Abstract
Photovoice is an established, qualitative participatory method for visualizing and deconstructing complex topics and research questions. We used Photovoice as a research methodology for understanding the proximal and social environmental stressors and their role in mental health equity and outcomes among young women residing in three urban slums in Kampala, Uganda. The Photovoice methodology was selected to encourage active participation and reflection from the women with lived experience to ensure their voices and reflections were captured as part of our overarching project goal. Photovoice has not typically been used in urban slums and similar low-resource settings with young women. Our Photovoice project was conducted in 2022 and engaged 15 women who participated in Uganda Youth Development Drop-in center activities. It comprised facilitated group discussions, photograph reviews, and culminated in a theme validation discussion. We focus on the application and the implementation process specifically of Photovoice, the women’s reactions to the project, and their fears, hopes and learning outcomes to guide others who may choose to implement Photovoice in similar populations and settings. The women found it a very positive experience overall, particularly the social aspects of the training, the discussion of the photos, feeling empowered to reflect on their situations and receipt of compensation. However, they also noted challenges with using the mobile phone and using it to take photos. Qualitative participatory research strategies are important for global health research seeking to improve health equity in urban low-resource settings, particularly with young women with lived experience. However, factors pertaining to the logistics and ethics of implementation strategies need to be thoughtfully considered in the design of these studies and for rigorous training of study participants.
Photovoice is a participatory visual research method that has been widely used to empower and give voices to vulnerable populations (Dassah et al., 2017). It has been shown to be effective in promoting individual and community change (Dassah et al., 2017) and to be particularly suitable for engaging participants with lived experience (Heinz et al., 2023). Photovoice allows participants to use photography as a means of self-expression and to highlight community issues (Dassah et al., 2017). By capturing the experiences and perspectives through photographs, participants can raise awareness, advocate for change, and promote social justice (Budig et al., 2018). Since its first use, photovoice has been employed as a participatory research method in various contexts, including health disparity research with underserved and represented groups (Ssemugabo et al., 2020). It involves using photography as a means for individuals to express their experiences, needs, and perspectives (Wang & Burris, 1997). Photovoice has been found to contribute to an enhanced understanding of community assets and needs, as well as empowerment (Catalani & Minkler, 2010). The approach also allows participants to identify, represent, and enhance their community using specific photographic techniques (Wang & Burris, 1997).
One of the key benefits of photovoice is its ability to empower participants. Through the process of taking and discussing photographs, participants gain a sense of agency and control over their own narratives (Budig et al., 2018; Cambaco et al., 2024). Participants can share their stories and experiences in a visual and impactful way, which can lead to increased self-confidence and self-esteem (Teti et al., 2013). Photovoice also fosters critical consciousness, as participants critically reflect on their own experiences and the social structures that shape them (Banik et al., 2023; Kimera & Vindevogel, 2022). This critical reflection can lead to a deeper understanding of the social determinants of health and the structural barriers that contribute to health disparities (Banik et al., 2023; Evans-Agnew & Rosemberg, 2016).
Photovoice has been used with a variety of vulnerable populations to empower their self-expression and agency, including individuals with physical disabilities (Dassah et al., 2017), marginalized youth living with HIV/AIDS (Kimera & Vindevogel, 2022), parents of youth with medical and gender-conforming challenges (Powell et al., 2024; Sonsteng-Person et al., 2023) poor and racial/ethnic minority women with HIV (Teti et al., 2013), and indigenous peoples (Bennett et al., 2019). It has been particularly effective as an approach for engaging these populations in research and promoting their active participation in decision-making processes (Koren & Mottola, 2023; McMorrow & Musoke, 2023; Subasi et al., 2023). By giving voice to populations with lived experience, Photovoice can challenge stereotypes, reduce stigma, and promote social inclusion (Kimera & Vindevogel, 2022). These contributions and the outcomes of this methodology may be particularly important for understanding the living conditions in urban slums and their impact on the residents’ mental health, which have been understudied in previous health research and is part of our overarching project goal.
