Photo Elicitation Interviewing Enriches Public Health Research on Fathers’ Role in Child Care and Feeding in Addis Ababa,Ethiopia

Abstract

Photo elicitation interviewing (PEI), as a visual qualitative research methodology, has been used widely in various fields with different participants. However, little has been written about using the method in public health research, especially involving men in low-income settings. In this paper, the authors reflect upon the use of PEI in a study that explored fathers’ experiences in child care and feeding in a low-income neighbourhood of Addis Ababa city in Ethiopia. The reflections focus on two overarching themes; (1) how PEI worked well as an effective technique in terms of addressing the research questions posed in this low-resourced setting and (2) how it served to enhance phenomenology in qualitative public health research. The researchers also discuss the limitations and lessons from employing this methodology through continuous reflexivity, which is valuable to qualitative work.

Introduction

Involving visual methodologies to supplement conventional interviews in qualitative research permits deeper exploration of the individual’s experiences (Collier & Collier, 1986; Harper, 2002). Photo Elicitation Interviewing (PEI) is the most commonly used visual approach in qualitative research (Glaw et al., 2017). It uses photographs taken by participants to guide and invoke more in-depth discussions in response to research questions (Collier, 2009; Glaw et al., 2017). PEI is a core component of Photovoice (Palibroda et al., 2009), a form of community-based participatory research that engages participants at each step of the research process as documentarians, commentators, and agents of change. Although many scholars use the terms “photo-elicitation” and “photovoice” interchangeably, in this study, we follow the distinction made by Bugos that PEI mainly focuses on the interview process augmented by the photos, unlike photovoice, which focuses on the photos without the follow-up interviews (Bugos et al., 2014). More precisely, PEI draws on the power of photos/images to elicit meaning by augmenting a conversation and providing a platform for the participant to express themselves as part of the interview process (Gomez, 2020).

Using photos allows participants to re-live the events; it ignites memories and feelings that help participants have a more open and intimate dialogue (Hatten et al., 2013). Photos, especially when generated by the participants themselves, allow the partakers to tell their own stories and perspectives through the images they choose to depict a specific phenomenon. This empowers participants to take a more active role during the discussion (Schaeffer & Carlsson, 2014). Furthermore, photos give the researcher a visual perspective, thereby gaining a more complex understanding of the participants’ world. Photo elicitation is claimed to be the means through which participants can hold their autonomy and control by documenting, selecting, and sharing their information/life situations free from pressure and coercion (Banks, 2007). In addition, PEI invokes memories, comments, and perceptions by permitting more detailed interviewing following a semi-structured fashion. The information then unfolds in more dimensions in an articulated form driven by the study question (Banks, 2007; Hurworth et al., 2005). In other words, the method allows participants to share their experiences and tell their stories like they want to, which in an ordinary interview, they would not have the opportunity to scope outside of the interview/discussion guide (Liebenberg, 2009).

Studies conducted in high-income settings have shown that having photographs during the interview serves as a mediator between the researcher and the interviewee, preventing the awkwardness that occurs during traditional in-depth interviews by minimizing the feeling of being put on the spot and/or grilling (Collier & Collier, 1986). Accordingly, not only are the photos there to guide the interviews, but they also serve to avoid prolonged and uncomfortable direct eye contact, as both parties can look away and break any tension by glancing at the neutral “third” party, the photo, as often as they want (Clark-Ibáñez, 2004). In addition, the rapport between the researcher and the participant would facilitate more in-depth responses from participants (Copes et al., 2018).

Employing qualitative research methods has been essential in investigating different public health problems. Systematic and rigorous approaches are needed when designing, implementing, and interpreting such research, which is critical for meaningful contributions to evidence-based knowledge making. Using innovative and strategic methods, such as PEI, rather than merely following traditional data gathering methods, is one way to enhance quality and rigor in qualitative health research (Banks, 2007; Schaeffer & Carlsson, 2014). This is beneficial in checking set standards for trustworthiness by allocating a good share of the power to the participants as owners of their own stories and experiences.

