Although only one of the studies aimed to build an intervention based on photo methods, many other studies reported anecdotal participant benefit. These benefits included processing their experience with cancer , feeling empowered and supported [22, 31], improvements in psychosocial stressors , and facilitation of discussions of topics that participants otherwise would have thought to be inappropriate to discuss with others . However, since these outcomes were not quantitatively assessed, the extent to which photo methods serve as an intervention in a cancer population remains unknown. Indeed, a review of photovoice use in public health concluded that extant literature in this space does not typically provide information regarding outcome evaluations . The only quantitatively-assessed outcomes of studies included in this review were depression, quality of life, and spiritual growth , but these reports from additional studies reflect other potential outcomes of interest including social support, self-efficacy, and post-traumatic growth.
In accordance with the principles of a scoping literature review and in order to understand more about what a photo methods-based intervention for cancer survivors could resemble and achieve, we looked to literature in other populations with physical and/or mental illness. Identified studies fall under one of two categories: photo methods alone [40–42] or photo methods as part of a multi-component intervention [43, 44]. Lennon-Dearing and Hirschi developed a 7-week photovoice intervention for women with HIV to document their lives with the express purpose of providing community education . Thus, photovoice was leveraged as an intervention for improving self-efficacy and empowerment by linking it with a broader community education event. Pre-post analyses demonstrated statistically significant improvement in coping self-efficacy. In a randomized pilot study by Werremeyer and colleagues, college students living with a mental illness were randomized to a photovoice group intervention or standard group counseling . Those randomized to photovoice demonstrated a greater reduction in anxiety symptoms over the 8-week program compared to those in the group counseling condition. Wharton and colleagues designed a community education program in which family caregivers of individuals with Alzheimer’s Disease attended four sessions led by a professional photographer. before taking photos for a gallery display . Participants were instructed in principles of photography and photojournalism (Session 1), and then spent the following three sessions viewing and discussing one another’s photographs documenting the caregiver experience. Pre-post intervention results reflected a significant increase in caregiver burden and a reduction in depressive symptoms which did not reach the level of statistical significance, but did reflect clinical significance.
Two studies investigated the use of photovoice in the context of a multi-component intervention for individuals with diabetes [43, 44]. Leung and colleagues used photovoice over the course of a 6-week intervention consisting of group meetings, taking and discussing photographs, goal-setting, and developing action plans to promote increased physical activity as a management strategy to improve diabetes and hypertension . Baig and colleagues integrated photovoice with an educational intervention and group discussion to encourage problem-solving skills, social support, and health behavior change . Both studies conducted qualitative analyses of the themes present in photos taken by participants and also measured outcomes of interest. Both interventions produced positive effects on targeted outcomes including number of steps taken (via accelerometry) , lower body strength and limb flexibility (via fitness testing) , confidence in diabetes self-management , and social support . While Leung and colleagues did not report data related to intervention adherence or satisfaction, Baig and colleagues found that 75% of participants attended at least one session and 52% took photos; in addition, 82% reported that they enjoyed discussing photos with other group members. However, because the control groups in these two studies were waitlist control  and enhanced treatment as usual , respectively, the extent to which photo methods uniquely contributed to improved outcomes in these multi-component interventions remains unknown.
All of the studies implementing photo methods as an intervention tool in the context of chronic physical or mental illness—including the one focused on cancer survivors [13, 14]—involved group discussion. Benefits of this include fostering relatedness and providing peer social support; however, reliance on facilitated group discussion also may pose potential barriers such as schedule conflicts and transportation difficulties. An alternative approach could be to formulate an individual-level photo method intervention such as integrating photo methods with expressive writing to create a self-directed intervention. Expressive writing interventions have been found to be effective in general populations ; however, in cancer populations, documented effects are small or null [46, 47]. Supplementing expressive writing exercises with accompanying photographs could bolster the effects on well-being among cancer survivors and reduce obstacles to attending in-person photo method group sessions. At the same time, expressive writing places a greater demand on individual literacy, whereas photographs eliminate the reliance on reading and writing abilities. Thus, future studies could investigate which methods or combination of methods work best for specific groups.
Results of this review must be contextualized within its limitations. First, the decision to omit non-peer-reviewed sources may have resulted in the skew toward qualitative photo method studies in a cancer population—especially if other interventions had null findings. However, the authors decided a priori that published abstracts were not thorough enough to address the aims of this review. Further, at the time of writing, there were no current or planned studies registered in ClinicalTrials.gov that involved photo methods in cancer. Second, the authors were limited by language constraints and reviewed only studies published in English. Given that many of the included studies took place in countries whose primary language is not English, it is possible that studies written in other languages that otherwise met eligibility criteria were not included in this analysis.
Despite focusing on a medical population, only three studies described an explicit effort to share findings with healthcare administrators and/or providers. None of these studies described what, if any, changes were made in a healthcare setting in response to photo-based investigations. Thus, there is significant opportunity for future studies to develop and evaluate initiatives in the healthcare setting based on themes that emerge from the use of photo methods. Based on the results of this review, photo methods appear to be a powerful approach to generating dialogue and understanding others’ lived experiences—particularly with respect to topics that individuals are otherwise inclined to keep to themselves [33,34]. Oncology providers may find it helpful to ask their patients to share photos from their daily lives that represent their questions, concerns, and hopes for living with cancer, which may serve to improve communication between patient, caregiver, and provider . A brief discussion of photographs during appointments may raise issues outside of providers’ awareness such as psychological concerns, family dynamics, or treatment side effects which can then be addressed directly or through referral. At the same time, providers should be aware of the time and resources required to engage in photo methods and evaluate whether patients and/or caregivers have the actual equipment, time, and energy to take and reflect upon photos in order for the intervention to be successful, and that recording their experiences actually has weight (e.g., emotional catharsis from documenting experiences; contributing to an outreach event; lobbying for better policy).