A Community-Engaged Research Approach to Improve Mental Health Among Latina Immigrants: ALMA Photovoice

Abstract

Recent Latina immigrants are at increased risk of poor mental health due to stressors associated with adapting to life in the United States. Existing social and health care policies often do not adequately address the mental health concerns of new Latino populations. Amigas Latinas Motivando el Alma, a community-partnered research project, seeks to improve immigrant Latinas’ mental health outcomes. Using Photovoice methodology, promotoras (lay health advisors) reflected on community factors affecting mental health through photography and guided discussion. Discussions were audio-recorded, transcribed, and coded using content analysis to identify salient themes. Promotoras reviewed codes to develop themes that they presented in community forums to reach local policy makers and to increase community awareness. These forums included an exhibit of the promotoras’ photographs and discussion of action steps to address community concerns. Themes included transitioning to life in the United States, parenting, education, and combating racism. Nearly 150 stakeholders attended the community forums and proposed responses to promotoras’photographic themes. Our findings suggest that Photovoice provides an opportunity for Latinas and the larger community to identify issues that they find most important and to explore avenues for action and change by creating sustainable partnerships between the community and forum attendees

INTRODUCTION

Latino immigrants face numerous social, economic, and political challenges as they adjust to life in the United States (Alegría et al., 2008, Hochhausen, Le, & Perry, 2011). Latina immigrants are at heightened risk of poor mental health due to the need to adapt to a new culture, undocumented immigration status, limited English proficiency, loss of support from an extended family, and financial constraints (Corbie-Smith et al., 2010; Ding & Hargraves, 2009; Keller, Silberberg, Hartmann, & Michener, 2010; Ornelas & Perreira, 2011). For many immigrants, the trauma of immigration combined with cultural and linguistic barriers intensify symptoms of depression and anxiety (Ornelas & Perreira, 2011). These stressors are heightened by work-place and domestic raids and deportations that leave families further fragmented and fragile (Thronson, 2008; Torres & Wallace, 2013). While disparities in mental health outcomes and quality of life compared to non-Latinos are well documented (Shattell, Hamilton, Starr, Jenkins, & Hinderliter, 2008; Vega & Lopez, 2001), access to health care and mental health services is limited (Cabassa & Zayas, 2007, Vargas Bustamante, Chen, Rodriguez, Rizzo, & Ortega, 2010). Existing social and health care policies often do not adequately address the mental health concerns of new Latino populations (Gill, 2012; Rios-Ellis et al., 2005).

The lack of adequate mental health care policies is felt acutely in areas of the United States that are new immigration sites, such as North Carolina. Similar to other states with high rates of Latino growth, 43% of Latino residents of North Carolina are without health insurance, and most are not eligible for Medicaid due to undocumented immigration status (Gill, 2012). Current community-based mental health services are limited and inadequate to serve this population (Fox & Kim-Godwin, 2011; Gill, 2012). In this community, the intersection of demographic shifts in the southeastern United States, inadequate health care infrastructure, and targeted immigration policies led to the development of Amigas Latinas Motivando el Alma (ALMA). This article focuses on describing the perspectives of Latina mental health promotoras (lay health advisors) of the ALMA program and community forum attendees on barriers to well-being among their peers and potential culturally relevant interventions and lessons learned that were elicited using Photovoice.

BACKGROUND

ALMA is a community-partnered research project guided by collaboration between UNC (University of North Carolina) at Chapel Hill and Duke University (Corbie-Smith et al., 2010). ALMA’s initial focus was to provide Latinas with the resources to identify symptoms of depression and anxiety in three counties in central North Carolina through training of promotoras in a 6-week, theory-based intervention to improve mental health (Green et al., 2012; Tran et al., 2013, 2014). The training sessions explored Latinas’ common experiences using an interactive format and built skills for coping with isolation, anxiety, and preclinical depression (Green et al., 2012). Promotoras were asked to share these skills with Latina peers (compañeras) in their communities to reinforce positive coping strategies and to facilitate healthy behavior change (Tran et al., 2013, 2014). Throughout the implementation of ALMA, participants identified a need to translate their reality to policy makers and to advocate for effective mental health policies and, more broadly, for interventions to address drivers of poor mental health in their communities. To support the ALMA promotoras in their effort to address policy issues relevant to Latino mental health, we implemented ALMA Photovoice.

