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Using Photovoice to Address Gender-Based Violence: A Qualitative Systematic Review

TRAUMA, VIOLENCE, & ABUSE 1-14 ª The Author(s) 2017 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1524838017717746 journals.sagepub.com/home/tva

M. Candace Christensen1,2

Abstract The purpose of this article is to examine how photovoice research addresses gender-based violence (GBV) among individuals and communities that experience and witness GBV. Photovoice action research (PVAR) methods act as both an intervention and a research method by engaging participants in using photography to depict a topic of concern and in developing potential solutions. To date, there is not a published review of PVAR publications that focus on addressing GBV. This article is comprised of a qualitative systematic review of studies that use photovoice research methods to address GBV. This review is conducted in accordance with the Supplementary Guidance of the Cochrane handbook and results in the examination of 17 publications that meet inclusion criteria. The data synthesis engages grounded theory (GT) methods and results in the emergence of one primary category transgressing the violence and three subcategories illustrating the problem, caring for self and others, and harnessing community resources. The results of this review reveal research, practice, and policy implications for photovoice projects aimed at addressing GBV. Keywords gender-based violence, photovoice, qualitative systematic review, action research

The World Health Organization (WHO) (2012) states that, globally, 29–62% of women are victimized by some form of gender-based violence (GBV) and as many as 10% of men report victimization (Garcıá-Moreno, Jansen, Watts, Ellsberg, & Heise, 2005). More than one in three US women and one in four US men have experienced rape, physical violence, and/or stalking by an intimate partner in their lifetime (Black et al., 2011). As the result of gender nonconformity, lesbian, gay, bisexual, transgendered, and queer (LGBTQ) people are subject to hate-motivated killings, sexual violence, torture, and illtreatment (United Nations General Assembly, 2015). In the United States, GBV disproportionately affects the LGBTQ community with approximately 3,500 reported incidents of hate violence in 2014 and 2015 (Jindasurat & Waters, 2015; Waters, Jindasurat, & Wolfe, 2016). Given that GBV is prevalent on a global and national scale, it is essential to find methods that mobilize community responses. Traditionally, empowerment training for survivors, masculinity norms education for men and boys, and social norms media campaigns are used to address GBV (Arango, Morton, Gennari, Kiplesund, & Ellsberg, 2014; Heise, 2011). For 20 years, photovoice has served as both participatory research methods and interventions (Catalani & Minkler, 2009; Viswanathan et al., 2004; Wang & Burris, 1997). Reviews of photovoice studies indicate that photovoice is a powerful tool for reforming various social problems (Catalani & Minkler, 2009; Viswanathan et al., 2004), and many photovoice projects endeavor to respond to factors associated with GBV. A search through photovoice scholarship does not reveal

any systematic reviews of photovoice studies aimed at reducing GBV. Thus, this current qualitative systematic review seeks to address a gap in the scholarship focused on GBV prevention, response, and photovoice methodology. The aim of this review is to summarize and synthesize qualitative research that explores the impact photovoice action research (PVAR) methods have on individuals and communities that have been victimized by GBV. A second goal is to provide practitioners, researchers, and policy advocates with recommendations based on the findings of this review.

GBV GBV is prevalent worldwide and in the United States (Black et al., 2011; World Health Organization, 2012). GBV results from hegemonic gender role expectations and is comprised of violence that reinforces unequal power relations between masculine and feminine gender identities and expressions (Bloom, 2008). In other words, GBV is the “physical, sexual, or psychological harm that reinforces female subordination and perpetuates male power and control” (United Nations High 1 2

University of Texas San Antonio, San Antonio, TX, USA Center for Positive Sexuality, Los Angeles, CA, USA

Corresponding Author: M. Candace Christensen, University of Texas San Antonio, 501 W. Ce´sar E. Cha´vez Blvd, San Antonio, TX 78207, USA. Email: [email protected]

2 Commissioner for Refugees, 2003, p. 10). For the purpose of this study, GBV is an umbrella term for domestic violence (DV), intimate partner violence (IPV), sexual violence, and any psychological violence that reinforces unequal power relationships between masculine and feminine gender identities and expressions (Bloom, 2008). Risk factors for GBV (global and within the United States) are assessed at the individual, community, and policy level. At the individual and family level, these risk factors include suffering abuse as a child, witnessing family violence, attitudes that perpetuate violence, gender inequality, hypermasculinity, hostility toward women, strong patriarchal family environment, desire for power and control in relationships, and experiencing poor parenting as a child (Morrison, Ellsberg, & Bott, 2007; United Nations Women, 2012; WHO, 2012). At the community level, social norms and practices that situate women to have less social and political status than men perpetuate the acceptability of GBV (Ali & Naylor, 2013; Garcıá-Moreno et al., 2005). Social policies that raise the risk for GBV include gender-based limits to resources such as education, health care, acquiring property, or divorce (United Nations Children Fund, 2008; United Nations SecretaryGeneral, 2006). Notable gaps in GBV research exist. Research on GBV has primarily focused on women and children (Carlson, 2000; Decker, Miller, Illangasekare, & Silverman, 2013) and while this research includes women and children who embody a diverse range of identities and positionalities, it is only the past 20 years that researchers have considered the impact race, culture, and ethnicity play in how GBV is perpetrated or prevented (Bent-Goodley, 2001; Carlson, 2000; Field & Caetano, 2004; West, 1998). Moving beyond women and children, there is an emerging corpus of research that identifies how GBV impacts the LGBTQ community (Carlton, Caettano, & Gebhard, 2015; Goldblum et al., 2012; Messinger, 2011; Waldner-Haugrud, Gratch, & Magruder, 1997). Further, most GBV research concentrates on victimization, with less research giving attention to perpetration (Decker et al., 2013). These gaps in scholarship on GBV provide future research opportunities.