Photovoice has been applied successfully to explore issues such as the experience of living with illness, feelings of being marginalized, experiences of recovery, and the challenges faced by marginalized communities (Barry et al., 2021; Keating, 2021; McMorrow & Musoke, 2023). It has also been used as a participatory action research strategy to address women’s health issues (Wang, 1999) and to explore experiences of integration, health, and healthcare for adult women refugees in Kampala, Uganda (McMorrow & Musoke, 2023). Photovoice has also been used to investigate knowledge and causal attributions for mental disorders in specific populations, such as HIV-positive children and adolescents (Nalukenge et al., 2019). In the specific case of Kampala, Uganda, and similar urban low-resource settings, there is a need for further research to understand the perceptions, experiences, and care-seeking preferences related to mental health in the community (Bwanika et al., 2022). The study by Bwanika and colleagues sought to explore the interpersonal and systemic issues that affect mental health in the community, as well as existing coping mechanisms (Bwanika et al., 2022). However, for the photovoice methodology to leverage the engagement and lived experience by young women in urban slums, methodological development around the context and implementation is needed.
To date, there are very few published scientific studies using the Photovoice methodology with a specific focus on residents in the Kampala slums in Uganda (Nuwematsiko et al., 2022; Ssemugabo et al., 2020). As examples, those studies have examined the unintended socio-economic consequences of COVID-19 among slums dwellers (Nuwematsiko et al., 2022) and their perceived health risks (Ssemugabo et al., 2020). Given the many unmet health needs in the slums of Kampala, Photovoice may be a impactful addition and complementary approach to other projects. However, the context around implementation and evaluation of this methodology has not been well described for populations in urban slums, particularly for young women who are often underrepresented in health research. As such, there is a shortage of insight and lessons learned to improve participant engagement and outcomes for future projects and for research studies in low-resource settings targeting populations with less agency.
In this study, we used Photovoice as a tool for understanding the proximal and social environmental stressors and their role in mental health outcomes among young women, 18–24 years of age, residing in three urban slums in Kampala, Uganda. Our extensive previous research of adolescent girls and young women in the Kampala slums show that there are several key factors that should be considered when conducting community-based research with this population, such as high levels of violence, sexual exploitation, suicidal ideation, and alcohol use and harm (Culbreth et al., 2019). As such, we asked the women to take photos of the urban stressors that they felt impacted their mental health. The Photovoice project is part of a broader study with several embedded research studies which examine the mechanisms for which Socioeconomic Strengthening Targeted Training (SeSTT) moderates the pathways between the adverse effects of poverty (proximal social and environmental stressors) and mental illness among young women in Kampala using a prospective cohort design which is in progress. We refer to the project as the Onward Project On Well-being and Adversity (“TOPOWA”) (meaning empowerment to keep pushing forward and never giving up, in Luganda, a local language spoken in Kampala).
The larger project builds on the frameworks for the social determinants of health (Alegría et al., 2018; Allen et al., 2014; Compton & Shim, 2015) and specifically seeks to capture the specific urban stressors in the slums that impact women’s mental health. However, the link between “place” and “mental health” remains poorly understood and these abstract terms are challenging to discuss. It is within this context, we designed this Photovoice project as a tool to operationalize, through visualization and discussion, the common themes related to the proximal and social environmental stressors that are linked to place (urban slums) and mental health (Swahn et al., 2022). The Photovoice project will inform the strategies and measures used in the cohort study on mental health trajectories as well as a community mapping project to understand the spatial distribution of these urban stressors.
In this paper we report on the application of the Photovoice methodology, the women’s reactions to the project, their engagement and concerns and the lessons learned. The intent is to describe the methodology and the process outcomes, as shared by the participant women, to increase the adoption of this methodology for mixed-methods research and to improve best practices for research, particularly in low-resource settings and with underrepresented populations.
Materials and Methods
The Photovoice project was conducted with 15 young women, 18–24 years of age in August and September of 2022 across three communities. Participants were invited to participate in the Photovoice project while attending one of three Youth Support Centers operated by the Uganda Youth Development Link across the metropolitan Kampala, Uganda. Potential participants were informed that researchers from Kennesaw State University and Makerere University were conducting a study to learn about young women and their community and how their environment impacts their well-being and mental health. Among those invited to participate, the first 15 women who fit the inclusion criteria (age and location) and who consented to the study protocol were included in the study.