Photovoice is a participatory action research strategy that involves community consultation and engagement (Wang & Burris, 1997). This methodology is intended to move the group from description of the identified problems to actions to address these problems (Freire, 2000; Lopez, Eng, Robinson, & Wang, 2005; Wang & Burris, 1997). With Photovoice, participants are encouraged to share their perspectives by taking photographs and discussing them in groups. Previous studies have demon-strated the use of Photovoice among marginalized communities as a tool to facilitate participation and promote both individual and social change (Freire, 1973; Ornelas, Perreira, Beeber, & Maxwell, 2009; Wang Burris 1997). These activities provide a unique opportunity to identify prominent concerns within a designated population through words and images. Photovoice’s accessible methods can be used to bridge the gap between minority and/or marginalized populations and key stakeholders and politicians. In ALMA Photovoice, participants were asked to record and reflect on their community’s strengths and concerns regarding mental health using photography to inform community leaders and policy makers through public forums.

METHOD

Setting and Participants: Photovoice Promotoras

Our ALMA Community and Academic Advisory Committee recommended for us to undertake a project to increase self-care coping skills for Latina immigrants (Corbie-Smith et al., 2010). Taking their recommendations into consideration, we wanted our intervention to focus on Latina immigrants’ unique experiences and how they were supportive of their partners and families (Green et al., 2012).

Eligible participants were self-identified Latinas aged 18 years and older, living in three counties in central North Carolina. Although our preference was to recruit women who were recent immigrants, this was not an eligibility criterion. A full description of the curriculum used in the first phase of ALMA, the study population and the results are described elsewhere (Corbie-Smith et al., 2010; Green et al., 2012; Tran et al., 2013, 2014). For the subsequent Photovoice phase, we recruited a total of 21 promotoras who had previously participated in the first phase of ALMA. The study was approved by the institutional review boards of the University of North Carolina and Duke University.

ALMA Photovoice was conducted sequentially over the course of 14 months (County 1: March-June 2011; County 2: August-December 2011; County 3: February-June 2012). We trained eight promotoras for County 1, eight promotoras for County 2, and five promotoras for County 3. The Photovoice sessions took place in community locations that were centrally located areas chosen by the promotoras, including a church and two community-based organizations.

Data Collection

Building from discussion, common generic English curricula and ongoing dialogue with promotoras, the ALMA team, which was composed of researchers, identified areas in need of modifications to create a cultural and social implementation of Photovoice for Latinas. We used ALMA VENCER, an adapted version of the commonly used SHOWED method that was modified for linguistic and cultural accuracy, to guide the ALMA promotoras through the process of analyzing their photographs by identifying and discussing issues surrounding mental health (Page, Cubillos Braswell, Perez, Tran, & Corbie-Smith, 2015; Wallerstein, 1994). The questions include the following: (a) Literally, what are you seeing in this photograph? (b) What is happening in this photograph? (c) How does this relate to our lives? (d) Why do these issues exist? (e) How can we become empowered by our new social understanding? (f) What can we do to address or resolve these issues? A manuscript is in progress to provide an in-depth discussion of the photo discussion sessions, methods, and linguistic and cultural adaptation to the Photovoice methodology (Page et al., 2015).

The Photovoice sessions consisted of the following activities: one orientation session; three distinct photo discussion sessions; two to three forum-planning sessions, as requested by the promotoras; one rehearsal session; one forum; and one debriefing session. During the orientation session, the facilitators explained the purpose of Photovoice and also obtained informed consent. Participants were given digital cameras and informational packets. The facilitators provided an orientation on how to use the cameras properly and concerning basic photography. During the three photo discussion sessions, participants had the opportunity to participate in two to five individual photo assignment activities. Once the participants shared their photo assignment, they all selected one photo that best illustrated the photo assignment theme for in-depth discussion.

Data Analysis

The overall data analysis process included discussions being audio-recorded, transcribed, and coded by the ALMA team using content analysis to identify salient themes. Participants reviewed codes for verification and to identify themes that they wanted to present in the community forums.