Overview of Solutions Many researchers critically review interventions that endeavor to prevent and respond to GBV (Arango et al., 2014; Cooper et al., 2013; Ellsberg et al., 2015; Heise, 2011; Morrison et al., 2007). Researchers classify interventions into two domains: (a) primary prevention, preventing the violence from occurring and (b) secondary intervention, reducing the impact of the violence (Cooper et al., 2013). First, primary prevention interventions strive to change attitudes that perpetuate the acceptability of violence (Heise, 2011; Morrison et al., 2007). Prevention education seeks to change misogynistic and homophobic sociocultural norms by promoting nonviolent behavior and challenging masculine gender norms that subordinate feminine gender norms (Morrison et al., 2007). Examples include empowerment training for those at risk for being victimized,

TRAUMA, VIOLENCE, & ABUSE XX(X) programming that challenges masculine norms, dating violence prevention programs, and social norms marketing campaigns (Ellsberg et al., 2015; Morrison et al., 2007). Empowerment training for those at risk for being victimized and dating violence prevention programs show the most promising evidence for effectiveness (Arango et al., 2014; Ellsberg et al., 2015). Second, secondary prevention interventions concentrate on the violence once it has already been perpetrated. These interventions support survivors through medical, counseling, and advocacy services, perpetrators through counseling and behavioral change strategies, and society at large through marketing campaigns to socialize others to embodying gender norms that promote gender equality (Cooper et al., 2013; Ellsberg et al., 2015; Morrison et al., 2007). Extensive reviews of these programs do not reveal sufficient evidence to deem them effective; the marketing campaign is the most promising with mixed results (Arango et al., 2014; Ellsberg et al., 2015; Morrison, et al., 2007). As such, additional research is needed to examine the impact interventions have on GBV. Photovoice as an intervention for GBV is underexamined.

Photovoice Research Photovoice action research is a community-based participatory research (CBPR) method, which engages participants in taking photographs about a topic of concern, critically reflecting on the topic, and developing solutions to address the problem (Wang & Burris, 1997). This approach is grounded in critical consciousness (Freire, 1973/1990) and feminist theory (Weiler, Giroux, & Freire, 1987) as described by Wang (1999). The goal of PVAR methodology is to use community-based descriptions of a social problem (photographs and narratives) as a tool for social change. PVAR is “a process by which people can identify, represent, and enhance their community through a specific photographic technique” (Wang, Cash, & Powers, 2000, p. 82). For example, a PVAR project directed toward responding to GBV gathers together community members (informants) who have experience with GBV, involves them in describing their perceptions of GBV through taking photographs and describing (narrating) the photographs, then displays the photographs for the larger community. After the public display, the informants critically reflect on the data they presented and the new data they gathered from the community’s response to the photographs. This critical reflection is used to develop a tangible list of solutions targeting the problem. Wang and Burris (1997) developed PVAR methodology to encompass three goals: (a) empower people to articulate strengths and concerns about their community; (b) initiate dialogue between community members, stakeholders, and decision-makers about important issues utilizing photographs; and (c) influence community practices to mitigate community issues. The object of PVAR methodology is to give research participants a mechanism to illustrate and discuss issues in a public forum and develop a multipronged plan for rectifying the issue. Informants, stakeholders, community leaders, and other residents are involved in this plan; first, through viewing

Christensen the displayed photos and second, through devising and supporting the change effort (Wang & Burris, 1997). Photovoice is beneficial to community members because it bears witness to their experiences, provides emotional and social support, and generates possibilities for how the community can respond to the problem (Wang, 1999).

Theoretical Framework The design of this study engages a critical feminist perspective because critical consciousness (Freire, 1973/1990) and feminist theory (Weiler et al., 1987) are the basis for PVAR methodology. A critical feminist perspective infuses the design of a study with a methodical examination of how patriarchal constructs of gender are related to the problem and how gender oppression intersects with other forms of oppression (race, class, sexuality) to create a compounding and interlocking system of domination (Collins, 1990/2009; Crenshaw, 1991; Devault, 1999; Fine, 1992). Further, the critical feminist lens has been essential for recognizing, naming, and addressing GBV. Critical feminism privileges marginalized experiences and uses those experiences as the basis for constructing violence-free homes and communities.

Rationale for the Study and Research Question Although researchers have written several critical reviews evaluating the effectiveness of a wide array of interventions aimed at preventing and responding to GBV, these reviews illustrate that there is insufficient evidence to determine the effectiveness of most interventions being used by practitioners (Arango et al., 2014; Ellsberg et al., 2015). Further, these reviews have not considered studies that use qualitative methods or alternative interventions, such as PVAR, which centralizes GBV survivors as researchers. This finding illustrates the need for producing reviews on interventions that evaluate CBPR methods, such as PVAR. This research method has not been evaluated in previous critical reviews of GBV interventions, despite its 20-year history. CBPR studies are grounded in community members’ perceptions and experiences, thus the current study will provide distinctive contributions to the GBV intervention literature. The question guiding this qualitative systemic review is how do PVAR methods address GBV among individuals and communities that have experienced GBV?

Design The protocol for this qualitative systematic review was created based on the Cochrane Handbook for Systematic Reviews (Higgins & Green, 2008), the Supplementary Guidance for the Inclusion of Qualitative Research of Interventions (Noyes & Lewin, 2011), and Methods for Synthesis of Qualitative Research: A Critical Review (Barnett-Page & Thomas, 2009). The included studies used qualitative research method and PVAR methods.

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Search Methods and Inclusion/Exclusion Criteria I based the study protocol, research question, inclusion and exclusion criteria, and the search strategy on the previously mentioned sources (Barnett-Page & Thomas, 2009; Higgins & Green, 2008; Noyes & Lewin, 2011). The title of the search was Using Photovoice to Address Gender-based Violence. Two tables (see Tables 1 and 2) illustrate the inclusion and exclusion criteria for studies that would be considered for the review. The tables were created based on the Effective Practice and Organization of Care Review Group data collection checklist (2010).

