“I see it now”: Using photo elicitation to understand chronic illness self-management

Abstract

Background

How people integrate self-management into daily life remains underexamined, and such processes are difficult to elicit through traditional approaches used to understand human occupation.

Purpose

This paper will provide a brief overview of one visual research method, photo elicitation, that holds promise for studying self-management of health behaviours and will present findings from an analysis of how the use of photo elicitation interviews contributed additional insights into self-management beyond those generated from the data collected through the other methods used in the study.

Method

A qualitative, multiple-methods, multiple-case study was conducted with a purposive sample of 10 low-income women ages 40 to 64 with type 2 diabetes.

Findings

The photo elicitation interviews contributed insights beyond those generated from other study methods about how individuals viewed their self-management behaviours and how occupations changed across time.

Implications

Photo elicitation is a valuable research method for better understanding clients' chronic illness self-management practices.

Worldwide, chronic illness has surpassed infectious disease as the primary risk for early morbidity and mortality, being responsible for nearly two thirds of deaths worldwide (World Health Organization, 2011). For individuals living with chronic conditions, engaging in chronic illness self-management is essential for reducing medical complications and comorbid conditions (Lorig & Holman, 2003). Important to successful long-term chronic illness self-management is the ability to integrate self-management behaviours into daily routines (Audulv, Asplund, & Gustaff-Norbergh, 2012; Ujimoto, 1998). Numerous modifications of daily occupations are also needed as part of self-management efforts (e.g., altering cooking methods). How people integrate self-management into daily life, however, remains underexamined (Glasgow, 2010). To fill this gap in knowledge, a multiple-methods, multiple-case study was used to examine the process of integrating chronic illness self-management into daily life in a sample of low-income women with type 2 diabetes. Photo elicitation was incorporated into the study design to collect data on how the people, places, and activities inherent in daily routines influenced self-management. The purpose of this paper is to present findings from the analysis of how photo elicitation interviews (PEIs) contributed unique insights about chronic illness self-management above those generated from the other methods used in the study.

Photo Elicitation as a Research Method in Chronic Illness

Chronic illness self-management is a dynamic enterprise. Self-management approaches change as life conditions change, barriers and facilitators change, and people's experiences of them change. However, the intricacies of such processes are difficult to elicit through traditional approaches used to understand human occupation. Participant observation, interviews, and client self-report questionnaires are commonly used to study occupation, and while each offers benefits, all have limitations. For example, participant observation is limited to witnessing current doing and offers little toward understanding how performance and participation have developed and changed though time. Interviews and research questionnaires can offer the advantage of depth of information but are too often administered out of context and after events have occurred. Moreover, dialogue-based methods, such as interviews, may not be seen as “accessible” for certain groups (Affleck, Glass, & Macdonald, 2012). Understanding how people integrate chronic illness self-management involves examining the implicit or taken-for-granted assumptions, value judgments, and perceptions that shape how chronic conditions are managed (Cross, Kabel, & Lysack, 2006). One method that has been successfully used to examine such dynamics is the use of photo methods either alone or in conjunction with other research methodologies (Harper, 2002; Lorenz, 2011).

The emergence of photo methods has been credited to anthropologist Collier (1957) who used photographs to understand the environmental basis for psychological stress. Collier conducted interviews both with and without photographs and concluded that the PEIs produced richer, more specific and focused data than the interviews that did not use photographs. Since Collier published his report, photo methods have been endorsed increasingly by scholars in the fields of anthropology, sociology, and health promotion for their ability to provoke emotional, profoundly detailed, and highly reflective insider accounts of human experience not readily accessed by other methods (Harper, 2002; Lorenz, 2011; Pink, 2001). Two of the most popular and widely used photographic methodologies include photo elicitation (Collier, 1957; Harper, 2002) and photo voice (Wang & Burris, 1997). Photo voice is a photo methodology framework used within community-based participatory action research (CBPAR) project designs that focus on the relationships among people and their social and cultural environments. CBPAR projects emphasize fostering community participation, empowerment of participants, the involvement of local stakeholders, and reaching policy makers (Wang & Burris, 1997). Scholars interested in the use of photo voice in occupational therapy research should read the recent review by Lal, Jarus, and Suto (2012), which provides a more in-depth overview of the method.