More specifically, sessions were recorded and transcribed initially into Spanish and later translated into English by bilingual, bicultural transcriptionists. Bilingual staff verified transcripts for accuracy of transcription and translation. We used Atlas.ti 6.2 to organize and manage the text data and photographic images. During each session, a designated “note taker” captured reoccurring topics and subject matter. These notes informed a preliminary set of codes, which were subsequently expanded on at the end of each session with the participants. At the end of each photo discussion session, the ALMA team asked participants to verify a set of codes by “recapping” the salient themes of the day’s discussion as a means of member checking. Member checking is a technique used to increase the accuracy and validity of the results and conclusions (Krefting, 1991). The coding process was iterative in that new codes emerged, and old codes were revisited, as the process continued. After the completion of the entire intervention, the coding team recoded all documents with the finalized codebook.

Photography Exhibition and Community Forum

The photo discussion sessions concluded with three promotora-led community forums, where the selected photographs and quotes were publicly displayed. The goal was to work with community partners, local politicians, and key stakeholders to identify action steps to create sustainable policy change. To elaborate further at the conclusion of the photo discussion sessions, the promotoras identified themes for presentation at their community forum. Promotoras were provided with the codebook generated from their photo discussions to identify themes that they believed reflected their discussions. The photo themes that emerged from the photo discussion sessions held with promotoras before the forum event were organized into four broad categories: transitioning to life in the United States, parenting, education, and combating racism. Each category has a great deal of overlap, reflecting the similarities between each cohort. Relevant codes were analyzed for co-occurrences. Quotations chosen for the forum were presented to promotoras for verification and further refinement.

Using simultaneous professional interpretation, selected themes and quotes were presented and discussed in English and Spanish at the community forums accompanied by the respective photographs. At each forum, guests were divided into groups to discuss the themes chosen by the promotoras. Participants contributed ideas and compiled a list of action items related to each theme. After the sessions concluded, the groups met to discuss the action items.

RESULTS

The demographic characteristics of the women who participated in Photovoice are presented in Table 1. Demographic characteristics for promotoras were similar across intervention sites. A total of 21 promotoras participated in ALMA Photovoice and had an average age of 35.8 years; most were married or living with a partner (76.2%) and had an average household size of 4 and an average of 10 years living in the United States. A total of 19 promotoras (90.5%) came from Mexico, and the remainder (9.5%) came from South American countries.

Table 1.

Promotoras’ Demographic Characteristics

Demographic Characteristics (N= 21)	Average	Range or %
Age, years	35.8	22–60
Years lived in United States	10	1–20
Years lived in North Carolina	8.3	1–18
Household size	4.0	2–9
Married/living with partner	16	76.2
Country of origin
Mexico	19	90.5
South America	2	9.5
Family income per week  Poverty level ($285/week   or less)	10	47.6
No. of people income   supports	3.6	2–6
Education
Less than high school	6	28.6
High school diploma or   higher	15	71.4
Currently in school (GED,   ESL, etc.)	6	28.6
Employment
Currently employed  Health	12	57.1
Self-rated health, fair or   Poor	6	28.6
Has health insurance	5	23.8

The promotoras and ALMA team discussed and identified potential forum invitees, including policy makers, elected and appointed officials, key stakeholders, and the general public. Invitees included members from the following categories: academic/research (i.e., university faculty/staff, researchers), community (i.e., school staff, law enforcement personnel, legislative personnel, staff of service organizations, community leaders, and the general public), clinician (i.e., clinical social workers, medical providers), promotoras (ALMA former and current promotoras), and the media (i.e., Latino radio/newspaper). Promotoras created invitations to the forum in Spanish and English to hand deliver to their invitees. In addition, the ALMA team in collaboration with the promotoras during the Photovoice sessions created a forum guest invitee list and e-mailed potential guests. Both the promotoras and the ALMA team contacted potential forum invites, which resulted in representatives from all backgrounds’ being invited to participate; however, for various reasons (e.g., location, personal connections, and time), not all backgrounds were necessarily represented at each forum. For example, only one representative from the local newspaper (media) attended the forum for County 3, even though the promotoras reached out to the media in Counties 1 and 2. A total of 146 participants attended the three promotoraled community forums. Community forum locations were centrally located areas chosen by the promotoras, which included a church and two community-based organizations. Photovoice forum attendance figures by guest background are presented in Table 2.