Search Strategy Several sources informed my choice of databases for the literature search. I considered my previous experience doing literature searches for PVAR studies and studies focused on GBV prevention, written descriptions about each database, and availability through the university library. In an effort to conduct a wide search, I used two different master databases: EbscoHost and PsychInfo Proquest. Within the EbscoHost Database search, I included the following subdatabases: Academic Search Complete, Alt Health Watch, Communication and Mass Media Complete, ERIC, MasterFile Complete, MEDLINE, Psych Extra, Psychology and Behavioral Sciences Collection, SocIndex, Communication Abstracts, Criminal Justice Abstracts, and Family Studies Abstracts. The PsychInfo Proquest search did not include additional databases. I followed the recommendations explicated in by Booth in Chapter 3 of the Supplementary Guidance of the Cochrane handbook (Noyes & Lewin, 2011). I developed key word search strings based on existing PVAR and GBV prevention research. The EbscoHost search yielded 7 studies and the PsychInfo search procured 13 studies (see Table 3 for key word search strings and the search results). In an effort to find as many eligible studies as possible, I also examined the references of the 20 articles procured through the database search. This search yielded five new studies. I also investigated the bibliographies of authors that published studies that met the inclusion criteria. This search yielded three new studies.

Screening/Sifting I reviewed all 28 found articles. This review resulted in the elimination of 11 publications that did not meet the inclusion criteria. Articles did not meet inclusion for the following reasons: (a) eight studies did not specifically address GBV, (b) one article did not present research findings, and (c) one article was written in Spanish only.

Data Extraction I used the National Institute for Health and Clinical Excellence (NICE) data extraction format as described by Noyes and Lewin (2011) which categorizes the extracted data according to the following categories: type of study, description of participants, study aims, key findings, discussion, and implications.

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TRAUMA, VIOLENCE, & ABUSE XX(X)

Table 1. Inclusion Criteria. Category

Criteria

Justification

Study design

Qualitative methodology, photovoice data collection methods Intervention must use photovoice, intervention is prevention focused Primary and secondary survivors of GBV

Photovoice was established using qualitative research paradigms and methods (Wang & Burris, 1997) The purpose of this qualitative systematic review is to assess the impact of photovoice methods Globally, up to 62% of women, approximately 10% men, and up to 25% of the LGBTQ community have experienced some form of GBV, over the life span (Garcıá-Moreno, Jansen, Watts, Ellsberg, & Heise, 2005; Waters, Jindasurat, & Wolfe, 2016) Given the prevalence of GBV, it seems prudent to explore potential interventions The settings are determined based on locations where previous photovoice research has been conducted (Catalani & Minkler, 2009) This assessment is adapted and used in a number of qualitative systematic reviews (Glenton et al., 2013; Hannes & Macaitis, 2012) The primary outcomes are based on the goals of photovoice research (Wang & Burris, 1997)

Intervention Participants

Participant problem Gender-based violence Setting

School and community settings

Quality criteria

Time frame

Critical Appraisal Skills Programme–10 questions Increase community awareness of GBV and develop indigenous solutions for the problem. 1997–2015

Language

English language only

Primary outcomes

Wang and Burris developed the methods (1997). Any article published after 1997 Due to not having the resources to translate articles, English-only journals will be searched

Table 2. Exclusion Criteria.

Table 3. Key Word Search String.

Category

Criteria

EbscoHost (Academic Search Complete, Alt Health Watch, Communication and Mass Media Complete, ERIC)

Study design

If studies found do not discuss using photovoice, they will be excluded from the review Studies that do not assess photovoice as a tool to address GBV will be excluded Participants that do not include primary survivors or secondary survivors of GBV (primary survivors have been victimized by GBV and secondary survivors have witnessed or have personal ties to someone that has experienced GBV) Studies that do not explore gender-based violence will be excluded Studies that do not explore the impact photovoice has on addressing GBV will be excluded Studies published before 1997 will not be included; Wang and Burris established the photovoice method in 1997 Due to not having the resources to translate articles, studies published in any language besides English will be excluded

Intervention Participants

Participant problem Primary outcomes Time frame

Language

I extracted both the text as it is written by the authors of the publications and quotations the authors used to support their findings. The data synthesis included (a) text written by the publication authors and (b) quotations from the study participants from the published manuscripts.

Methods for Synthesis For this study, the methods used for data synthesis are based on grounded theory (GT) as described by Charmaz (2014).

MasterFile Complete, MEDLINE, Psych Extra, Psychology and Behavioral Sciences Collection, SocIndex Communication Abstracts, Criminal Justice No. of Citations Abstracts, Family Studies Abstracts.) [(Gender-based violence) OR (domestic violence) OR (intimate partner violence) OR (sexual assault) OR (sexual violence) OR rape] 159,826 [(photovoice*) OR (photo-voice) OR (visual 2,154 sociology)] Search with the two search strings using AND 7 PsychInfo No. of Citations [(Gender-based violence) OR (domestic violence) OR (intimate partner violence) OR (sexual assault) OR (sexual violence) OR rape] 34,176 [(photovoice*) OR (photo-voice) OR (visual 901 sociology)] Search with the two search strings using AND 13

Grounded theory constructs theory that is “grounded” in the data; analysis of the raw data (both words from the researchers and the informants) informs the development of constructs. Researchers have established and articulated how to use GT methodology (and methods) for conducting a systematic review of qualitative studies (Chen & Boore, 2009; Eaves, 2001). These researchers argue that multiple schools of thought exist on how to approach GT data analysis (e.g., Glaser & Strauss, 1967 vs. Charmaz, 2014) and that the challenge is to identify which method aligns best with the given research

Christensen

Figure 1. Conceptual model.