Photo elicitation interviewing has been sporadically used in health research for over five decades; studies have been carried out in various areas; clinical studies, behavioral sciences, non-communicable diseases, and violence (Fritz & Lysack, 2014; Gomez, 2020; Kyololo et al., 2023; Torre & Murphy, 2015b). However, the majority of the earlier research is from high-income countries where individuals have relatively higher literacy levels and better access to technological innovations (Bugos et al., 2014; Krieg et al., 2009; Padgett et al., 2013; Rayment et al., 2019). This method, in particular, has not been explored in the rapidly urbanizing settings in low-income countries, a situation where rapid development has substantially widened the gap between the “haves” and the “have nots” (Boucher, 2017). When there are such briskly changing and divisive neighbourhood discrepancies, the challenges and complexities of people’s lives and their roles in different social circumstances increase exponentially, subsequently affecting their health (Boucher, 2017; Hong & Goh, 2019). Childcare and feeding is a critical public health issue in low-income settings. Particularly paternal roles in childcare and feeding using engaging methods such as PEI have not been widely studied in similar settings. Yet studies recommend that a more -in-depth focus on fathering roles may pave the way for developing interventions that effectively support fathers during the first years of their children’s lives (Bakermans-Kranenburg et al., 2019). Therefore, in this study, photo elicitation interviewing was used to enhance the understanding of fathers’ roles in child care and feeding in a low-income setting in Addis Ababa, Ethiopia, to capture more comprehensive data.

This article aims to document the experiences and reflections of the research team while implementing PEI to explore fathers’ experiences in child-care and feeding in the city’s low-income neighbourhoods. Given that PEI is a relatively new approach in the study area, sharing what we learned about the method, what worked well, and what challenges were encountered is deemed relevant. By briefly describing the steps we followed in this study and providing our reflections/observations, we show how this method can contribute to public health research. The material presented focuses on two overarching themes; how PEI worked well in a low-income setting and how it enhanced this qualitative work phenomenologically, permitting the researcher a visual dimension to augment a comprehensive picture of the participant’s lived experience.

Study Approach, Procedures, and Ethical Considerations

The Study Approach

The study was designed to investigate fathers’ role in their children’s feeding and overall care. We used a qualitative phenomenological study design employing PEI with participant-driven photo generation. This aimed to allow participants to share their living situations and capture their own worlds through their viewpoints.

The study participants were fathers residing in Lideta sub-city in Addis Ababa, the capital city of Ethiopia. The fathers were recruited with the help of urban health extension workers. We conducted individual in-depth interviews, augmented by photos, with ten fathers whose children were under the age of five years. We used purposive criteria such as having lived in the sub-city for at least six months and efforts were made to diversify fathers by employment type, education level, age, and community involvement. Fathers in this study ranged in age from 28 to 45. The potential fathers were first contacted via telephone and then invited to come to the health center where their child was vaccinated. Volunteer fathers who accepted the invitation were then met in a private room in the health center, where they were given information on the study objectives, procedures and asked about their willingness to participate. Those willing were given the complete orientation to the study along with digital cameras and instructions.

Procedures

The study instructions involved two main components. The first was a detailed orientation guide entailing a point-by-point procedure guide for the participants. A thorough orientation delivered simply with practical examples was found beneficial to increase the comprehensibility of the technique to the participants (Bugos et al., 2014). This orientation guide explained the technical operations of the device (digital camera), what type and number of pictures to take and how long they had to do this, as well as how to communicate with researchers.

The orientation was well-received by the fathers, and they did not have difficulty understanding the intentions. We asked for any questions, and if they understood well, they could summarize what we discussed in the orientation in their own words, which captured the main points. Generic and confirmatory questions were posed, such as the minimum number of pictures expected and how often the camera needs charging. Clarification regarding taking photos of strangers and the ethical and cultural appropriateness of taking photos of other people were also discussed.

The second component was a semi-structured interview guide developed to invoke conversation based on each picture, augmenting information required based on the research objectives. The guide could not account for all eventualities, but interviewers were instructed to use their judgment should the participant talk about other issues not mentioned in the guide but still pertinent to the aim. The opening question was: Tell me the story of this photograph, where the father was encouraged to tell his story. After the opening question, there were general follow-up questions relevant to the study aims, such as: What stands out for you in this photo? and How does this relate to your life and life within your community? Finally, there were summarizing questions such as: Looking at all these photographs together, what story do they tell about your role as a father in the care and feeding of your children?