Table 2.

Photovoice Forum Attendance Figures by Guest Background

Amigas Latinas Motivando el Alma Cohort	Academic/ Research	Community	Clinician	Promotora	Media	Total Attendance
County 1	12	16	0	5	0	33
County 2	21	32	7	9	0	69
County 3	7	24	3	9	1	44

The results are threefold: photo themes, proposed associated action steps, and proximal outcomes. The photo themes emerged from the photo discussion sessions held with promotoras before the forum event, and they are organized into four broad categories: Transitioning to life in the United States, parenting, education, and combating racism presented in Table 3. Proposed action steps associated with each theme were identified by forum participants in Table 4. Proximal outcomes are items accomplished by the promotoras and community shortly following the forum.

Table 3.

Promotora Photovoice Forum Themes and Pictures

Category 1	Transitioning to life in the United   States
Theme 1	The impact of social isolation
Theme 2	The way we adapt to this country
Category 2	Parenting
Theme 1	Involvement in children’s lives
Theme 2	The importance of being good parents
Category 3	Education
Theme 1	Our community needs to access   existing programs
Theme 2	Women are a power for change
Theme 3	Academic achievement of their children
Category 4	Combating racism
Theme 1	Documentation status and profiling
Theme 2	Regulation and inspection of housing   complexes

Table 4.

Photovoice Forum Proposed Action Steps (Sample Items Listed)

Training Latinos

•  Having more programs such as Amigas Latinas Motivando el Alma, in the community

•  Adapting and designing an Amigas Latinas Motivando el Alma program for men Hosting events

•  Uniting churches and providing dismantling racism workshops

•  Educating the community on preventive care Educating Latinos

•  Learning more about immigration and laws protecting Latinos

•  Finding ways to educate others on housing regulations Increasing dissemination of information

•  Finding scholarships and other educational resources for Latino youth

•  Using the media and other social networking methods to distribute information and promote events Effect personal change

•  Adapting to a new culture while incorporating our own culture

•  Being empowered as promotoras and being vehicles for change Using existing resources

•  Continuing to work with existing promotoras and contributing to the sustainability of the promotora model

•  The need to promote change by building a network with local agencies

Photo Themes

Transitioning to Life in the United States

The impact of social isolation.

The promotoras identified community fragmentation as a cause for decreased mental health in their community. Promotoras discussed how difficult it is to emigrate from other countries, often having to leave family and friends behind and move to a part of the world with limited support and social connections. Promotoras discussed the feelings of loneliness and how they can lead to feelings of despair and angst. Participants noted addiction as an unhealthy coping mechanism due to lack of resources and education on healthy coping strategies. The following quotation exemplifies a promotora’s beliefs on how ALMA helped to facilitate social networking by encouraging information sharing and peer support, thereby reducing the sense of isolation and improving access to resources:

I like attending the ALMA meetings because I think that when you are in a group, and you have the opportunity to talk about many things, your stress starts to go away, especially if you have stress. For example, this is a program where we ourselves can talk about what we feel. Why? Because there is a bond of trust between us because one of our rules is that what is said in the group stays in the group.

In addition, ALMA offered them a safe space to learn new ways to cope with stress and depression and helped them learn about mental health services in their community.

The way we adapt to this country.

Promotoras discussed how many Latinos struggle with the challenge of identifying what is good about their home cultures and working to continue those traditions while embracing the positive and discarding the negative of U.S. culture. One of the promotoras shared the following:

There is nothing wrong in absorbing some of the American customs. There are things here that are done in a certain way. It would be wise or intelligent to use the good ones and discard the ones that aren’t good. And the same goes for our customs.

Learning English was identified as a positive adaptation. Participants observed that living in Latino communities makes it possible to get by without learning English. Barriers that keep parents and older family members from assimilating are less present in the generation of Latinos attending school. This difference causes intergenerational tension between the children and parents, placing differing cultural values at odds with each other.

Parenting

The importance of being good parents.