project. After reviewing different approaches to GT, I find that Charmaz’s (2014) approach is the best fit for this project, because it provides mechanisms for organizing large amounts of data that are collected, analyzed, and presented in diverse ways. Charmaz’s (2014) instructions for developing codes and categories that lead to a conceptual model (the theory) provide a systematic, structured approach to conducting an in-depth analysis of rich, varied forms of data. For this study, the data analysis methods follow Charmaz’s (2014) approach to GT research. The first step involves intensive coding. I use line-by-line coding, which involves developing in vivo codes (p. 134) of particularly rich segments of the data. The next step is comprised of using focused coding, which involves recoding the data with conceptual codes that emerge from the line-by-line analysis (pp. 139–161). The second step includes the focused coding process, which results in the emergence of several categories: (a) illustrating the problem, (b) caring for self and others, (c) harnessing community resources, and (d) transgressing the violence. Third, I reexamine the data to search for confirming and disconfirming evidence to support or revise these four categories (pp. 193–224). After reexamination, I conclude that the category of transgressing the violence represents the primary outcome derived from participating in PVAR. Finally, I reexamine the data, as it is organized into categories, to determine what relationships exist between the categories (see Figure 1 for an illustration of these relationships). Determining these relationships is where the GT emerges (pp. 225–259) and these relationships are illustrated in the results below.

Reflexivity With a critical feminist lens, the researcher is attuned to the exercise of power through the complete unfolding of a research project (Hesse-Biber & Piatelli, 2012). This lens asks researchers to reflect on how power is used through the construction of knowledge. For this study, I engaged in critical reflection as to how my power as a reviewer of research would shape knowledge produced about PVAR that addresses GBV. I wrote memos that examined the implications of decisions made

5 through this research process, and I engaged in peer debriefing with colleagues who also practice critical feminist reflexivity in their research. For example, the focus of this study is borne out of my past experiences with related research that is tied to my identities as a performing artist, feminist, and survivor of GBV (Christensen, 2013). My challenge was to maintain awareness and document how my previous experiences shaped the decisions I made through the research process. Through memo writing, I documented data collection and analysis decisions and processed those decisions with my peers. This effort ameliorated the possibility of pushing the data synthesis in a direction that would not represent the original findings of each study. Further, it is through critical reflection that I saw how my personal relationship to this study situated me to have an insider’s perspective that aligns with the goals of PVAR aimed at addressing GBV.

Results The data synthesis results in the emergence of one primary category that seems to authentically represent the results from all the publications included in this review: transgressing the violence. In the final stage of analysis, it became clear that transgressing the violence acts as an umbrella for the other three categories: illustrating the problem, caring for self and others, and harnessing community resources. Transgressing the violence serves to conceptually integrate the findings that emerge in each of the 17 publications, and the three secondary categories represent strategies that the informants use, via the photovoice projects, for transgressing the violence (see Online Supplemental Appendix for information about each of the included studies).

Transgressing the Violence This category refers to the way in which participating in a PVAR project that examines GBV helps the participants to disrupt, reorganize, activate, recover, restory, reclaim, and/or represent their perceptions and experiences so that they no longer feel trapped, victimized, imprisoned, defined by, or contained by the violence. These participants are not merely transforming as a result of their participation, they violate sociocultural norms by way of dismantling the identities, stereotypes, and social statuses that perpetuate the acceptability of this kind of violence and situate the informants as primary or secondary victims. These informants refuse to conform to the social laws that say they must accept GBV as a norm for those that do not embody heterosexual male supremacy. The informants develop strategies they can use to transgress the violence, and this development involves illustrating the problem, caring for self and others, and harnessing community resources. Transgressing the violence is an intrapersonal, interpersonal, communal, and systemic way of bearing witness to the violence that these informants have experienced. The informants accomplish this transgression by using specific strategies

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that lay the foundation for a life without the violence. These new possibilities have the end goal of allowing the informants to be emotionally and physically present in their worlds without fear of violence and giving them the tools to stop the violence should it reemerge (see Figure 1 for a model conceptualizing the relationships between the categories). Illustrating the problem. Illustrating the problem transgresses the violence by depicting the problem as it is perceived and experienced by the survivors of the violence. This depiction counters narratives about the violence that have historically marginalized, silenced, or distorted the survivors’ point of view of how the violence impacts them. Moletsane and colleagues (2007) conducted a PVAR study with 21 girls and boys in eighth and ninth grade in KwaZuluNatal, South Africa: Of particular relevance to this project were the children’s photographs and writings depicting HIV-related stigma and it’s negative impact on both the individual and the community. Many wrote about instances in which people have been shunned and isolated by friends, disowned by family, discarded because “they are no longer needed,” and driven out of communities because of their HIV-positive status . . . . To illustrate this, one photograph depicts a boy beating his girlfriend because she has disclosed to him that she is HIV positive: “He does not accept that she is HIV positive and chooses to beat her. He thinks she has infected him and thinks that by beating her he will silence her because he does not want people to know . . . .” (translated from IsiZulu) (Moletsane et al., 2007, p. 25)

Participation in this PVAR project allows these children to transgress the assumptions adults in their community have about them and assumptions the children may have about themselves. Adults may presume that these children are not aware or affected by the GBV being perpetrated within their communities. These children may assume that their perceptions of the violence are not important to adults. The PVAR project gave these children the opportunity to illustrate the problem as they perceive it and develop solutions for intervening against the violence (see the corresponding quotation in the caring for self and others category for details about how these children propose a solution). Below, Frohmann (2005) completed a PVAR project with 42 women who identify as Mexican or South Asian immigrants and have survived GBV and described the outcome of a public display of the informant photographs and narratives: Viewers of the exhibit not only learned about the lives of women who have been or are battered, they also learned about their own stereotypes and assumptions about battered women and Mexican immigrant women. The cultural images of battered woman as victim, a person without agency, someone who is not us, are challenged by the images and stories of the participants. The images also shatter stereotypes of Mexican immigrant women as simply passive victims of machismo, locked into traditional gender roles. Instead, we are presented with the multidimensionality of women’s

lives, their strengths, and their struggles. They are women with agency who put themselves in the public eye to create change. (Frohmann, 2005, p. 1430)