The Photovoice project comprised 5 sessions. Participant engaged in a one-day larger group training and practicing session with all 15 participants. This training was followed up with three weekly small group session at each of the three study sites with the five women from that specific site. During those weekly sessions, photographs taken by participants were reviewed and discussed following specified prompts. The final session was as a one-day, large group theme validation session with all 15 women. At this final session a photo gallery workshop approach was used to discuss thematic areas noted in the pictures taken by the women across the three sites. The participants grouped photos and labeled the themes and subthemes. Participants were all given a smartphone (Samsung) to use during the project period to take photographs with the GPS detection enabled, for the weekly discussion meetings. The GPS coordinates were needed for another mapping project to identify the locations of where the photos were taken. We opted to use smartphones for the project because they were deemed to be less conspicuous than cameras in the community, and more cost-effective given that we wanted geotagged photos (i.e., photos with GPS coordinates). The phones were collected by the study team following the project. The participants were also trained in the ethical issues of taking photos in the community and were discouraged from taking pictures of people. Instructions were provided for obtaining consent for taking pictures of identifiable persons. Participants were also instructed on safety issues and had the opportunity to discuss and share any concerns. The one-day training also included a discussion of how to caption the photos and how best to convey the intended message of the selected photos. The training day ended with a guided community visit and field practice session of taking photographs, framing the pictures and key elements, and overall community navigation.
The materials presented in this article are derived from the final one-day theme validation session and evaluation. The one-day theme validation session presented in this paper reflects the culmination of the project period and a group discussion of all the 15 study participants and the two lead and four supportive project facilitators. The focus is to examine and present the application of Photovoice, the women’s reactions to the project, their participation and the lessons learned given the scarcity of Photovoice projects that engage young women in slums or that address environmental stressors and mental health needs.
The 15 participants who were self-selected to participate in the project were informed about the study and provided written informed consent prior to participating in the study. Ethical approvals were obtained from all relevant institutions. Participants were selected from the Uganda Youth Development Link (UYDEL) Drop-in centers for vulnerable youth. UYDEL is a non-governmental organization that works with youth ages 10–24 to provide psychosocial support, services, and skills training to vulnerable youth. They operate drop-in centers as well as a larger residential rehabilitation center. For this project we selected three different centers for participant recruitment, the Makindye Youth Centre, the Bwaise Youth Centre and the Banda Youth Centre, all in the Kampala district.
The training was led by two Ugandan women facilitators, representing the leadership at UYDEL. Both facilitators were CITI-certified and were also trained in the methodology to be used for the Photovoice project. One of the facilitators had also received specific training in participatory photography and had previous experience with research project implementation and data collection. The project Principal Investigator has also been trained in the Photovoice project approach. English is the official language in Uganda. However, the facilitators are fluent in both English and Luganda (local language) and could facilitate translation as needed for participants who may have expressed some statements in the local language.
The fifteen participants ranged in age from 18 to 24 years of age. None of the women were married, but one was cohabiting with a partner. Only one of the participants received upper secondary schooling; the remaining had obtained education at lower secondary (9 women) and primary school (5 women). In terms of religion, nine identified as Christian and six identified as Muslim. Only two of the participants were mothers and had one child each. More than half (8) of the participants were unemployed, four were self-employed and two were employed and there was no information about the one remaining participant. Among those who were employed, the income earned per month ranged from 15,000–320,000 Uganda Shillings (which converted to dollars would be about $4.30–91.42). For context, the average monthly salary in Kampala, Uganda varies widely, but estimates suggest that it is about UGX 1,000,000 to UGX 2,500,000 or $261-$653 indicating that the women in our study are substantially below the city average (UNESCO, 2023). The top two employment skills listed were hairdressing/cosmetology (8 women) and bakery (3 women). Overall, their family size ranged from one to ten people.
Data Collection and Analyses
During the final theme validation project meeting where the findings of the research project were finalized and discussed (not presented herein), participants were also asked to provide their expectations (hopes and fears) using small sticky notes. Participants were also asked about the positive and challenging experiences they had during the project. As the theme validation ended, and as part of the final evaluation, participants were also asked what they liked the most about participating in the project, what they liked the least about participating in the project and what types of skills they may have developed by learning about Photovoice, taking photographs and sharing their thoughts and opinions with others. They were also asked if their knowledge and experience prepared them to take part in future Photovoice projects, if they gained confidence to participate in future Photovoice projects and if they had anything else to add.
The verbal discussion items and written sticky note responses pertaining to the project evaluation, were recorded and organized into broad themes by the facilitators. Participants grouped photos and labeled the themes and subthemes and then co-analyzed and finalized the results together with the facilitators. These themes were then interpreted, and ideas were grouped within the overarching context of the project implementation and evaluation by the facilitators and presented in a final project report to the Principal Investigator. Any responses provided in Luganda were translated into English. All responses from the 15 participants were included in the analyses and final report. Because of the few respondents and responses and the fact that participants effectively completed the theme validation, no software was needed to identify themes or to organize the findings and analyses in the final report. The findings in this manuscript reflect the key implementation issues and participants’ reactions and reflection of their project engagement.