Participants believed that it is the parents’ role to find ways to blend the Latino and U.S. culture in their upbringing by creating strong bonds within the family and understanding that a child’s education begins in the home. The promotoras shared that they faced challenges in finding ways to preserve their culture for their children such that they do not forget “who they are and where they came from.” The promotoras also expressed a desire for their children to be proud of their heritage and not be ashamed.

Involvement in children’s lives.

The promotoras described long work hours and language as barriers keeping parents from getting more involved in their children’s lives. One of the promotoras shared the following:

Communication among parents and children is being lost. Parents do not have time to spend quality time with their children, and the biggest barrier that exists is technology. And some parents do not control the excessive time that their children dedicate to video games, computers, and cell phones.

Participants discussed the necessity of reprioritization, having a balanced schedule that is family focused, and a commitment from parents to participate actively in the education of their children. It is easy to overuse television and video games as entertainment with children when both parents are overworked and to not encourage their children to participate in recreational activities. Additionally, promotoras shared that a portion of parents opt to buy things for their kids in order to compensate for the lost time. Although there was a strong call to action, the forum participants decided that the community needs additional tools, resources, and education on how to transform their goals into actual results. Participants discussed the importance of finding scholarships and other educational resources for Latino youth and using the media and other social networking methods to distribute information and promote events.

Education

Women are a power for change.

Participants described Latinas as the foundation of the family unit and as having a key role in the workplace and community. As such, it is important to educate and empower women. Promotoras shared how many Latinas in North Carolina feel isolated and have limited access to resources because they live in rural districts, and need help. Participants discussed how the promotora model is an effective model to disseminate information to those who are not able to access community and mental health resources easily.

Our community needs to access existing programs.

Although participants agreed that many Latinos have access to many local resources, they identified barriers to access and utilization, such as a taboo against seeking assistance, undocumented status, and lack of confidence in English and written Spanish. A recurring point of discussion was the need for Latinos to learn English to be able in order to help their children with homework in addition to relieving pressure from their children to interpret and translate.

Academic achievement of their children.

Promotoras noted that many Latino parents fear and worry about the pressures adolescents experience at school that can interfere with their academic accomplishments. Identified pressures included bullying, teenage pregnancy, pressure to lose virginity, drugs, college, migration status, and uncertainty of what to do in their future. There is also concern that their migratory status limits access to higher education in the United States and that many adolescents with a strong desire to continue their education must go back to their native country to continue their studies.

Combating Racism

Documentation status and profiling.

Promotoras described how being undocumented can cause considerable angst and fear among Latinos living in the United States. The following quotation exemplifies the promotoras’ beliefs on how changes in the law can often contribute to discrimination and racial profiling:

Although sometimes one might say that you can go to the police and tell them if something is happening to you, if there’s a problem, but unfortunately, there are times when it ends up being counterproductive. You go and instead of them helping you, they end up harming you. The police focus more on whether you’re legal in this county than on the situation you are going through, or what’s happening to you.

Participants discussed how Latinos in the past were able to obtain driver’s licenses and how currently, due to their undocumented status, they are not able to obtain them.

Regulation and inspection of housing complexes.

Promotoras described how people are living too long in poor conditions without any relief in addition to the large numbers of people per household. Participants relayed fears of lodging complaints about poor housing conditions because of the lack of information concerning their rights. A promotora shared the following: “It’s really sad to see how people, because of their lack of knowledge of their rights, continue to live like that. This is also part of the minimal living conditions that we have a right to.” Participants at the forum felt that though housing residents may not have proper documentation, there are still human rights and codes that must be upheld. Participants discussed the importance of educating Latinos on housing regulations and on immigration rights.

Associated Action Steps.

A debriefing session for member checking was scheduled for approximately 1 month after each forum for each of the three cohorts. During this session, the promotoras met with the ALMA team to provide feedback on the Photovoice process, identify desired next steps, and develop an action plan. This session also provided the promotoras an opportunity to brainstorm ideas on how to proceed with the feedback they received from the forum attendees. Promotoras were provided with a forum summary (break-out session descriptions, generated action steps, and a list of forum attendees) along with a summary 4” × 6” photo book of the Photovoice exhibit including the presented themes photos and quotes in English and Spanish. Promotoras were encouraged to use the Photovoice books as a tool to share their work with their social networks and communities.

