberg (2018) alerts us to the instrumental use of photovoice or when it is used as a method to gather information about participants’ lives without the underlying goal of collective action or social change. Photovoice is then stripped from its original foundation and may even re-establish existing power differentials between experts and lay people. Using the photovoice method can also raise ethical dilemmas related to the visual exposure of people, places and their privacy (Mitchell et al., 2017). Navigating the complexity of potential risks is part of the moral responsibility of researchers engaging children in research using photovoice.

Research involving children and young people raises a series of ethical questions related to harm and benefits, privacy and confidentiality, information and consent (Alderson, 2014). Who benefits? How is power distributed and (mis)used? Young children are especially vulnerable to being exploited or labelled, and they may find it difficult to defend themselves. Consent may be particularly complicated in research with children, including unresolved issues such as: should we always obtain parents’ and children’s consent? While it is for instance clear that a child’s decision not to join a research project should be respected, it is less evident what to do when children want to participate but their parents refuse. Another situation that is ambiguous concerns research taking place in schools: while every child observed or interviewed should be informed, difficulties arise when not all parents and children in the school or class have given their consent. Another underlying question is when children are old enough to be (considered) competent to consent. Again, there are no simple answers and much depends on the researchers’ views on the competency of children, the confidence of the children, the type of research, the research setting and the researchers’ ability to talk with children and help them make unpressured informed decisions. Ethics review boards encourage research teams to think about ethical questions beforehand, but cannot ensure that all problems will be prevented (Alderson, 2014).

Participatory research in general, and especially projects that involve children, demands that researchers constantly reflect on their actions, relationships, values, intentions and ethical principles and includes issues related to power sharing, voice and co-ownership. To support participatory researchers, ethical guidelines have been developed for responsible research with children and on children’s voices (Christensen, 2004; Dedding, et al., 2013; Gibbs et al., 2019; Spyrou, 2011; Warming, 2011) and for participatory health research in general (Banks & Brydon-Miller, 2019; Banks & Manners, 2012).

Ethical guidelines are helpful and important in that they can sensitize and prepare researchers for potential and expected ethical dilemmas. Photovoice ethics guidelines stress the importance of preparing participants and making them aware of the need to protect people’s privacy (Phelan & Kinsella, 2011; Wang & Redwood-Jones, 2001). For the proper use of photovoice (Creighton et al., 2018; Wang & Redwoord-Jones, 2001), it is advised to train photovoice participants in advance to ask for permission before they take a picture. It is also advised to prevent the release of images that may be perceived as embarrassing or stereotypical. Another issue is the ownership of photos and protection against the use of images for commercial benefit. In addition, Wang & Redwood-Jones (2001) stipulate that working with professional artists may raise issues related to the aesthetic and visual quality being more important than giving voice and agency to participants. More recently, Creighton et al. (2018) add to this list the ethical issues related to consent and copyright as photos can be used beyond the scope of the study, representation if participants disagree on the release of images and vicarious trauma, if photos trigger mental health issues among participants.

Participatory research and the method of photovoice depart from the notion that young people have equal opportunities to participate in research. Their opinions should be listened to in research and opportunities need to be created for genuine dialogue between young people and adult researchers (Dedding et al., 2013). There are various frameworks for research ethics involving children, including a principle or rule-based approach or a human rights approach (Alderson, 2014). We work from a care ethical approach with a focus on the lived experiences in everyday situations. The underlying notion in care ethics is that ethically sound decisions cannot be universally defined. What is ethically right depends on the particularities of a situation, and the complexity of a situation often entails a myriad of values and value-commitments. Value plurality and the involvement of various participants with their own perspectives on situations requires detailed and in-depth understandings of all values and perspectives that matter in order to determine what is the best action in a particular situation (Abma et al., 2020). This implies that ethical challenges and tensions cannot be completely prevented and regulated by ethical guidelines and principles. It is the responsibility of researchers to stay sensitive to and see ethically salient situations and act in an ethical way (Banks & Brydon-Miller, 2019).