Frohmann (2005) describes how her PVAR project results in the transgression of labels assigned to Mexican immigrant women who have survived GBV. The informants learn to dismantle their own assumptions about their victim status (e.g., a victim is not agentic) and to see themselves as strong survivors. The community that bears witness to the photo exhibit absorbs the power embedded in the images and narratives produced by the informants, which dissolves assumptions about GBV survivors (e.g., victims as passive objects for male violence). Ten years after publishing a book in partnership with 20 Maya Ixil Women of Chajul (Guatemala), Lykes (2010) reexamines her experience with that project and discovers the following: Through creative dramatisations and dialogue women performed emotional, non-verbal and oral representations of their social suffering, experiences that were then re-storied in the texts and images that they combined . . . . Over time they constituted and performed new subjectivities as photographers, oral historians, bookkeepers, project coordinators, marimba players and, in one case, a single mother whose children were conceived through sexual pleasure, not rape. (Lykes, 2010, p. 241)

Lykes (2010) is illustrating how participation in the PVAR project results in a multidimensional transformation for the study informants. The women use the project to transgress and reconstruct representations of their suffering, which results in the informants taking on new roles within their communities, such as active agents of change who aim to preserve their cultural identities and reimagine how they have been situated as indigenous women. Caring for self and others. Caring for self and others transgresses the GBV because it teaches the survivors to have selfcompassion, to ameliorate self-blame for the violence, and to create a support system for the informants. Within this support system, the informants have emotional and tangible support from others, with similar experiences and goals, to transgress the violence through healing. The following quotation is from a PVAR study by Haymore and colleagues (2012) that focuses on offering support to women who survived GBV: Our findings suggest that the program did help the participants to creatively express their stories of past victimization, discuss the range of their lived experiences with violence, address issues of blame, and increase their available social support (14/19) . . . . The nonjudgmental environment permitted them to reflect on their own experiences and where they were in the healing process. (p. 11/19)

The PVAR process provides the informants with an opportunity to openly reflect on their experiences and share that reflection with others who have had similar experiences. This sharing

Christensen helps the informants to ameliorate the self-blame they carry for the abuse and develop pertinent social connections that provide emotional, social, and communal healing. Sharing this experience transgresses the violence by giving the informants emotional support to reform their self-perceptions as alone and powerless. Moletsane and colleagues (2007) conducted a series of photovoice projects in South Africa associated with understanding how HIV/AIDS1 affects underrepresented communities. Through this exploration, the researchers found that GBV was associated with misconceptions about the contraction and spread of HIV/AIDS. This quotation is from a photovoice project implemented with schoolchildren living in a community acutely affected by the disease: A theme which ran through many photographs was the notion of friendship and the role of friends in taking action against stigmatisation on behalf of infected and affected others. A learner wrote: “I am writing about this picture because the one lying down has the disease HIV and AIDS. Now she is continuing with school. Some of her friends have run away because they see that she has this disease. Then, one of her friends remained behind because the others tell themselves that a person with that disease should not be touched. Now this one understands the state of this girl.” (Moletsane et al., 2007, p. 26)

This quotation illustrates how the photovoice project gives the child informants the opportunity to transgress the violence by showing empathy for those affected by HIV/AIDS. This act of caring, this display of friendship, transgresses the violence perpetrated against those infected with HIV/AIDS by establishing a new cultural norm for how to respond to the disease. The photovoice experience creates the opportunity for these children to develop a more empathic response to peers who are infected. The same group of researchers I mention in the previous quotation (de Lange, Mitchell, Moletsane, Stuart, & Buthelezi, 2006) conducted a photovoice study with educators2 enrolled in a master’s of education module on research methodology. The purpose of this project is to see whether informants embodying more powerful identities (teachers vs. students) illustrate similar strategies for addressing HIV/ AIDS compared to the schoolchildren in South Africa. The publication includes several photonarratives (a selection of photos with text) depicting how the educator informants viewed HIV/AIDS and strategies for addressing the problem. The third photonarrative, in this publication, illustrates how GBV is associated with how the informants understand the problem: The third photo-narrative explored domination, bondage and restrictive role expectations, particularly in male–female and intimate heterosexual relationships, symbolised by shackles and physical barricades in the selected photographs. The narrative raised the question whether causes for the high infection rates lie in unequal power relations between men and women . . . . It also raised the

7 question of what would happen if these “shackles” were broken and there was genuine gender equality. (p. 54)

The final photonarrative centers on the theme, “A sense of hope,” and illustrates physical depictions of people hugging and smiling and a small group of people engaged in conversation. The text describing this photonarrative is as follows: This photo-narrative consisted of a selection of ten photographs and contrasted the previous narrative in that there was a firm suggestion of hope in the title, “Do not lose (sic) hope.” Unlike the other narratives, this one looked to the future and presented the future scenario as hopeful. Could the hope lie in being there for the other? That in together there is strength? (de Lange et al., 2006, p. 59)