For researchers whose project focus falls outside of CBPAR, or who are interested in a less prescriptive approach, the photo elicitation approach is a flexible photo method that, in its most basic form, involves the use of photographs in conjunction with research interviews (Harper, 2002). However, there is a myriad of variations on the method, each of which has potential benefits and drawbacks that must be negotiated in the study design. For example, design questions may include “Who will take the photographs?” (e.g., researchers or participants), “How will the photographs be taken?” (e.g., disposable camera or electronic device), “How will the researcher honour participants desires for anonymity or representation?” (e.g., obscuring identity in photographs), “How will the researcher manage consent of individuals captured by the participant's photographs?” or “How will the researcher structure the interview?” (Clark-Ibanez, 2004; Nutbrown, 2011; Phelan & Kinsella, 2013). These are just a few of the key decisions to consider when using photo elicitation. Despite the many ethical and application dilemmas that must be considered, the PEIs continue to consistently enrich research studies. Not only do PEIs yield a qualitatively different type of data than that derived from other methods, but the use of PEIs can further enhance research interviews by easing rapport building, balancing power dynamics between the researcher and participants, and providing a structure to the interview through the use of and ordering of photographs (Clark Ibanez, 2004; Harper, 2002).

Even though research has established the utility of photo elicitation methods, only a handful of occupational therapy research has incorporated PEIs into the study design. Recent studies conducted within occupational therapy and occupational science have included the use of PEIs to better understand the meaning of co-occupations (van Nes, Jonsson, Hirschler, Abma, & Deeg, 2012); the role of the social environment on health, well-being, and social inclusion (Bishop & Purcell, 2013); the influence of physical and social environments on children's out-of-school time occupations (Harding et al., 2009), and how occupations shape the identity for children with disabilities (Phelan & Kinsella, 2013). As occupational therapy researchers continue to explore new methods for understanding the relationship between occupation and health (and how to best facilitate that relationship), photo methods appear to be particularly promising. The purpose of this paper is to contribute to the ongoing dialogue about the use of photographic methods through presenting the results of an analysis of how PEIs contributed unique insights into chronic illness self-management above and beyond those elucidated from the other methods used in the study.

Method

This research report presents the analysis of data collected as part of a study about the process by which low-income women with type 2 diabetes integrate diabetes self-management (DSM) into daily life. The larger study design was informed by contemporary constructivist and pragmatist epistemologies (Hickman, 2009). DSM integration was conceptualized as a complex social process that necessarily included the individual's experience of DSM while also extending into the larger social sphere. Thus, an individual's reality of DSM was seen as socially constructed through experience within socioeconomic, political, and cultural contexts. In the course of research, the researcher became a part of the ongoing experience. Thus, understandings of the DSM integration process were viewed as co-constructed knowledge emergent from the dialectical process among researcher and participants.

A multiple-case, multiple-methods study design (6 & Bellamy, 2012; Stake, 2006) was used. The case study approach was chosen to achieve a depth of understanding of DSM integration within individual cases and across cases. Specifically, case study approaches are sensitive to the temporal chronology and context of cases (6 & Bellamy, 2012), making it a desirable method for understanding how individuals integrate DSM across time and within particular life contexts. Using multiple methods facilitated understanding DSM integration from a variety of angles. For example, semi-structured interviews provided data on changes in DSM integration across time, while time geographic diaries (TGDs) provided insights into how time use and daily routines shaped the integration process.

Study data collection began with participants completing the Diabetes Care Profile (DCP; Fitzgerald et al., 1996). The DCP is a standardized patient self-report assessment of participants' demographic data along with a self-report of their DSM practices, knowledge, and perception of supports and barriers. For each participant, completion of the DCP was followed by participation in a semi-structured interview, participant-generated photography and a PEI, and completion of a TGD and a follow-up TGD interview.