In this article, we focus on the everyday ethical issues that arose and needed to be acted upon when using photovoice with children in a participatory research project. We chose to focus explicitly on the ethical tensions felt by the involved researchers as we intend to raise awareness and to stimulate dialogue between researchers. Our aim is to provide insights into some of the pressing ethical dilemmas that may be encountered when using photovoice with children and thereby the complexity of empowering and the potential of disempowering children through this method. Our work is situated in two primary schools in a multicultural neighbourhood that has been subjected to stigmatizing representations of poverty and what are considered unhealthy lifestyles.

Context and Design of Our Photovoice Work

The findings of this article are embedded in a project in which we used and reflected critically on the use of photovoice in a participatory health research (PHR) project with children. The first, third and fourth authors initiated and worked on the project with primary school children in an urban neighbourhood in the Netherlands. The second author acted as a critical friend (Kember et al., 1997). She was not involved during the research process itself but, together with the other authors, critically reflected on the ethical issues that occurred. The PHR project was called KLIK. KLIK refers to the click of the camera and is an acronym for the name of a Dutch programme (Kinderen Leren Inventief Kracht), which translates into English as Children Learn Inventive Strength (see: www.klikrotterdam.nl).

KLIK aimed to improve the health and resilience of children whose families have less access to what is considered ‘a healthy lifestyle’ (healthy food and sport/exercise). The project was carried out in a neighbourhood in Rotterdam, a city in The Netherlands with diverse socio-economic groups of citizens. In Rotterdam, one out of four children grow up in poverty. We worked with two primary schools and four school classes with 75 children aged 10–12 years old over a period of 4 years (2015–2019). A participatory health research design was used (Abma et al., 2019).

PHR is a participatory action approach in the field of health and health promotion. It recognizes the capacities and resources present within citizens and communities to improve their own health and well-being. One of the core principles of PHR is to maximize the participation of the people whose life or work are at stake and to engage them in a mutual learning process to generate collection action for change.

KLIK pursued a non-normative approach to health promotion. We did not prescribe ‘as experts’ what was best for the children and their families. We instead focused on understanding, awareness and empowerment regarding health related issues. Plans and activities were developed in collaboration with the children and other relevant stakeholders and organizations within the neighbourhood. The project was funded by Fonds Nuts Ohra, a charity fund in The Netherlands, as part of a larger programme called Healthy Futures Nearby (Gezonde Toekomst Dichterbij), which focused on the reduction of health disparities among children (Vaandrager et al., 2020). Many activities, such as a so-called wildpluk walk and sportlab, were developed over the years as part of KLIK (Abma et al., 2020; Abma & Schrijver, 2020). The first year was devoted to developing plans together (Abma & Schrijver, 2019). During the second year, food was the main theme and in year three we focused on exercise and sports. In the fourth and last year, themes developed during years two and three were merged, transcended and conceptualized, with a focus on attention and growth. During that final year, we organized a plant lab, where plants were used as a metaphor for the process of growing. We asked the children to take care of their own plants (See Figure 1) and to find out how much water they needed, what happened if they gave them too much or too little water and what else their plants needed to grow.

Figure 1.

Plant lab picture taken by the professional photographer.

Throughout the years, the children were continuously engaged through creative and arts-based research methods, resulting in short digital movies and scripts made by the children that they played out on stage for other classmates and adults (Abma & Schrijver, 2019). The experiences of the children were the base of a bottom-up health promotion process, and engaging them through photography was the common thread throughout this process. We felt that photography was an appropriate, creative and positive way to engage children who are being raised in a visual society, and a child-friendly method the children could use to research their own lives and articulate their voices. No longer were they being watched (an object), rather they themselves were watching and observing. The third author, a professional documentary photographer, also took photos of the KLIK activities during the research project. Therefore, photovoice was one of the methods we used in combination with other creative methods. We recognize the value of multiple methods as pointed out by Darbyshire et al. (2005) in their research with children: ‘Research with children demands flexibility and creativity on the part of both the researchers and their ‘data collection’ approaches. Such flexibility is, we contend, not methodologically sloppy, but an important element of a research relationship with children. We had to modify and adapt elements of the study as it progressed in the light of the children’s responses. This required experienced researchers who understood research, schools and children (Darbyshire et al., 2005 p. 428).