The data collection involved three steps. The first step consisted of building rapport with the participant, acquiring informed consent, provision of digital cameras, and orientation as per the guideline. This took approximately 20–30 minutes. Step two was the actual capturing of photos by the fathers. The fathers took several photos of different types. Most photos were of their children engaged in different activities, followed by times shared as a family, such as meal and play times. Photos capturing the living conditions and their neighborhoods were also among the pictures brought for discussion. The third step was planned to take place after a week of photo taking time. The fathers then presented all their photos to the researchers and eventually chose 5-6 of the most salient photos that they wished to discuss. Then we followed the in-depth interviewing approach, where the interviewer audio-records the interview with the father’s consent, keeping field notes which later were transcribed and translated into textual data. The focus of the interviews was the participants’ interpretation of their chosen photos, at which point the interviewer probed deeper about the participants’ motivation in capturing this particular image and what meaning it held for him. This approach was supported by previous researchers when they questioned whether researchers’ choice of photo would match what the empowered participants would choose (Deal and Fox, 2006).

Ethical Considerations

Ethical clearance was obtained before the study from the ethical review committee of Author’s Continental Institute of Public Health, reference number: ACIPH/IRB/003/2020. Necessary permission letters were also obtained from study site sub-city and district health offices. Written informed consent was obtained from participants after providing a detailed explanation of the study objectives, procedures, risks, and benefits. Standard operating procedures for photo elicitation were outlined based on Bugos et al. regarding ethical concerns (Bugos et al., 2014). The fathers were given a detailed orientation to address any ethical issues that may surface around taking photos of people and places. They were briefed on the potential challenges they may encounter. They were informed, in accordance with ethical guidelines involving visual research methodologies, to respect individuals’ wishes whether or not to be in their photo (Ford et al., 2017). The fathers were also thoroughly reassured that the photos, as well as the audio-recorded interview would not be publicly available.

Reflections on Using Photo-Elicitation to Augment Qualitative Interviews

In this section, we focus on reflecting on PEI as a method in our study. Thus any reference to the father’s lived experiences and findings will be brief. The researchers have detailed those findings in another published paper (Berhane et al., 2023). Our experiences are organized into two main themes, and we illustrate these experiences in line with previous research/existing evidence concerning PEI. The first theme revolves around how well the PEI technique works in this study context. The second theme describes PEI as a phenomenological enhancer of public health research.

Photo Elicitation Interviewing Technique Worked Well Among Fathers in a Low-Income Urban Setting

Technical and Logistical Issues:

Generally, the photo capturing, storing, and overall use of the rechargeable cameras by the fathers went smoothly, proving to be effective in the study setting. While we did not aim to take structured socio-economic information from the fathers, as the focus of the main study was merely capturing fathers’ role, the respondents had similar backgrounds, particularly in terms of low socio-economic status and housing conditions, as we could observe both from the photos and their utterances in the interviews. According to Clark Ibanez, visual methodologies such as PEI must consider the skill of the photographer, as well as inherent costs and the time required to generate and use photographic methods (Clark-Iba´n˜ez, 2007). In this study, we provided the fathers with a simple digital camera to have comparable pictures in terms of quality. Additionally, the provision of cameras allowed all participants to participate instead of demanding a smartphone, which was a selection criterion in previous studies. However, we were conscious of the low utilization of digital technology in low-resource settings (Saeed & Masters, 2021). That made us question the fathers’ abilities to operate the cameras and how that might impact the study. However, there were no technical difficulties encountered in utilizing the digital cameras. Overall, the fathers were comfortable manipulating the device after the first orientation.

The fathers showed keen enthusiasm towards the study’s aim. This could be one reason that made them to attentively learn the camera operation and photo-taking procedure and increased their motivation to apply the method. We noticed that photos taken by the fathers varied according to the participant’s understanding of the research purpose and how they viewed their experience of fatherhood. For example, some fathers ultimately focused on capturing their children’s activities, such as playing, feeding, or smiling. Other fathers tried to show their roles in the household as a father having someone else take their pictures while cleaning the house, washing dishes, feeding, or playing with their children. Yet others took pictures that mainly portrayed the overall household life, such as depicting all family members having a meal together, going to religious places as a family, etc. Generally, the photos taken could be seen as indicators of how they perceived their role as a father.