Study Setting and Sample

The participants in this study were 10 urban, low-income women who met the inclusion criteria of self-reported as either Caucasian or African American, between the ages of 40 and 64, and having a diagnosis of type 2 diabetes. Seven women identified as African American and 3 as Caucasian. Five of the participants were married, 6 were employed full-time, and 9 of the women lived in households with extended family (household size range = 1 to 7 people). The years since diabetes diagnosis ranged from 3 to 30 years. The highest level of formal education within the sample was an associate degree (n = 1). All participants had a household income below 200% of the federal poverty line. Low-income and minority women were purposively sampled because the scientific literature confirms low-income and minority women face the greatest challenges in regard to DSM (American Psychological Association, n.d.). With permission from the medical director, participants were recruited from the ongoing DSM classes offered at a local nonprofit medical clinic. Afterward, potential participants were further screened via phone interview, and if eligible for the study, meetings were scheduled to review the study consent forms, answer additional questions, and obtain informed consent. Participants were also provided a photo-release form whereby participants elected how their photographs and PEIs could be used in the future (e.g., publications, scientific presentations, classroom use, and secondary analysis). The study design and recruitment procedures were approved by the University of North Carolina's institutional research board.

Data Collection

The first author (HF) conducted all data collection and analysis procedures for the study. Each participant completed the following data collection activities to more fully capture the complexity of how participants integrated DSM into daily life. Participants took an average of 7 weeks to complete all data collection activities (range = 5 to 16). Data collection activities occurred in the following order: (a) completion of the DCP and participation in a semi-structured interview, (b) participant-generated photography followed by participation in a PEI, and (c) completing a TGD for 1 weekday and 1 weekend day and participating in a follow-up TGD interview.

The DCP and semi-structured interviews were conducted at either the clinic or a location of the participant's choosing. The semi-structured interview guide used for the study was designed to elicit data on the following aspects of the DSM integration process: (a) experience of DSM through time, specifically from diagnosis onward; (b) past and current process of integrating DSM tasks into daily life; (c) facilitators and inhibitors of DSM from the participant's perspective; and (d) aspects of decisional processes, such as negotiating competing activities/circumstances.

At the end of the first meeting, participants were instructed on the photo elicitation components of the study and given a disposable camera (27 exposures) along with a prepaid mailer for returning the camera. Participants were given the following instruction: “Take photographs of the things you associate with [DSM].” Participants were asked to take their photographs and return the camera at some point during the following 2 weeks. Participants took between 2 and 6 weeks to return the cameras (due to personal situations). On receipt of the returned cameras, the film was taken to a local commercial photo developer. Once the photographs were developed, an appointment was made to meet with the participant for the PEI. At the beginning of the PEI, participants were asked to review their photographs and to select the ones that they wanted to discuss. Each photograph was presented individually as the participants were asked to describe the content of the photo, why a photo was taken (its meaning, value, or representation), where it was taken, and if applicable, with whom the photo was taken (see Table 1). At the end of the PEI, participants were asked to discuss anything that they had wanted to take a picture of but did not because of not having the opportunity or access. At the end of the second meeting, participants were instructed on the TGD components of the study.

Table 1. Sample of a Photo Elicitation Interview Guide.

Can you tell me about this picture?

Why did you take this picture?

What does this picture mean to your diabetes self-management?

Can you tell me about what is in this picture?

Who is in this picture?

Where was the picture taken?

TGDs (Kroksmark et al., 2006; Michelson, 2005) provide a unique method for eliciting data about daily life patterns, including activities completed, time use, and social contacts. Because previous research confirms there is no significant difference between the quality of data when 2 days are recorded versus 3 days or more (Michelson, 2005; Pentland & Harvey, 1999), participants were asked to complete the TGD for 2 days of their choosing (1 weekend day and 1 weekday). Participants were provided with a TGD packet, which included the leave-behind TGD formatted in 15-min intervals and an example of how to complete the diary. The TGD packet also contained the first author's contact information (if participants needed additional guidance) and a prepaid mailer for returning the TGD. Each participant was instructed on how to complete the TGD (including a demonstration). When participants felt confident that they could complete it independently, the TGD was left with the participant. Upon receipt of the returned TGD, an appointment was made with the participant for the TGD interview. Throughout the study, interviews were audio-recorded (with participant permission). Participants received $100 worth of gift cards for their time and effort in completing the study.