In this article, we focus on the ethical dilemmas and the notion of empowerment through photovoice. We assumed photovoice was an appropriate way to hear children’s voices and enable them to represent their thoughts, understandings and constructs in a way that is accessible for them but can also be shared with adults. As a part of KLIK, the children took photographs with digital cameras of their neighbourhoods, meals at home and school and their playing activities during and after school. Their photos were also used to engage other citizens and share findings with the neighbourhood, for example via photo exhibitions and a newspaper made by the researchers and kids (Groot et al.,, 2021).

In the following section, we focus on our approach to using photovoice: In the first year we started familiarizing ourselves with the context and building up commitments with the schools, partners and children. More specifically, we started by engaging 73 children from four classes of two primary schools in three walking tours throughout the neighbourhood. When we had built up a rapport, we organized a photovoice workshop, for which 19 children signed up, of whom we selected a group of 12. We selected 12 children because we wanted to offer small group learning and good supervision by the two facilitators.

This selection was made in consultation with their teachers. Together with the teachers, we distinguished which children would benefit from this project most. We tried to balance the number of girls and boys, the variety of cultural backgrounds and age groups. Their parents received a letter informing them about the aims of the project and the workshop, which was designed to elicit the children’s opinions about their health and well-being. The result was a diverse group consisting of eight girls and four boys; two with Dutch origins, three East-Europeans, five Surinamese/Dutch Antilles and two with Turkish backgrounds. The children joining the photovoice workshops met four times for about 2.5 hours on Wednesdays immediately after school. They reflected on their own photography work in two informal focus groups and presented their findings to other classmates for further reflection as well as to parents, teachers and community partners to develop future action plans. The focus groups had a playful character and included a game that facilitated discussion of the photographs they made about health-related issues, like food and exercise. Additional focus group sessions were held with community partners during which time they could respond to the work of the children (10–20 adults per session). In the years that followed, we started to use other creative and arts-based methods to engage the children in the research, such as making collages, but making photos remained a main method throughout KLIK, and an activity that the children really appreciated.

Alongside these activities during and after school, we conducted a mixed-methods responsive evaluation to monitor the implementation and impact of the project, including interviews, participant observations and focus group sessions (Abma & Schrijver, 2019).

We also kept a logbook and had regular conversations within the research team, with colleagues from our university department and with critical friends to discuss the tensions we encountered when using photovoice. Critical friends are peers who empathize with the intentions to encourage the researchers to reflect on their actions and experiences. The second author, one of our critical friends, read all the relevant documents and interviewed the researchers involved on their moral dilemmas, analysed the interviews and used her observations as input for reflexive dialogues with the research team. These dialogues form the basis of this paper, which focuses on photovoice and its ethical dilemmas.

KLIK was approved by the Ethical Review Board of Amsterdam UMC (VUmc 2016.582). We gained informed consent from the parents and children, secured anonymity and protected their confidentiality. We also followed the ethical principles of PHR (Banks & Brydon-Miller, 2019; Banks & Manners, 2012) and ethical guidelines for research with children (Phelan & Kinsella, 2012). In addition to gaining approval for the activities in KLIK, we gained approval for the publication of all photos used in publications from the children and their parents. Ethical guidelines as well as dedicated time within our research team meetings and conversations with critical friends and peers were helpful to discuss issues of power, ethics and responsibilities.

Everyday Practice: Pressing Ethical Dilemmas

In this results section, we present our findings based on a critical analysis and reflection on our experiences using photovoice with children in a participatory health research project. We present the most pressing ethical tensions we faced in practice because they offer rich learning opportunities for other researchers working with photovoice and children. Ethical questions that arose included: ‘Who controls the outcome?’; ‘Photos to assess needs or to give voice?’; ‘Giving voice or aesthetics?’; ‘Who decides who is visible?’ and ‘Disrespectful and stereotypical representations?’. One specific ethical issue, on the use of the children’s pictures by a journalist of a national newspaper, is presented in a separate article and therefore is not included here (Groot et al., 2021).

Who Controls the Outcome?