Results
Hopes and Fears Expressed by TOPOWA Photovoice Participants During Final Project Meeting.
Positive and Challenging Experiences Faced During Photovoice Project Implementation Expressed by TOPOWA Photovoice Participant During Final Project Meeting.
Regarding using the phones, participants enjoyed the smartphones as a tool for taking the photographs, but they also indicated that they were stressed about losing or damaging the phones and also about turning on the GPS function to provide a location for the photos. Several participants responded that they enjoyed both taking the photos and discussing them and that they learned more about their own community as part of the process. They enjoyed walking around the community and taking pictures and also felt that they learned to take pictures, an experience they likely never had before. However, there were also several notable challenges with taking pictures. Participants felt that it was challenging to take pictures without people in the frame, or taking pictures of someone’s business, or convincing people in the community that they were not taking pictures of the people. It was also challenging for them to select the best pictures for the discussion. Participants were also concerned and frustrated about handing the phones back to the study team after the project ended.
The timing of the session and the length of time required for the project was also a challenge raised by several participants. This concern was also related to weather, specifically rain which presented the challenge of moving about the community and delays in returning home. Participants appreciated being compensated for their time, engagement and transportation to get to the project meeting site, but some noted challenges with delayed payment and that payment was given after each session (not before).
TOPOWA Photovoice Participation Evaluation During Final Project Meeting.
Participants were also asked what types of skills they developed by learning about Photovoice, taking photographs and sharing their thoughts and opinions with others. Key statements including learning more about their own community, learning how to take pictures, learning how to communicate and speak up in group setting, learning creativity, learning how to work in a group setting, and learning how to tell a story using a picture. Their comments and self-described learning outcomes are depicted in the form of a word cloud (See Figure 1). Word art comprised of self-described learning outcomes among participants in the TOPOWA photovoice Project.
Finally, all participants were also asked if they gained confidence and if they would be interested in a future Photovoice project. All 15 participants reported that they felt confident because of the project and wanted to participate in future project implementation.
Discussion
In this formative research and qualitative evaluation of a Photovoice project, the perceptions and reactions of young women participants in the slums of Kampala, Uganda are reported and summarized. We found important themes or lessons learned, particularly related to the logistics of project implementation as well as the need for strengthening training prior to project launch. The goal of this evaluation is to enhance the Photovoice methodology implementation given the unique situational context of young women residing in urban slums and to make sure their lived experience is captured in an ethical and safe manner. Also, even though Photovoice has been used as a methodology for decades, there are surprisingly few studies that focus on participants who live in slums or informal settlements, a relatively unique and resource poor setting (Merriam-Webster, 2022) and a context where women specifically face significant challenges and marginalization (Swahn et al., 2022; Whitton et al., 2022).
Positive Outcomes and Benefits of Photovoice Participation
Overall, the Photovoice project was successfully implemented with high levels of participant engagement and satisfaction. Participants were excited and engaged, they all reported that they had gained confidence as part of the project and shared that they would be willing to engage in a future project. Of all the comments received, the social aspects of the project were very valuable to the participants, as were the use of smartphones for taking pictures and learning how to take better pictures. The group discussions were clearly the favorite aspect of the project as several participants mentioned that they valued discussing the photos and engaging in group work, noted by several participants as a positive experience. Several participants also commented about making friends, spending time with friends and engaging in discussions with peer groups. They also reported learning about their community and several aspects of feeling empowered to speak up, to speak so that others can hear, and how to tell a story using a picture and how to engage in group work. These are all key benefits and represent the transformational potential of using Photovoice for community action or for research (Budig et al., 2018).
Importantly, several of the positive experiences and recurring themes that participants reported specifically described the logistics of project implementation and were centered around being fed, keeping time and being reimbursed for their time and transport money to the project site. It was clear that for this population of young women, the logistics around project implementation were key to their participation, availability and engagement and should be thoughtfully considered in future studies. The 15 women participants in this study represented 3 different study sites, and they reflected different socioeconomic context as more than half had only obtained lower secondary education and were also unemployed. Family sizes ranged from 1 to 10 people and among those who were employed, monthly earnings varied substantially ($4.30-$91.42). With this context, the need to be fed and compensated appropriately for their time is a critically important consideration given the urgency and context of food insecurity (Swahn et al., 2015).