One challenge encountered with the photographs was the volume of pictures taken. Although the participants were instructed to take a maximum of fifteen pictures, almost all fathers took numerous photos. That made the selection process both time-consuming and difficult. In addition, fathers in such situations chose to discuss many pictures, rendering it challenging to keep the conversation within the time and topic frame. Such challenges could be mitigated by strongly informing participants to take fewer pictures and consider providing a camera with limited storage capacity. It would not be feasible to discuss copious photos in one interview. The idea was to capture the most interesting/meaningful/sentient aspects of fatherhood for them so that the conversation would have more depth later. On the other hand, a few of the pictures chosen for discussion were fuzzy and hard to make sense of, in which case the researchers improvised and conducted the in-depth interview, using the father’s understanding of the picture as a background. We recommend thoroughly emphasizing the purpose of photos in PEIs before handing over cameras to participants. Limiting the time for photo capturing to a few days could also be one method to help participants focus on the requirements for the study and not feel obliged to capture excessive photos beyond their daily encounters. That said, we as researchers believe from the following interviews that having taken many photos widened/deepened our understanding of fathers’ experiences.

Photo Elicitation Interviewing Worked Well Previously Done Work Among Fathers in a Low-Income Setting

Most previous research around photo elicitation has been done in Western, high-income societies (Johnson et al., 2010; Leonard & McKnight, 2015). We were curious why not much had been done in other settings, so we were motivated to employ it in our study setting. The process required heightened reflexivity and bracketing of researchers’ preconceived ideas (Tufford & Newman, 2010). This improved the study quality as we checked (and corrected) our presumptuous notions about communities in low-income settings in terms of the following two main aspects.

First, we were inquisitive about how PEI would play out in such a setting. It was quite revealing, through the photos from the fathers’ and their utterances, that the study area was underprivileged and overcrowded, including poor housing conditions. In addition, we visited the actual neighbourhoods through which we could appreciate how photo elicitation raised housing conditions as a salient point substantiating how context matters in making sense of one’s subjective reality (Liebenberg, 2009). Secondly, as there is undeniable underrepresentation of fathers in such research (Khandpur et al., 2014), we questioned whether targeting only fathers for childcare and feeding would generate rich information for the study as classically, mothers are most often associated with a closer engagement with childcare and feeding than fathers (Campbell et al., 2010; Patrick et al., 2005). In addition, this study on fathers’ role grew out of one of the researchers’ doctoral study where mothers' were interviews and how they highlighted the fathers' role as essential for the care and feeding of kids (Berhane et al., 2018). In our experience with this study, the fathers were remarkably expressive when discussing their children and their fatherhood experience. Their interest in participating in the research without seeking reward or payment exceeded our expectations. Despite the participants being from poorly resourced communities, the method effectively yielded the intended information as per our goals. The fathers not only capably captured photos that reflected their situations, but the PEI method ignited deeper conversation regarding their involvement in their children’s lives.

Photo Elicitation Interviewing Enhanced the Phenomenological Design of Public Health Research by Enriching the Quality of Interviews

Decolonizing Research: “Entering Their World With Their Permission.”

In this study, the photos were entirely produced by the informants, both capturing and later chosen for discussion, following native image making techniques instead of being selected by the researchers (Wagner, 1982). This, in and of itself, can be considered a method to decolonize research by recognizing the “owner” of the story. Decolonizing research strategies are gaining popularity in health and social research in low-income countries (Keikelame & Swartz, 2019). Decolonizing research broadly refers to placing concerns and world views of non-Western (and mostly low-income) nations and individuals while dutifully knowing and understanding theory and research from previously alienated “objective” perspectives (Keane et al., 2017; Thambinathan & Kinsella, 2021). In our study, empowering the participants to control the taking of photos as they saw fit helped create room and inviting autonomy, thereby invoking less social pleasing.