Data Analysis

Data analyzed included 10 completed DCPs, transcripts of audio recordings from 30 in-depth interviews, typed field notes from all data collection activities, 182 photographs, and the completed TGDs (both weekend and weekday data). Interview transcripts and field notes were analyzed using the Atlas. ti software package (Scientific Software Company, 2012) guided by a grounded theory approach (Charmaz, 2006). Data analysis began with open coding (coding small segments of text line by line) of all text sources of data. Participants were enrolled sequentially to facilitate theoretical sampling as themes emergent in early cases were explored in later interviews. Open coding was followed by focus coding, which involved taking initial analytical directions developed from the line-by-line coding and applying them more selectively to larger chunks of text (Charmaz, 2006).

The interview texts were also analyzed in conjunction with participants' photographs and TGDs. To analyze the photographs, each participant's transcription was read while viewing her corresponding photographs. Notes were made on the back of the photos to indicate what they represented to the participant. If a particular photograph was not discussed or alluded to during an interview, no information was written on the back other than an ID number to identify the source of the photo. Next, all participant photos were combined and analyzed as a group by participants' explanations of content and by participants' explanation of the photograph's meaning (Riessman, 2007; Rose, 2007). This double analysis of content focus and narrative focus revealed 11 major content categories (e.g., people, places, pets, food items, and media materials) and 20 narrative categories (e.g., strategies, supplies, and change agents). TGDs and TGD interview transcripts were analyzed at several levels to yield different perspectives on how the sequence of daily activities affected engaging in DSM. These included the types of primary and secondary activities that each participant engaged in during a typical day (defined by participants as their normal and usual daily routine), their total time use of activities, the types and frequencies of co-occurring activities, and the structure of their daily routines (Kroksmark, 2006; Michelson, 2005; Pentland & Harvey, 1999).

Data analysis was an iterative process as the multiple sources of data were constantly compared throughout data analysis (intra-case and across cases and data types) as new cases were added and earlier cases were revisited. For example, emerging themes (e.g., responses to a specific photograph, perceptions of the PEIs) were added to as new cases were included in the analysis. Emerging themes and representations, along with discrepancies in the data, were discussed with research colleagues and participants, which contributed to the trustworthiness of the data and led to a more complete understanding of the dynamic nature of illness self-management and its integration into daily life. Data analysis resulted in the development of three primary themes illustrating how the PEIs contributed insight into self-management integration above the contributions of the other methods used.

Findings

The photo elicitation process facilitated highly reflective dialogue between the first author and the participants about how they managed their diabetes. This reflective discourse was heightened through exploring discrepancies that occurred between the data collected through the PEIs and the DCP, interview, and TGD data. Segments of interview transcripts used below to exemplify certain points have been edited for clarity, and all names used are pseudonyms.

Discrepancies and Reflective Awareness

Using PEIs in conjunction with other data collection methods and comparing a participant's reports across data sources revealed points of divergence. Sometimes discrepancies became apparent to participants while viewing their photographs, while at other times, the first author prompted the discussion of such differences. Lydia's and Yolanda's cases provide examples of how the PEI brought discrepancies existent among data sources to the forefront. This in turn led participants to reflect on their differing representations of DSM and the taken-for-granted challenges of integrating self-management into daily life.

For example, Lydia's DCP indicated that she had a good understanding of how to manage her diabetes (score 50/65: Understanding subscale), and she noted that despite not strictly adhering to a diabetes diet, she “mostly” ate healthy vegetables and tried to incorporate them into her diet on a daily basis:

You know you have to cheat every now and then, but I would say I'm not too bad about it and eat what I am supposed to most of the time. The only exception to that is I really do like to have my sweet tea every day. (Interview 1)

Lydia's photographs told a different story. The first author noted the numerous images of unhealthy foods (16 of the 27 photographs in the album). Lydia noted the discrepancy as well. Upon reviewing the photographs that she had taken, Lydia stated,

I was just taking pictures of the stuff I ate during the day. I cannot believe this. You see that box of donuts [see Figure 1]. I remember, I ate the whole box in one day. I mean I knew I cheated sometimes but I can't believe I ate all this!

Figure 1.

Lydia photographed a box of store-bought donuts that she ate in one day and was surprised that she had eaten such unhealthy food.