Logistical and Unexpected Issues in Project Implementation
It may be surprising that several participants mentioned weather as a concern for participation, specifically rain. Several of the study sites in the urban slums are hard hit during rains due to poor drainage systems and construction of homes in flood zones, making roads often impassable. The intensity of the rainy season has also increased due to climate change, which has worsened traffic in already congested areas.. Additionally, due to poor housing construction, many of the homes lack proper roofs, so water also leaks through, damaging property or flooding living quarters. Similarly, the concerns regarding lack of solid waste management and garbage pick are also exacerbated when it rains, further complicating living conditions in already dense and impoverished communities. As such, it is clear as to why participants were concerned about the weather and that it may rain when they were away from their homes to participate in the project. Future projects may want to consider these logistics when designing study protocols and engagement for participants who live in urban slums, like those in Kampala. Also, for projects related to mental health specifically, it may also be important to assess climate anxiety as a specific and important measure given the direct impact and health vulnerabilities for urban populations residing in slums (Damte et al., 2023).
Handling the Smartphones Yielded Excitement and Concerns
Given the context of urban poverty, it was clear that most participants had no previous experience with a smartphone. While most Photovoice projects rely on regular cameras, smartphones can also be used for Photovoice implementation. Each type of tool has its own advantages and disadvantages and should be selected based on the project context and population. We selected the smartphones for our project for several reasons but primarily because of their availability in the community, the price, portability, battery life, and the inclusion of GPS coordinates for the photos so that they could later be mapped. We also determined that a smartphone would be less conspicuous or noticeable when handled in the community by the women than other types of cameras, particularly in this setting, as we were concerned about participant safety.
Previous research also indicated that a sizeable youth population would have experience with smartphones. In 2011, and again in 2014, research found that about half of the young people surveyed in the Kampala slums reported owning a mobile phone (Louis, 2018; Swahn et al., 2014). Given that this Photovoice project was conducted nearly a decade later, we had anticipated a higher proportion of mobile phone ownership including smartphones. However, it may be that the financial distress caused by COVID-19 in these urban slums reduced the prevalence of smartphones used in the community. It was clear that using the smartphones was a highlight of the project participation among some of the women because of their scarcity and possibilities for multiple other functions. The phones we used did not include a sim card and were not registered and could therefore not be used for other functions such as calling and texting. That said, the phones still caused some distress as several participants were concerned about damaging or losing the phones, underscoring the unfamiliarity with the phones and the risk they may pose in the community. During the training we provided some key strategies for safely navigating the communities with the phone and how to remain safe in interactions with community members. Given the participant feedback, this training component needs to be revisited and strengthened which is important given the high levels of violence that young women experience (Swahn et al., 2012), As mentioned earlier, one key reason for using the smart phone was the ability to collect GPS coordinates for each photograph so that the coordinates could be mapped. We have not yet mapped the photos but plan to do so for another study project component. However, turning on the phone feature to enable GPS coordinates to be part of the photo file created some confusion for several participants. The technique for activating and enabling this feature was a step that was demonstrated repeatedly in training and during the follow-up sessions, but nonetheless it created some anxiety. Some participants were encouraged to retake their photos without the GPS coordinates, a recommendation we should have omitted had we realized earlier the stress it caused participants.
Ethical and Safety Considerations in Project Implementation
Photovoice is intended to be a methodology that empowers participants; however, it can also represent some risks. In this study, several participants raised concerns about being uncomfortable taking pictures in the community and noted risks inherent in navigating their communities with the purpose of taking pictures. Unfortunately, the levels of gender-based violence remains very high among young women who live in the slums of Kampala, both within the context of intimate partners (Culbreth et al., 2019, 2021) and in the community in terms of physical fights (37%), being threatened with a weapon (28%) and being raped (30%) (Swahn et al., 2015). We thought the one-day training session had sufficiently addressed their concerns and given enough context for navigation and safety. We even provided specific examples of how to take photographs with no people as a strategy for mitigate any community concerns. However, given the level of marginalization of these young women in their own communities, increased efforts and training are needed to ensure their safety and reduce risk.
We had also debated on the appropriate compensation for the participants’ time, a topic we had to operationalize at the time of the ethical review process and protocol approval. Review boards typically want compensation to be commensurate with participants’ time and transportation related to the project completion. One needs to establish a formula for compensation that is fair and equitable and not coercive, meaning providing reimbursement for their time that participants may not be so enticed to participate because of the large compensation promised. For this study we provided compensation for their time, their transport to the project location site and we also fed participants while they attended the project sessions. Several participants noted with gratitude that they had been fed, particularly during the longer first and final sessions.