This first quotation shows how the informants see that gender inequality as a direct cause for high HIV infection rates among women. One of the root causes of GBV is individuals’ beliefs and cultural norms that perpetuate gender inequality. The first quotation asks how can this violence be transgressed? The second quotation illustrates a potential solution “being there for the other.” The first quotation illustrates the problem and the second quotation depicts a strategy for addressing the problem. It seems that the informants perceive caring for others as an integral element of generating hope for thwarting the social stigma and GBV that permeates a community affected by HIV/AIDS. Harnessing community resources. Harnessing community resources transgresses the violence by helping the informants to locate and bolster resources and engage in advocacy for preventing and responding to the GBV. Moya, Cha´vez-Baray, and Martinez (2014) worked with 22 Mexican immigrant women who had experienced GBV in a PVAR project: Group discussion participants also described how structural barriers like stigma, discrimination, humiliation, oppression, economic control, and fear have forced victims of IPV to hide their struggles . . . . Participants discussed and proposed a “Call to Action” that included several items to help prevent and address IPV and improve sexual and reproductive health. These included increasing the visibility of people affected by domestic violence, working for equality, raising awareness, increasing prevention services, identifying strategies to reach affected victims and aggressors, allocating funding and resources for domestic violence, and increasing the quality of and access to sexual and reproductive health. (2014, p. 885)

Participants in this project develop a plan for locating and bolstering community resources that respond to GBV. This quotation portrays how the informants transgress the violence by documenting systemic challenges that prevent an adequate defense against GBV which, in turn, inspires the informants to cultivate a grassroots action plan to transform these structural challenges into strategies that may prevent and respond to GBV.

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With this book chapter, Mitchell (2009) is illustrating the results of a PVAR project she conducted with seventh-grade students in Swaziland, South Africa: But it was the photographs of the toilets that were particularly revealing . . . pupils mentioned that they were not safe for girls. “You can be raped in the toilets,” wrote one of the girls. The “making public” process itself was an interesting one . . . at a regional UNICEF workshop on girls’ education, at an international workshop on Gender and Human Security, and at a conference on gender equity in South Africa—I have found that the image of the toilet has provoked a great deal of discussion among participants, and in the instance of UNICEF . . . has led to some new alliances between the Child Protection Unit and those working on Water and Sanitation. (Mitchell, 2009, pp. 66–67)

Mitchell is portraying, in this quotation, how the photograph data, from a PVAR project, document a problem with sexual violence about which stakeholders were not previously aware. From the point of view of schoolgirls, the toilet is a site of danger, something teachers or other adults have not previously recognized. The PVAR project helps these schoolchildren transgress the violence they experience or witness by giving them the opportunity to depict and discuss safety issues they see within their school environment. The photovoice project gives the child informants the platform to illustrate danger in the toilets, which raises the awareness of stakeholders, and results in the formation of new alliances between nongovernmental organizations and public service systems. This final quotation is from a photovoice project conducted by Jategaonkar and Ponic (2011) with women who are struggling to find safe housing after leaving a violent relationship. As part of this project, the researchers use the photovoice data, generated by the informants, to develop policy recommendations with the aim of bolstering community resources for safe housing for survivors of GBV: We urge the federal and provincial governments to develop strategies that address the needs of women leaving violent relationships, including the following:

Develop a national housing strategy that includes attention to the needs of women leaving violence and the provision of family housing, broaden the CMHC criteria for “acceptable” housing to encompass a measure of safety, increase the supply of nonprofit housing and cooperative housing, including units appropriate for families and women with disabilities, monitor and establish accountability mechanisms for the conditions/standards of rental housing available on the private market, and develop integrated health and mental wellness services for women and children who have experienced violent relationships (Jategaonkar & Ponic, 2011, pp. 51–52).

This quotation reveals how the data captured by the informants represents their experience of the problem, which includes a failure to provide safe housing to women leaving violent relationships. This list of recommendations shows a clear link between the photovoice data generated by informants and the development of policy recommendations that could address the problems depicted by the informants. This project transgresses the violence experienced by the informants through using the informants’ indigenous representation of the problem to develop solutions based in the community.

Summary of Results The results from the GT data synthesis reveal how PVAR methods address the GBV in a complex, multilayered manner. These PVAR studies depict strategies the informants use to transgress the violence present in their communities and these strategies include illustrating the problem, caring for self and others, and harnessing community resources. Participation in the projects help GBV survivors to illustrate the problem in a way that challenges internalized beliefs and stereotypes that perpetuate the stigmatizing nature of being a victim of GBV. The results of the photovoice studies also expose how participation in the PVAR promotes social support, amelioration of self-blame, and empathy for those afflicted by specific social problems. Finally, the reviewed studies bring to light how photovoice research generates community-based illustrations of the problem and methods for addressing the problem that are grounded in creating grassroots advocacy that begins in the community and influences governing systems.

Quality Appraisal For this review, I used the Critical Appraisal Skills Programme (CASP; CASP, 2013)–10 questions to assess the methodological quality of each published article. This assessment has been adapted and used in a number of qualitative systematic reviews (Glenton et al., 2013; Hannes & Macaitis, 2012). The CASP worksheet is comprised of 10 questions that evaluate the methodological rigor and transparency of the research methods. Based on the results from the CASP assessment, most of the studies adequately cover at least 5 of the 10 quality criteria. Each publication sufficiently speaks to the following CASP criteria: (a) states the aims of the research, (b) justifies the use of PVAR methods, (c) describes how PVAR responds to the aims of the research, (d) illustrates how taking the photos aligns with the research purpose, and (e) states clear findings from the research. Many of the publications do not adequately address the following CASP criteria: (a) provides an in-depth description of the data analysis methods, (b) critically examines the relationship between the researcher(s) and the informants, and (c) describes how ethical issues are considered. However, six of the included articles are narrowly written as book chapters which do not focus on details about the research process. Further, word and page limits for manuscript publication may have forced authors to leave out information. It is possible that each

Christensen research team used all 10 CASP assessment criteria but needed to cut details to fit within the editorial specifications (see Table 4 for specific details about how each publication scores according to the CASP criteria).