Many of the proposed action steps generated at the forum breakout sessions can be grouped into five categories: training Latinos, hosting events, hosting Latinos, increasing dissemination of information, effect personal change, and using existing resources presented in Table 4.

Proximal Outcomes

Per the request of the promotoras, forum participants (the ALMA team and UNC LINC [Linking Immigrants to New Communities] community members) connected the promotoras and their church community to UNC LINC, the mission of which is to help facilitate the transition of recent immigrants through student interaction. The ALMA team collaborated with LINC forum participants and the promotoras to coordinate a LINC-Know Your Rights presentation to a Latino church on immigrant rights.

As a result of their involvement in Photovoice and support from forum participants (UNC academic researchers and the ALMA team), three of the promotoras organized and created ALMA Coffee with funding from a UNC Latino migration research support award. The promotoras’ aim was to address all the action items identified at the forum by creating a Facebook page as a mechanism to disseminate information on health and education resources available to the Latino community. The ALMA Coffee promotoras gave a presentation regarding their group to the community engagement team of the North Carolina Translational and Clinical Sciences Institute (NC TraCS), obtained alternate ethics training, received CITI certification at UNC through a Spanish-language training, collaborated with the ALMA team on grant submissions, copresented at national and local conferences, and identified a need for a Spanish-language Research 101 workshop, which is now available at NC TraCS.

In addition, the ALMA Coffee promotoras expressed a desire to be coauthors on future ALMA publications. The ALMA team in collaborating with the ALMA Coffee promotoras organized a manuscript meeting regarding forum outcomes. Manuscript drafts were translated into Spanish, distributed in person and via e-mail, and discussed in Spanish. The promotoras suggested edits to the reported findings, and their contributions were collected in Spanish, translated to English, and incorporated into this article.

DISCUSSION

This article describes the use of Photovoice to present Latinas’ perspectives on mental health to decision makers in their communities to drive community-initiated solutions. We determined that Photovoice is an effective tool to give Latinas with limited English proficiency a platform to inform interventions designed to improve community health. The issues identified by the promotoras included transitioning to life in the United States, parenting, importance of education, and racism and discrimination. Two common motifs uniting the proximal outcomes were the value in increasing community awareness of the themes and diffusion of information about resources within the community. The LINC presentation to educate the community on immigrant rights is one example of the community’s desire to be informed. Another example is how the promotoras increased community connections by creating a Facebook page to engage additional community members in ALMA Coffee activities, community events, resources, and information.

While these themes are similar to those identified previously through traditional research methods using a community-based research approach had distinct benefits. First, Photovoice provided an opportunity for the promotoras, as well as the larger community, to set priorities and to explore avenues for action and change. Second, community-identified priorities may or may not be the same as those identified by researchers and policy makers that make recommendation based on health statistics (Altman, 1995; Baquero et al., 2014). ALMA was developed as a response to the needs, as expressed by newly immigrated Latinos in central North Carolina, for capacity building in mental health and for developing coping skills (Corbie-Smith et al., 2010). Additionally, we observed that proposals for interventions raised by the promotoras often went beyond the traditional purview of mental health. For example, they suggested interventions must address how immigration status can affect confidence to participate in community events and even basic expectations of rights from tenants and employers.

Due to ALMA’s success in reducing stress associated with transitioning to life in the United States, the forum participants and promotoras expressed interest in expanding and spreading the ALMA model by training promotoras as new facilitators using a train-the-trainer model. The positive outcomes produced with ALMA could also have similar effects on the men of the community. Promotoras felt empowered and found it easier to share resources in this setting.

While participation is widely considered a fundamental aspect of health promotion initiatives, it is often difficult to achieve in practice, especially for immigrant communities with limited English proficiency. The Photovoice methodology enabled the promotoras to advocate for themselves and their community by valuing participants’ personal experience and by creating sustainable partnerships between the community and forum attendees. Additionally, Photovoice provides a structured process to achieve shared goals by establishing a time line and steps to transfer sentiments into action. This process was one of the most powerful lessons that the promotoras took away from the experience.