Although most of the research team were natives of the same country, we still acknowledge the outsider position we possess as researchers and, therefore might not fully understand the father’s “world” as they know it. In that accord, we believe that this research has sparked light, given that it worked well, on the importance of acknowledging the implicit power dynamic between researchers and participants, allowing ample room for participants to assume the deserved role in the research around them. In principle, PEI is designed to be a collaborative work between the researcher and the participants (Jenkings et al., 2008), and this study revealed that maintaining a collaborative attitude in every step of the research process yields more accurate information to inform interventions targeted to the participants' realities. Challenging status-quo concepts that often disregard contextual veracities in research approaches is beneficial to understand the “researched” from their standpoint and thus generate more accurate knowledge of the shared field (Datta, 2018; Zavala, 2013). Promoting that autonomy enabled the fathers in our study to open up and let us into their world to an unexpectedly larger extent. Providing the fathers with an opportunity to capture the moments they deemed worthy of sharing gave the researchers a chance to see through the father’s lens. It revealed more of the everyday life of the fathers and their context, including where and how they lived, where they worked, and how they interacted with different members of the community, enabling a more expansive view of the father’s role within the broader community.

In addition to giving the researchers insight into the nuances of the father’s role and life, the photos encouraged the interviewees to provide relevant details or the so-called “Backstory” not always accessible in interview-only-investigations. Together with the interviewer’s prompts/inquiry, they reflected and told their story. Furthermore, introducing photos and giving the participants opportunities to select the photos more relevant for them; reduces the power differential and potential awkwardness between the researcher and participant, creating a friendlier environment for free/open discussion. In this way, photo elicitation is more akin to participatory action research (Liebenberg et al., 2017). Here we demonstrate how PEI enhanced phenomenology in three specific ways; thick description, credibility, and confirmability

Thick description: Having extensive experience in qualitative public health research with various techniques and designs, we (the researchers) appreciated the increased depth, flow, and ease of the interviews while employing PEI. Studies have shown that PEI results in more substantial information as it eases the stress of being questioned and focuses on the voluntary interest in sharing one’s story (Schaeffer & Carlsson, 2014). This sharpens the interviewee’s memory, providing much richer depictions. The pictures the participants took facilitated the discussion by providing spontaneous reminders to the fathers, igniting sparks of emotion as they saw their worlds, becoming observers of their own lives. For some, looking at the pictures brought suppressed memories and emotions to the surface, especially about their childhood. The pictures visibly reminded the fathers of their lives in the present and in the past as they described their joys, adventures, and struggles of their childhoods. This experience was considered one of the strongest “eye-opening” moments for the researchers, and due to encouraging the fathers’ autonomy in that he picked the photos for discussion. We realized that fathers took certain photos that they deeply related to, although that might not seem very obvious to the outside observer. For example, some pictures enabled the fathers to convey their feelings and perspectives in a generous detail because they attached meaningful experiences to them. In addition, we appreciated that using a combination of visual and verbal data gave a comprehensive picture of people’s lives (Bennett, 2015), thus creating more space for thick description so crucial to the qualitative process.

Credibility: Photos speak reams, thus demanding less evidence to convey credibility. While visual images smoothly transport the researcher to the everyday lives of participants, interpreting the photos without the explanation of the person who took them might lead to untruthful interpretations (Coussens et al., 2020; Sigstad & Garrels, 2021). This is PEI’s strength, as in our specific situation, to testify to the photos and place the individual’s meanings to his situation (Kunimoto, 2004). The participant speaks for the photos’ meaning, which helped expand the conversation.

Confirmability: Our study made sufficient room to allow member checking by supporting the photos with the participants’ own words and interpretation. This underscores the story’s confirmability (Hopkins & Wort, 2020).

Limitation

While our study methodology was effective in this setting, we acknowledge that we did not have prolonged engagement in the study area with the participants despite having Ethiopian nationals on the team. This was accounted somewhat for by giving the participants a prolonged period to capture meaningful pictures. PEI can be more demanding time-wise, so it is essential to encourage participants to take various photos yet choose only a few photos for the interview process.

Conclusion

Using PEI yielded fruitful insights in the study context with this underprivileged population. The willingness of the participants to engage in this study quickly erased any of our early skepticism that these fathers may not want to or be able to share such information. The PEI method requires a high degree of reflexivity in the researcher. We recommend using these techniques in public health research; they aim to generate in-depth knowledge concerning individuals and their intimate contexts in low-income countries. The subsequent consequences of more customised interventions aligned with the participants’ realities could potentially pay off in better allocating the often scarce funds available for improving childcare and feeding.