The funding agency that sponsored the project stimulated participatory research, but also set boundaries that conflicted with the underlying principle of photovoice, which is to start the process openly. One of the funder’s requirements was that the project led to the development of health promotion plans targeting one of several pre-ordained outcomes including weight, alcohol and cigarette use and subjective health experiences. These indicators were derived from evidence on important health parameters related to chronic diseases with the aim being to reduce health disparities among disadvantaged families and children. Another requirement was to gather information about the health conditions of the population in the research setting.

We explained to the funding agency that there was a tension between the intention to use participatory approaches with the children through photovoice and to meet these preset requirements on outcomes. What if the children photographed and valued other outcomes? Should we then override them and select and focus on the outcomes set by the funding agency? The funding agency understood this tension and adjusted the requirements, but still asked us to gather data on at least one outcome measure. As weight seemed to be the most relevant outcome for the children participating in our project, who were at risk of becoming overweight, we negotiated with partners to focus on this outcome. This meant that the children were not entirely free in setting their own agendas and choosing what topics were photographed, as these had to remain within set boundaries. It also implied that we had to gather some information on the children and their context, while we wanted to do to the inquiry with them. The idea that photovoice is empowering because children are holding the camera is thus a bit naïve in light of our experiences. They can still become an object of research because outsiders set the agenda and frameworks. By becoming an object of research, the method of photovoice can potentially be disempowering instead of empowering.

Boundaries were also set by the school setting, which is regulated by adults and values like predictability, measurement and linear planning. The creativity and flexibility needed for PHR and photovoice did not match well with the school context that was regulated by pre-ordained programmes, where it was hard to adjust and change elements. To start with, the children were used to being expected to obey the instructions of teachers, including us (as they also saw us as teachers). The children were able to decide if and how they wanted to participate in the project and what they would like to photograph, but many assumed they had to participate or to take photos of predetermined ideas. This came to the foreground in the way the children performed the instructions given by the facilitator of the photovoice workshops (Abma & Schrijver, 2019). When the facilitator started the instructions with an example, many children took pictures that looked similar to the example. They simply copied it. The photovoice facilitator reflects:

‘The children are so used to following instructions in a certain way, and it takes a lot to really create a trustful environment and to let them come up with their own ideas’.

If the children just copy the facilitator, we still would not hear their voices. It required a lot of creativity and reflection from us as facilitators to balance what children brought to the fore as pressing topics and outcomes for themselves, and what they felt the school setting – including us – expected from them. The ethical tension here has to do with the set boundaries that limit the freedom of children to express themselves on their own conditions. In photovoice, the aim is to start from the perspectives of the participants. Yet in this case, boundaries and expectations were already set and limited the space for the children’s genuine participation. This gave the researchers a sense of discomfort and made them realize that while striving for empowerment through photovoice, the conditions may still hamper empowerment of the children. Moreover, this ethical tension gave us an everyday example of the contextual notions of empowerment and disempowerment.

Using the Photos to Assess Needs or to Give Voice?

The pictures made by the children were used to give them a voice but simultaneously served our research purposes, namely, to get insights into their life worlds and the funding agency’s request to monitor their weights. We experienced a tension between our goals (empowerment) and the goal of the funding agency (measurement); the latter being not the same as empowering the children to express their voices. This meant we used photos of and taken by the children to gain information about their lifestyles, including what they ate, with whom and in what setting, their daytime activities, sport and physical activities and pictures of their neighbourhoods. For example, they took photos of their meals at home, which we presented at a photo exhibition and in our first research report for the funding agency (See: Figure 2).

Figure 2.

Meal alone at night taken by one of the children.

In fact, this was a sort of visual anthropology; the children’s pictures offered unique and rich insights into their neighbourhoods and home situations, which made them valuable to share with the funding agency to give them an impression of the health conditions and lifestyles at the start of the project (i.e. a baseline measurement). For example, we displayed a picture of a single meal on a table, which seemed to show that the child was eating alone at night.