Finally, we observed participation in Photovoice to be an influential experience for many of the promotoras. Promotoras described both personal growth and improved ability to contribute to efforts to improve their community. The promotoras commented that often, Latinos in their community ignore stressors and problems due to the perception that they cannot do anything to change them. The promotoras felt Photovoice caused them to reflect on issues that were “staring them right in the face” and gave them the opportunity to do something. The promotoras reflected that because non-Latinos were interested and engaged in the forum discussions, their perspective on their ability to influence their environment changed. In the words of one of the promotoras, “It’s a way to see our surroundings and learn how to help and share that with other people who have the capacity to change things.”

Lessons Learned

Our ALMA Photovoice experiences are common and inherent within community-based participatory initiatives (Baquero et al., 2014; Corbie-Smith et al., 2010; Hergenrather, Rhodes, Cowan, Bardhoshi, & Pula, 2009; Israel et al., 2010). While Photovoice was demonstrated to be a valuable tool to enable Latinas to reflect on strengths and concerns of their community and to promote dialogue on issues they deemed important, we also observed that it presents a number of challenges. We struggled with recruitment and retention of participants over the course of the project. As described previously, eligible participants were Latinas who had previously participated in the first phase of ALMA. While we had overwhelming interest in the project, many of the previous participants moved back to their country of origin or out of the study region in the time between the ALMA intervention and Photovoice. In addition, the intervention occurred in each of the counties through a series of 8 to 10 sessions over a period of approximately 4 months. While previous research (Catalani & Minkler, 2010) has suggested that implementing Photovoice over a longer period leads to greater quality of participation, promotoras mentioned the time course as a barrier for participation, as well as transportation and child care. Several promotoras expressed feeling that the Photovoice process was intimidating and that even the name (FotoVoz in Spanish) was unapproachable. The promotoras expressed that they would like to have more capacitybuilding sessions from experts in the areas surrounding the themes and photos they selected for the forum. Interestingly, several prior studies employed such a training-intensive approach, with participants receiving instruction in safety and ethics, as well as the basics of professional photography. Conversely, a number of other studies provided their participants little or no training in photography in the belief that a more naturalistic, informal approach to photography would yield more useful findings (Catalani & Minkler, 2010). The promotoras would like to be instructed by someone who knows the available resources pertaining to the themes and subsequently to be able to share this information with others in their community. In addition, the promotoras suggested that training by a professional photographer would improve their comfort with taking and sharing photos.

While Photovoice was intended to give the promotoras a stage in front of policy makers, we determined that this process could also be used as a tool to promote dialogue among members of the Latino community. The promotoras suggested adding a session to share their work with community members at a familiar community location and receive feedback prior to the forum.

Although the three cohorts for this study were not established for the purpose of comparison, several clear differences became evident through the process and forum action items. Each cohort varied in their skill set and confidence in executing action items. Variation in number and composition of attendees at the forums influenced the quality of discussion. As a result of these differences, the cohorts needed varying degrees of facilitation, training, and external support both during the Photovoice process and when planning follow-up steps on action items. Several of the promotoras felt that Photovoice placed them in the role of community educators and asked them to reach conclusions, which they felt underqualified to offer. The promotoras suggested that emphasizing the responsibility of being engaged community members, rather than community educators, could ease this stress.

Future Photovoice projects should consider including skill-building components in their studies to provide participants training in public speaking, navigating group dynamics, and learning about organizational structure. Furthermore, consideration should be given to providing participants with tools and resources that will enable motivated individuals to further their training and goals after the research period has concluded.

Conclusions

Photovoice serves as an important methodology for Latinas and the larger community to identify issues they find most important and to explore avenues for action and change. The promotoras’ strong group dynamic and experiences provided them with skills that allowed them to approach their goals in a structured manner. The promotoras’ unique experiences as Latina immigrants, lay health advisors, and Latino community stakeholders will allow them to be valuable partners to any community-engaged research initiative that may share similar goals with the promotoras.

While promotoras endorsed the findings of the Photovoice forum, they also identified additional outcomes from the forum and suggested additional analyses of the findings. Outcomes included lessons that are still affecting their lives and examples of the success of the forum. The promotoras also proposed contextual factors that influenced the variation of results across cohorts. The greatest lesson that the promotoras gained from ALMA Photovoice was an appreciation for the formalized due process of community-engaged research. This process redefined for them the value of what the promotoras bring to the table as agents of change.