The use of Photovoice raises several ethical considerations. As researchers we must navigate the potential barriers and dilemmas that arise when employing Photovoice, such as the meaning of photography within participants’ cultural context, the safety during data collection, the compensation of participants as collaborators, and the representation and dissemination of participant photos (McDonald & Capous-Desyllas, 2021). It is important to ensure that the research process is culturally safe and respectful of participants’ rights and autonomy (Bennett et al., 2019). While we had employed that approach, we still found important lessons learned where we can improve the protocol design and implementation strategies for future projects.
Limitations
While this study offers valuable insights into the implementation of Photovoice in urban slums, there are several limitations to consider. First, the small sample size, limited age range, and selected geographic scope limits the generalizability of the findings to other populations or urban settings. Although, Photovoice is rarely conducted with the specific purpose of generating generalizable findings, the unique sample and location may produce findings that are not applicable to other populations or settings. Second, participants had some challenges with the technology. As such, the use of smartphones posed both opportunities and challenges. While smartphones were chosen for their portability and GPS functionality, they also introduced anxiety among participants due to their unfamiliarity with the technology and fears of damage or theft. This unease may have affected the participants’ ability to fully engage in the photography process. As highlighted earlier, a more thorough pre-study training on smartphone use, as well as alternative, less anxiety-inducing devices, could be considered for future studies. Third, there were logistical constraints and environmental factors, particularly rain and poor infrastructure, which posed significant barriers to participation for some women. The unpredictable weather in Kampala, compounded by poor drainage and flooding in the slums, may have influenced participants’ engagement. Future research should account for these logistical issues and possibly adjust the project’s timing to mitigate participation challenges. Fourth, ethical and safety concerns are very important and although the study provided training on safety, a few participants reported some concerns about taking photos in public due to the high levels of violence in their communities. This suggests that the training may not have adequately addressed the risks associated with navigating the slums and should have been expanded in both duration and scope. More comprehensive safety protocols and ongoing risk assessments should be integrated into future projects to better protect participants and ensure they are comfortable with the assignments. Fifth, there may be biases in the financial compensation to participants.
Determining appropriate compensation for participants’ time and effort posed challenges. Although we aimed to ensure that compensation was fair, ethical review boards’ requirements around avoiding coercion may have led to participants feeling undercompensated given their precarious financial situations. This could have affected their willingness to participate or the quality of their engagement. Future studies should carefully balance compensation to reflect participants’ needs without introducing undue inducement. These limitations and lessons learned may be of great value to future Photovoice and other qualitative projects in similar populations and settings.
Conclusion
Our approach for embedding this implementation evaluation as part of the Photovoice project was rather exploratory given the dearth of research and tools available to examine the implementation process of these types of projects and settings and information about the actual participant experience. However, we sought to elicit responses from the women and encouraged them to think about how the study impacted them, above and beyond the articulated goals of the Photovoice project (linking place and mental health). While some of the concerns raised by the women were expected, we also found some unexpected concerns, particularly regarding the study logistics. Those are the lessons learned that we highlighted in this evaluation to guide and enhance future projects and their implementations. We also hope that these lessons learned, particularly the excitement by these young women and the many benefits including the self-described learning outcomes they took away from the project, will encourage the design and implementation of new projects with young women in similar settings to amplify their voices and lived experiences.
Footnotes
Author Contributions
Conceptualization, M.H.S., A.N. and J.P.; methodology, M.H.S. and A.N.; analysis, M.H.S.; investigation, J.N., A.N. and J.P.; resources, J.N. and A.N.; writing—original draft preparation, M.H.S.; writing—review and editing, M.H.S., J.N., A.N.; supervision, J.N., A.N. and J.P.; project administration, M.H.S. and J.P.; funding acquisition, M.H.S. All authors have read and agreed to the published version of the manuscript.
Declaration of Conflicting Interests
The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The material has not been published in whole or in part elsewhere. The paper is not currently being considered for publication elsewhere. All authors have been personally and actively involved in substantive work leading to the report, and will hold themselves jointly and individually responsible for its content. All relevant ethical safeguards have been met in relation to patient or subject protection. The research has complied with the World Medical Association Declaration of Helsinki.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research reported in this publication was supported by the National Institute of Mental Health, of the National Institutes of Health under award number R01 MH128930 to Dr. Swahn.
Ethical Statement
Disclaimer
The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