Lydia continued to explain that her photographs of a two-litre bottle of Coke and a box of pizza came later in the same day. As Lydia viewed the additional photos in her album, she expressed surprise that she had eaten so many unhealthy foods (e.g., cakes, soda, doughnuts, and cookies). Although Lydia was aware that her diet could be better, viewing the photographs prompted Lydia to confront the two disparate representations of her dietary self-management, as she stated, “It's crazy! I mean I obviously ate that, but when you're sitting around with everyone else and they're eating it and you are too, you just don't think about it.” Addressing the discrepancy across the data sources prompted a dialogue about the difference in self-management when one was alone versus when one was around friends and family. In this case, Lydia's spouse worked very long hours and was often away for several days at a time. While alone, Lydia ate “healthy stuff” but when she was with her spouse, Lydia valued providing her spouse with “the foods he likes because he works so hard.” Lydia ate whatever her spouse wanted to eat while they were together, which were often foods that were not “healthy stuff.”

Similar to Lydia's album, Yolanda's was dominated by photographs of unhealthy food and fast-food venues, which stood in contrast to her reports in both the initial semi-structured interview and her comments made prior to receiving her camera. The following segment of text illustrates Yolanda's perception of her self-management and her intention for the PEIs.

HF: How are you feeling about taking the photographs?

Yolanda: I think it will be easy. It might be boring for you though because I pretty much do everything good at this point.

HF: Boring?

Yolanda: You know, the eating, and medicines, and stuff, I got that, it's like whatever you know? But I have been off of my game lately as far as the exercise because of school and all that mess. I think I'm going to take some pictures of that, maybe it'll motivate me.

Yolanda entered the photo elicitation phase perceiving that she managed her diabetes well with the exception of her exercise. During the PEI, Yolanda presented 3 photographs that she described as “motivating me to exercise.” However, 11 of the photographs were images of “junk food,” vending machines, and fast-food restaurants. Toward the end of the PEI, while viewing her photographs organized on the table, HF asked Yolanda the following:

HF: I remember you saying you were OK with, you know, managing your diabetes, except the exercise stuff, right?

Yolanda: Yeah.

HF: Well, I was wondering, I mean I am looking at these and

I am noticing—

Yolanda: Oh yeah, yeah, yeah, I see what you're getting at. Yeah, I see it now when they are out here [in a group] like that.

HF: Yeah, what's that?

Yolanda: The food stuff [laughing] ain't that some mess!

Yolanda went on to share that she had been experiencing a variety of stressors in her life. In particular, she recently enrolled in college course work and was working two jobs while negotiating a strained marital relationship. The recent and significant changes in Yolanda's life situation made it difficult for her to continue to manage her diabetes as successfully as she had in the past. Yolanda concluded that the underlying emotional stress must have led her to engage in “mindless eating.” Yolanda explained, “I thought I did [have my diet under control], but it looks like all I'm doing is not even thinking about what I'm eating right now. I know better. I am not supposed to eat that mess.” Lydia's and Yolanda's cases provide examples of how using PEIs contributed a unique type of data that ultimately allowed the first author to better understand the intricacies of self-management and how beliefs, perceptions, and social context influence self-management practices in ways participants may, at times, not be aware of.

DSM Is a “Never-Finished” Story: Doing and “Doing Better”

After the photo elicitation component of the study, participants completed a TGD and met with the researcher a last time for the TGD interview. Because the TGD interview was the final data collection interview, the first author allotted time at the end to discuss the research experience with participants and revisit any themes that the participants wanted to pursue. Seven of the 10 participants revisited the photo elicitation experience in the final interview and provided examples of how it had influenced them to further modify their behaviour. Revisiting the photographs and participants' responses to their photographs facilitated discussion about DSM as a “never-finished” story, one in which there was always an opportunity to “do better.” Alyssa's and Lori's cases (presented below) provide an example of how participants perceived their performance of DSM and their desire to “do even better.”