Implications From the Review Each of the articles reviewed for this synthesis contains valuable findings, which can inform future practice, policy, and research on using PVAR methods to address GBV. It appears that using PVAR to address GBV does give the PVAR participants specific strategies they can use to heal from the violence, raise the awareness of their community about the violence, and identify resources aimed at ameliorating the violence (See Table 5 for a list of implications). Three primary practice recommendations emerged from the review: (a) implement a display of the photovoice data (the photographs and narratives) for stakeholders, (b) foster social support among informants, and (c) focus on the sustainability of a project. This first recommendation is not new to PVAR practice, but this review reifies the powerful outcomes that occur when the photovoice data are shared with community stakeholders (Frohmann, 2005; Lykes, 2010; Mitchell, 2009; Mitchell et al., 2006b). For example, seventh-grade students took photos of unsafe spaces at their school, and the photos were shown to teachers and school administrators (Mitchell et al., 2006b). The adult stakeholders said that the photos illuminated safety issues about which they were previously unaware. This second recommendation is a consistent finding from PVAR GBV research; the participants derive emotional and social support from the PVAR experience; and this emotional and social support act as both a tool for healing from the violence and a way to prevent the violence from reentering their lives (Frohmann, 2005; Haymore et al., 2012; McIntyre, 2003). The emotional support quells the self-blame many survivors of GBV carry, and it acts as a buffer against violence-prone relationships reentering their lives. Researchers should consider designing PVAR GBV projects in a way that allows the participants to develop emotional and social support from one another. The third implication is implied within the community-based design of PVAR; however, few studies are explicit about the sustainability of a given project. Several studies mention that the participants want guidance and resources on how to sustain the PVAR project or use the results to advocate for community-based change (Frohmann, 2005; Haymore et al., 2012; Lykes, 2010; Moya, Cha´vez-Baray, & Martinez, 2014). Within the design of a PVAR project, researcher-practitioners should consider mentorship of the participants on how they may maintain and grow the project beyond the PVAR study. The results of this research synthesis did reveal several implications for policies that govern the development and implementation of PVAR GBV studies. This review reveals the need for university and government support to develop and implement PVAR studies aimed at addressing GBV, such as policies to manage the expenses involved in implementing

9 PVAR studies (Frohmann, 2005; Ponic & Atkey, 2014; Taylor, de Lange, Dlamini, Nyawo, & Sathiparsad, 2007). This recommendation extends to agencies providing research funds aimed at addressing GBV to include PVAR methods as a legitimate form of intervention evaluation. Finally, institutions of higher education should provide opportunities for students and faculty to receive training for how to implement and fund PVAR GBV research projects. Two primary research implications emerged from the review: (a) devise ethical protocols that address power relations and (b) educate institutional review board (IRB) members about ethical protocols that apply to PVAR GBV projects. When participants are also researchers, rules for maintaining confidentiality, protecting the participants from harm, and accessibility to the data need to be generated in partnership with the informants. This is particularly important when working with participants who have been victimized by GBV. This victimization strips power away from the survivor and leaves them feeling like they have no voice in what constitutes a safe, equal partnership (Ali & Naylor, 2013; United Nations Secretary-General [UNSG], 2006). This means that giving participants choices in how their data are used is even more salient when working with survivors of GBV. Research ethics developed a priori to a PVAR GBV study are inadequate for helping PVAR researchers develop ethical protocols that meet the multiple roles, relationships, and experiences embodied by the informants and researchers. For example, an important aspect of PVAR GBV research is to give the informant the choice to implement a public display of their photographs and narratives, which violates positivist notions of participant confidentiality and is considered harmful to the participant. However, if this a priori ethical protocol is imposed on the informants, that strips the informants of making their own decisions about how to use their data. This lack of power over determining how the data are used reflects a traditional binary where the researcher has power over the informants and may reflect the “power over” dynamics between an abuser and victim (Ali & Naylor, 2013; United Nations Women, 2012). In an effort to address this power discrepancy, PVAR GBV researcher-practitioners should consider (a) developing ethical protocols about data collection, analysis, and dissemination in partnership with the informants and (b) advocating for with IRBs to allow for such a partnership. This second implication means that PVAR researcher-practitioners will need to educate IRBs on how ethical protocols differ for PVAR projects compared to projects developed from a different paradigm. Other research implications that emerge from the review include (a) develop strategies to recruit larger and more diverse samples, (b) combine photovoice methods with other research methods, for example, quantitative, longitudinal, (c) develop strategies to recruit a larger, more diverse sample, and (d) beware of marginalizing indigenous perspectives documented by informants. A few studies recommend devising methods for recruiting more participants and participants with diverse backgrounds (Latourneau et al., 2012; Moya et al., 2014; Taylor et al., 2007). Two of the studies suggest combining photovoice

10


Table 4. Quality Assessment. Authors

Quality Assessment

de Lange and colleagues (2006)