The various pictures helped us and our partners to critically enquire into our assumptions on their lifeworlds and lifestyles, but what about the children? Did they want and like to take these photos, and did this give them enough control over the process? Did these pictures help them to get a greater grip on their lives (empowerment)? Or did the photovoice assignment intrude in their private spaces and further increase their awareness of limitations, taboos and unsolvable problems (disempowerment)? Perhaps health was not even their priority; in their lives there may have been other issues that needed to be solved more urgently, like poverty, being bullied, social isolation and loneliness. And if we used the pictures as a source of information, who owned the data and determined the analysis?

The photographer recalls a meeting with the children where they discussed the pictures:

‘For the children it was not clear what we meant with this assignment [interpreting the images]. They made the pictures because we asked them to. But in talking about these pictures, we realized that this had nothing to do with giving those children a voice. We struggled because the last thing we wanted to do was to give those children an uncomfortable feeling about their situation at home’.

Tensions Related to Voice and Aesthetics

In our project we decided to work with a professional photographer (JS) because she could train the children to use the cameras, spur their creativity and extend their horizons. We felt this was important because some of the children had never learnt to work in a creative manner. It also appeared that many children were not skilled in using a digital camera and needed to be trained to use it. The professional photographer’s role was crucial in this. She taught the children how to use the digital camera. She also taught them visual and aesthetic thinking in a playful manner: to see patterns, colours, black and white, different perspectives, use of mirrors, etcetera. The children started to watch and see differently due to the training. Not only did the visual quality of their pictures improve, but this way of thinking also provided a means to speak back and counter traditional representations of their lives and neighbourhoods. It thus offered agency, authorship and increased their creative capacity and skills.

Still, despite the promise of agency and empowerment, we might question whether and to what extent photovoice really put the children in the subject-position, and whether their voices were genuinely taken into account throughout the research process. For example, we struggled to determine who would decide on the pictures selected for the children’s KLIK newspaper and on what basis. We sometimes felt that aesthetics implicitly played a role in the selection process of the photos, and that, in the end, we were in charge. This complexity became explicit when the photographer was selecting pictures to print. Most children made over a hundred pictures and not all could be printed. She therefore selected about 25 pictures for each participating child. At that time, we already felt the difficulty of not including the children in this selection process. But we were also focused on the outcome and we felt the present time pressure. In hindsight, we should have made more time and space for the children’s voices here.

By selecting the pictures, the photographer tried to select more common pictures but also the pictures that ‘failed’ because the children were running and shooting pictures at the same time. In retrospect, the photographer relates:

‘I felt that these “failed” pictures showed something about the way the children were shooting pictures together. But the children often saw this picture as a “failure” and thus not interesting’.

Another example was when a child was very disappointed when the photographer did not print his picture of a mushroom (see Figure 3). He had taken this picture in his own garden after the Wildpluk walk and loved it. The photographer:

‘From my perspective as a photographer and an adult, this picture did not seem that interesting. But for this child it was!’

Figure 3.

Picture of a mushroom taken by a child in his own garden.

The question remains: Who decides which pictures are interesting and how to do justice to the voices of children in a photovoice project like this? How can we empower children by showing and publishing their stories through photos? And how can they retain this empowerment if adult and professional stakeholders are involved in the selection of photos?

Tensions Related to the Issue of Visibility

The fact that some children did not want to be in any pictures confronted us with another issue. Subsequently, the ethical tension that emerged was about the privacy of the children and visibility of the pictures. Clearly, the children did not always want to be recognizable in the pictures; it all depended on the context. As photovoice aims to give control to participants, and let them remain in control, this implies a picture should not be used when a child does not want it used. At the same time, the researchers noticed the joy the children experienced during exercises and activities. This tension was also found in analysing pictures with the children. The meaning of the pictures to the researchers, or to the project’s goals, was not always supported by the emotions of the children. One of the researchers reflects:

‘Sometimes the children called their picture “stupid” to show off. I knew that they had fun at the time, but they did not want to admit this in the group setting. This is also a perspective. But what is the “real” perspective and may I influence this?’

Again, the question is who decides what is acceptable, embarrassing or meaningful to show?