Alyssa had proudly presented a photograph of a baked pork chop during the PEI. The photograph was important to Alyssa because it was central to her telling of her story about learning, practice, and change; in essence, it embodied her success in modifying her situation and her own habits to better support her DSM. However, not all of Alyssa's photographs aligned with her perception of herself as a competent and successful self-manager. During our final interview, Alyssa shared how seeing one particular photograph (see Figure 2) had led her to strive to “do even better.” Alyssa stated,

I was so proud of that baked pork chop and had told you I was cutting all this butter and stuff out of my home. … Then I saw those pictures of me making butter biscuits in the morning for breakfast? … Well, I wanted to tell you, they had to go. Those biscuits are no more! I haven't even bought any since the last time we met.

Figure 2.

Alyssa was photographed cooking butter biscuits and was motivated to eliminate them from her diet.

Similar to Alyssa, Lori had presented a photograph during the PEI and discussed her success in increasing her physical activity. During the TGD interview, Lori referenced the photograph of herself exercising that she had discussed during the PEI. Lori explained how the photo had inspired her to continue to do better, saying,

You know, talking about that picture made me feel so good. I mean, I had been doing well, but not as well as I could be, and I thought about that picture and I have been really making an effort to step it up since the last time we met.

For Alyssa and Lori, the PEIs provided a visual representation of their current DSM to which they could respond in relation to the continual story of their ongoing DSM efforts. The PEIs stimulated rich dialogue about future plans and the intentions that participants had as they worked to integrate DSM further into daily life.

Explicating Changes in Self-Management Performance

During the semi-structured interviews, participants were asked to discuss their past and current self-management regimens. However, they often struggled to explicate how their self-management had changed through time. In other words, how and why (or why not) did participants become better at their self-management, and what acted as the catalyst to such changes? The photographs provided a concrete point of reference because their content evoked a specific history. When participants focused their discussion on a photograph, they provided more explicit accounts of how aspects of their DSM had changed. In particular, by juxtaposing photographs of “then and now,” participants emphasized how their engagement in DSM had changed through time and the conditions that influenced such changes. Glenda's case provides an example of how processes of change were enhanced through the use of the PEIs.

HF: So, you said “tackling” breakfast was a major milestone. How did you get to that point? I mean, where you could finally manage that well? (Interview 1)

Glenda: Yeah, um, well I think, you know, just experience. I mean, plus I think I've had more time to focus on it maybe … I think it's really just, it's more serious to me too.

HF: More serious to you? Can you break that down for me?

Glenda: Yeah sure. Well you know, I think there is just a point where you have to grow up right? I mean, you hear it. Well I mean I hear the ladies in the classes [DSM classes] saying how they don't want to give up this or that, but you have to. At some point you have to. You just have to be serious about it or it [diabetes] will get you.

During the PEI, Glenda juxtaposed two photographs (see Figure 3) while explaining that her employer had gone out of business several months prior to her involvement in the study. She discussed how her diet had changed from when she was working to when she became unemployed and began babysitting her grandchild several days a week:

I eat breakfast all the time now; I mean a real breakfast, not what I used to do [fast food]. When I lost my job, I started watching the baby [her granddaughter] and she loves breakfast. I asked the [grandchildren] why do you like coming. They'll say, well you cook breakfast and mama never cooks breakfast. On my own I just do the oatmeal and coffee, but my granddaughter loves having breakfast. So the days that she's there I usually have the eggs. If I do a pancake I make sure its whole wheat and use the sugar-free syrup. I'm not going to give them anything bad.

Figure 3.

Glenda now opts for a healthy breakfast of oatmeal versus a fast-food breakfast.

Centring the conversation on the photographs facilitated more explicit discussion of the how and why Glenda's DSM had changed than was obtained during the initial semi-structured interview. Without the PEI, the first author would have been left to interpret that time, experience, and simply “taking DSM seriously” were perhaps the deciding factors in Glenda's dietary change. However, her PEI reveals a much more complex interrelationship of factors, both good and bad, including job loss and valuing her role as a grandmother, that were at the heart of how her dietary practices had changed.

Discussion

The value of any research method ultimately lies in what it can or cannot help us understand about the phenomenon of study. A plethora of researchers have advocated for the use of photo methods, pointing to their ability to elicit highly reflective accounts of human experience (Harper, 2002; Lorenz, 2011; Pink, 2001). However, findings suggest that it was not only the “highly reflective narrative” in isolation that led to a better understanding of DSM. Rather, it was the process of discussing discrepancies, participants' use of their photographs, and their responses to the PEI that led to a deeper understanding of what it means to integrate DSM into daily life.