This article adequately addressed 8 out of 10 criteria from the Critical Appraisal Skills Programme (CASP) assessment worksheet. Main concerns (a) authors did not discuss relationship between researcher and participants and (b) the authors did not describe how ethical issues were considered This article adequately addressed 10 out of 10 criteria from the CASP assessment worksheet. The author provided an in-depth description of each aspect of the research methodology, including justifying the methods This article adequately addressed 8 out of 10 criteria from the CASP. Main concerns (a) authors did not discuss relationship between researcher and participants and (b) authors did not provide an indepth description of data analysis This article adequately addressed 9 out of 10 criteria from the CASP. Main concern (a) authors did not discuss relationship between researcher and participants This article adequately addressed 8 out of 10 criteria from the CASP. Main concerns (a) authors did not discuss relationship between researcher and participants and (b) authors did not provide an indepth description of data analysis This book adequately addressed 8 out of 10 CASP criteria. Main concerns (a) authors did not discuss relationship between researcher and participants and (b) the authors did not describe how ethical issues were considered This article adequately addressed 10 out of the 10 criteria from the CASP. The author provided an indepth description of each aspect of the research methodology, including justifying the methods This article adequately addressed 9 out of 10 criteria from the CASP. Main concern (a) author did not discuss implications resulting from the research This book chapter adequately addressed 5 out of 10 CASP criteria. Main concerns (a) authors did not provide an in-depth description of data analysis, (b) authors did not discuss relationship between researcher and participants, and (c) the authors did not describe how ethical issues were considered. This book chapter adequately addressed 3 out of the 10 CASP criteria. Main concerns (a) describe the purpose and aims of the research,(b) authors did not provide an in-depth description of data analysis, and (c) authors did not discuss relationship b/w researcher and participants This book chapter adequately addressed 7 out of 10 CASP criteria. Main concerns (a) authors did not provide an in-depth description of data analysis, (b) authors did not discuss relationship between researcher and participants, and (c) the authors did not describe how ethical issues were considered This book chapter adequately addressed 7.5 out of 10 CASP criteria. Main concerns included the following: (a) authors did not provide an in-depth description of data analysis; (b) authors did not discuss relationship b/w researcher and participants; (c) the authors did briefly mention describe how ethical issues were considered. This article adequately addressed 8.5 out of 10 CASP criteria. Main concerns (a) the relationship between researchers and participants and (b) authors did not provide enough details about the value of this research, particularly, how it relates to similar research This article adequately addressed 8 out of 10 CASP criteria. Main concerns: (a) did not justify the research design; (b) authors did not discuss relationship between researcher and participants This book chapter adequately addressed 8 out of the 10 CASP criteria. The chapter partially addressed the following: (a) relationship between researcher and participants and (b) provide an in-depth description of data analysis This book chapter adequately addressed 9 out of 10 CASP criteria. Main concerns (a) relationship between researcher and participants This article adequately addressed 9 out of the 10 CASP criteria. Main concern (a) relationship between researcher and participants

Frohmann, L. (2005)

Haymore, L. B. and colleagues (2012).

Jategaonkar & Ponic (2011) Letourneau, Duffy, & Duffett-Leger (2012)3 Lykes (2000)

Lykes (2010) Mitchell and colleagues (2006) Friday absenteeism Mitchell and colleagues (2006) Speaking for ourselves

Mitchell, DeLange, Stuart, Moletsane, & Buthelezi (2007) Mitchell (2009)

Mitchell and colleagues (2010)

Moletsane and colleagues (2007)

Moya, Cha´vez-Baray, & Martinez (2014) Ponic & Atkey (2014)

Taylor, de Lange, Dlamini, Nyawo, & Sathiparsad (2007) Umurungi and colleagues (2014)

research methods with a quantitative or longitudinal research design (Jategaonkar & Ponic, 2011; Moya et al., 2014); this effort would provide multiple forms of data (perspectives) on the same research topic, which stands to illustrate a more comprehensive understanding of the issue. Several studies (Lykes, 2010; Mitchell, DeLange, Stuart, Moletsane, & Buthelezi, 2007; Mitchell, 2009) assert that the data analysis must be infused with an awareness of how researcher bias may usurp

indigenous perspectives portrayed by the informants. One objective of PVAR is to understand and report the problem from the point of view of the participants even when this perspective clashes with the researcher’s understanding of the problem. Directions for future research on this topic could go multiple directions. The research on GBV has notable gaps. Research focusing on how GBV impacts the LGBTQ community

Christensen

11

Table 5. Implications From the Review.

Notes

Practice Implement a display of the photovoice data for stakeholders Foster social support among the informants Focus on the sustainability of the project Policy Compose policies that allocate resources to conduct photovoice action research (PVAR) gender-based violence (GBV) projects Fund PVAR GBV studies Provide training for the implementation and funding of PVAR GBV projects Research Devise ethical protocols that address power relations Educate institutional review board members on ethical protocols that apply to PVAR GBV projects Combine PVAR methods with other research methods Develop strategies to recruit a larger, more diverse sample Beware of marginalizing indigenous perspectives documented by participants

1. Gender-based violence (GBV) increases the risk of HIV infection for women, and HIV-positive women report fearing physical violence and community ostracization if they disclose their infection status (Fustos, 2011). 2. The researchers do not identify the participants as primary or secondary survivors of GBV, but educators come into contact with children and families that have been victimized. The participants in this study do meet the inclusion criteria 3. The Letourneau, Duffy, and Duffett-Leger (2012) study provided secondary analysis of two separate studies. The second study engaged the participants in a photovoice project. This table reports on the results from the second study.

remains limited (Carlton et al., 2015; Goldblum et al., 2012; Messinger, 2011; Waldner-Haugrud et al., 1997), and there is a critical need for identifying the causes of GBV perpetration and identifying effective perpetration prevention strategies (Decker et al., 2013). PVAR GBV researchers should consider developing PVAR projects that address these topics.

Conclusion This article is comprised of a qualitative systematic review of publications that report the results of PVAR projects that concentrate on GBV. A GT analysis of the data extracted from the 17 publications reveals one main category transgressing the violence and three subcategories which represent strategies the study informants use to transgress the violence: illustrating the problem, caring for self and others, and harnessing community resources. Practice, policy, and research implications emerge from the review, with an emphasis on designing PVAR GBV projects that can be sustainable, advocating for policies that support PVAR projects, and developing ethical protocols in partnership with the study informants. The results of the review show how PVAR GBV studies stand to make a significant contribution to addressing GBV within a given community and the unique contribution PVAR makes within violence prevention/response research. Declaration of Conflicting Interests The author(s) declared no potential conflict of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

Supplemental Material The online appendix is available online.

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TRAUMA, VIOLENCE, & ABUSE XX(X) Author Biography M. Candace Christensen is an assistant professor of social work at the University of Texas San Antonio. Candace’s research interests primarily concern using feminist research methods to explore gender-based violence prevention and response with youth. Candace was awarded the Feminist Manuscript Scholarship Award for 2013 from the Council on Social Work Education. Her current research is focused on sexual assault prevention and response on college campuses and the use of arts-based research methods to address genderbased violence.