Parents and children were asked for permission to join this study. Sometimes, parents were protective in such a way that it resulted in situations where their children wanted to be in a picture but were not allowed to be by their parents. In one instance, we ‘solved’ the dilemma by working with masks. Children made masks of fruit and vegetables and a photographer took a group picture of the whole class wearing these masks. This was a way to include every child and to avoid differentiation or exclusion. But the question is, once again: who decides if children may be visible? And how empowering can this visual method (photovoice) be, knowing of the difficulties of being visible? Figure 4

Figure 4.

Picture of masks taken by the professional photographer.

Tensions Related to Disrespectful and Stereotypical Representations

We also sensed tensions between dignity and respectful representations on the one hand and the wish to give voice to the children on the other hand. For example, a child would take a picture of an obese parent eating fast food on a couch. Whether the child asked permission for such a picture was not always clear, nor was it clear if the parent would like to be represented in such a way. In these cases, we felt the moral responsibility to protect the dignity of the parent and prevent the picture from being spread. This was also the case for pictures wherein the children were not represented in dignified ways in our eyes, for example, because they were dressed in a way that may be perceived by others as socially unacceptable. We realized that in these cases, we as researchers decided if the pictures represented the child or family member in a dignified way. This, in itself, is an ethical and difficult question. After long discussions within our team of researchers, we decided not to use and share those pictures, even if the kids liked them.

Many pictures presented negative and stereotypical images of the neighbourhood, including dirty spaces, poo, fast food and unhealthy lifestyles (See Figure 5). Those were the images that were constantly in the national news and repeated and emphasized the problem of a stereotypical representation.

Figure 5.

Dirt on the streets.

The dilemma we felt was that the children saw and wanted to show things, and that we wanted to make their stories visible and give them a voice, but we also wanted to stop unwanted stigmatization of the neighbourhood. We did not want to discredit the people living there. Again, creativity was required to find ways to show negative images with some irony and a with a twist. The children were very good at this, coming up with very funny titles like, ‘Does this poo have legs?’ alongside the pictures of poo and dirty spaces. We struggled again with how much we should interfere in the way the children’s pictures were exposed. . This shows the potential to both empower and disempower children by using photovoice. By defining this ethical tension, we can ask ourselves once again: Whose voice, is it?

Discussion

In this article, we presented the most pressing ethical issues we encountered in our photovoice project with children. The questions that arose included: ‘Who controls the outcome?’; ‘Photos to assess needs or to give voice?’; ‘Giving voice or aesthetics?’; ‘Who decides who is visible?’ and ‘Disrespectful and stereotypical representations?’ Although some ethical issues are common and relatively predictable in research projects using photovoice, the ones highlighted in this article show the everyday ethics and the personal and contextual challenges faced by the researchers involved.

Most of the ethical issues we encountered had to do with creating space for the children to speak up for themselves and be in control, for example, by derogating or withdrawing from assignments. Creating space for the voice or silence of children depends on the context, as well as the flexibility and willingness of others. The ‘promise’ of empowering participants through photovoice projects seems complex in interpersonal and contextual practice. Whose voice is it really, if the researchers and the context interfere? We understand the process of empowerment as a moral relational process that requires continued reflection of all parties involved (Groot & Abma, 2019, 2020). This continued reflection is clearly required in using photovoice with children.

In comparable studies about photovoice and ethics, ethical questions about interference and who determines what is pictured have also arisen (Allen, 2012; Joanou, 2009; Murray & Nash, 2016; Prins, 2010). The researchers in prior studies struggled with ‘everyday ethics;’ ethical situations that could not have been predicted beforehand. In these situations, the ‘power relation’ between researchers and participants is also discussed and reflected upon. Some authors have recognized the power they have as they shape the participants actions and output in an unintended way as if the researchers were an imagined audience (Prins, 2010). Moreover, these researchers were also asked by participants if the pictures were ‘good enough’. And if the participants found certain pictures unsuitable, they were deleted before being shared with the researcher (Murray & Nash, 2016). Christensen reflects on power relations with children in her study, realizing that she was the one who was determining the questions being asked: ‘Most importantly, it reminded me that research questions are very rarely posed at the request of the participants in our research. The questions were posed by me and were central to my interests and concern, not theirs’ (2004, p. 170). We understand the ethical tensions around power described by these other authors as highlighting the complexity of empowerment and the unintended potential for disempowerment.