A key finding is the value of the PEIs in drawing attention to discrepancies throughout the data collection and analysis. Discussing disparate representations of self-management provided participants an opportunity to critically reflect on their DSM. These findings align with existing evidence that demonstrates that reflecting on photographs in educational and research settings enhanced self-awareness of one's own thoughts and actions (Brand & McMurray, 2009; Linz, 2011; Lorenz, 2011; Pellico, Friedlaender, & Fennie, 2009). Moreover, for some of the participants, self-reflection prompted them to make further changes to aspects of their DSM. This finding has relevance to practitioners working with clients to improve chronic illness self-management. Improving self-management practices necessitates working with clients to identify their current approach to DSM and identifying supports and barriers to performance and participation (Hwang, Truax, Claire, & Caytap, 2009; Pyatak, 2011). Findings suggest that PEIs may have practical implications for occupational therapists seeking to elicit more detailed and context-specific data about individuals' efforts and circumstances that impede and/or support their ability to engage in self-management. However, more research is needed to better understand the possibilities of using photo elicitation in the clinical context.

Findings also suggest that how photographic data are used can increase our understanding of occupation. Changes in DSM (i.e., how and why performance changed) were difficult for participants to explicate. When compared to the interview data, photo methods allowed participants to reconstruct and unpack the catalyst and contextual influences that contributed to such changes. More specifically, juxtaposing “then-versus-now” photographs prompted participants to narrate the history of their engagement. In the current study, participants initiated photo juxtaposition on their own. The technique, however, has a history in visual methods research and has been previously used to facilitate dialogue about processes of change (Collier, 1957; Harper, 2002). This technique has not been widely used in occupational therapy. Nonetheless, the technique may be useful for eliciting more rich and nuanced data about how and why clients' participation and performance have changed through time, particularly where changes in the performance may occur slowly and the reasons for the changes may be difficult to articulate (Cross, Kabel, & Lysack, 2006). Further research is needed to investigate the application of the method in this context.

Limitations and Future Directions

This study's readily identifiable limitations are its relatively small sample and that the PEIs were situated within a specific continuum of data collection methods. Thus, the influence of the photo elicitation process may not be the same across different contexts and study designs. Moreover, all participants were taking part in additional DSM education as part of another research project while enrolled in this study. Therefore, the sample might not be representative of typical middle-aged, low-income urban women faced with DSM. Because of their previous DSM educational experiences and their prior participation in research, it is likely that this group of women were better able to reflect on certain aspects of their DSM.

Conclusion

Photo methods are becoming increasingly popular in social sciences and health research. Yet only a handful of occupational therapy researchers have incorporated photo methods into their research designs. The findings presented here serve to contribute to the ongoing dialogue surrounding the utility of photo methods in the study of human occupation. More specifically, findings suggest additional benefits of using photo methods to understand the explicit and implicit “doing” of chronic illness self-management. More research needs to be done to further determine the feasibility of using photo methods in occupational therapy research and clinical settings.

Key Messages.

• Using photo elicitation interviews in conjunction with other data collection methods led to a better understand the intricacies of self-management.

• Photo elicitation interviews promoted reflective awareness of beliefs, perceptions, and social-contextual influences on self-management practices that participants were, at times, unaware of.

• Photo elicitation methods hold promise for developing better understandings of the dynamics at play in chronic illness self-management.

Biographies

Heather Fritz, PhD, OTR/L, is Postdoctoral Research Fellow, Institute of Gerontology, Wayne State University, Detroit, Michigan, USA. At the time of this study, Dr. Fritz was a doctoral candidate, Division of Occupational Science, University of North Carolina at Chapel Hill, North Carolina, USA.

Cathy Lysack, PhD, OT(C), is Acting Dean, Eugene Applebaum College of Pharmacy and Health Sciences, Professor, Occupational Therapy Program, Department of Health Care Sciences, and Professor and Deputy Director, Institute of Gerontology, Wayne State University, Detroit, Michigan, USA.