In our photovoice project, we also struggled with the everyday ethical tensions around power. The ethical tensions we described were all related to the questions of empowerment or disempowerment. Increasing control by funders, researchers or parents in a research design simultaneously limits the space for children to experiment and put forward what is important to them at specific moments. As Harley (2012) asks herself: ‘Perhaps photovoice should instead be used to allow others – community members, the poor, women, whomever – to take photographs, and then show them to themselves. Perhaps the photographs should then be used in a truly democratic space as codes, and be decoded, in the Freireian sense, to uncover the multiple layers of oppression the photographs truly represent’ (p. 335). This question aims for a more open approach in photovoice projects that will primarily serve and empower respondents.

But how can we create space to empower respondents? The first important notion here is that empowerment is not something that is ‘given’. It needs to grow from within (Groot & Abma, 2019; 2020). Moreover, the way ‘giving voice’ is often framed makes it seem as if adults do the work and that they are granting children the opportunity to speak (Woodgate et al., 2020 p. 10). Yet the voices of respondents, and in this case children, are always relational and situated in a complex network of different meanings and perspectives (Carnavale, 2020; Christensen, 2004; Facca et al., 2020; Luttrell and Chalfen, 2010).

In several studies about ethics and photovoice, researchers have noticed that participants take photos of other subjects or objects ‘outside’ of the assignments (Joanou, 2009; Murray & Nash, 2016). They describe the ethical tension of collecting data when the respondents are ‘playing around’ (idem.). We suggest another view on this ethical tension. Rather than not using the pictures that respondents took while ‘playing around’, we argue that in this space of playfulness lies the opportunity for empowerment. Additionally, by deleting the data that was made while ‘playing around’, the photovoice project can potentially become disempowering.

In our photovoice project, we saw the potential of playful spaces for children, as suggested by Harley (2012). We also saw the potential resilience that can come from playing around. During the lessons and assignments, the children had fun and sometimes deviated from or took a picture ‘outside’ of the assignment. By analysing some ethical tensions, we faced in this article, we recognized the function of and need for ‘playing around’ to facilitate empowerment. Empowerment comes from within and is something that requires confidence in oneself and in groups (Baur & Abma, 2011); therefore, we argue that the use of photovoice itself is not empowering. It is the space to ‘play around’ and the space to not follow the assignment explicitly that is empowering. While creating and facilitating these spaces, it is also important to notice what is not said or photographed (Spyrou, 2011, 2016).

Creating space, as described above, is not something easily accomplished or something that can be set by a protocol. Cook (2009) describes places of imaginary freedom and new ideas as ‘messy areas’ (2009, p 281). This is a space where children can celebrate that they do not always know what they are doing and become comfortable with the feelings of vulnerability that often come with learning and growth. In other words, this is a space where they can experiment and be open for that which will happen between people in a certain context. In line with this argument, (Bos & Abma, 2018) explain space as ‘experimental’ because none of the participants know exactly what will happen beforehand (ibid). At the same time, the encounters between people necessarily have relational character as in this space people who are ‘other’ to each other meet and communicate (ibid).

In retrospect, we understand the process of empowerment in photovoice as giving people, in this case children, the tools to create an experimental-relational space from within, where participants can experiment and explore situations with the camera. For photovoice as a research method, this means a space where participants can experiment and explore situations with the camera

Conclusion

We showed pressing ethical issues that we faced during our photovoice project with children. The issues we encountered were examples of ‘everyday ethics’ as they were embodied in the researchers, embedded in everyday practice and overall, about issues surrounding empowerment that resulted from using photovoice. Two lessons are central to heighten the sensitivity of researchers or others who will work with photovoice. First, we underpin those ethical issues cannot be predicted or regulated by guidelines. Second, we stress the importance ’playing around’ and creating free space as ways to facilitate empowerment in photovoice projects. By being more attentive to the experimental-relational space, there can be more space for the voice and empowerment of children. The collaborative way of working in participatory health research and photovoice demands continued dialogue and reflection about empowerment, disempowerment, context, relationships and the importance of experimental-relational space in research.