key: cord-0954620-mpubmkj9
authors: Oliffe, John L.; Bottorff, Joan L.
title: The Gendered Dimensions of Photovoice in Men’s Health Promotion Research
date: 2022-03-14
journal: Health Promot Pract
DOI: 10.1177/15248399211055432
sha: a0d0613fa0bb917f4c7ad78a297e5ee7f1445189
doc_id: 954620
cord_uid: mpubmkj9

The use of photovoice in men’s health promotion research has grown significantly over the past 15 years. Initially mobilized as an elixir for men’s talk about health practices and illness experiences, participant-produced photographs and accompanying narratives have grown significantly in reach, influence, and application. The current article highlights the gendered dimensions of photovoice in men’s health promotion research across three studies addressing (1) psychosocial prostate cancer care, (2) fathers’ tobacco reduction and smoking cessation, and (3) male suicidality. Insights drawn from the psychosocial prostate cancer care project emphasize the plurality of masculinities, and the implications for health promoters treating the common treatment side effect of erectile dysfunction. The relational nature of gender is central to the fathers’ tobacco reduction and smoking cessation work whereby the well-being of partners and children strongly influenced men’s behavior changes amid guiding adjustments to smoke-free policies. The male suicidality research highlights the unmuting powers of photovoice for making visible the interiority of men’s mental illness, and the destigmatizing potentials for sharing participants’ accompanying narratives. Evident across the three projects are the gendered dimensions of photovoice processes and products for advancing understandings of, and avenues toward, promoting the health of men and their families. After reflecting on these advances, we offer recommendations for future men’s health promotion photovoice work.

M en's health practices are indelibly linked to masculine ideals wherein the historical, and most often told stories are of men's gendered risk taking and reticence for help seeking (Bilsker et al., 2018; Courtenay, 2000) . Contrasting these deficit model depictions of masculinity as unitarily incompatible with men's well-being have been assertions that some aspects of masculinity (courage, strength) can work for (rather than entirely against) men's selfhealth (Sloan et al., 2010) and effective illness management (Robertson, 2007) . These diverging viewpoints reveal a plurality of masculinities (Connell & Messerschmidt, 2005) to offer some important nuanced accounts about how and why men do, and do not do health promotion. Shifting the deficit-strength dichotomy to a continuum, photovoice has emerged as a highly influential method for illuminating contextual understandings about men's health promotion practices (see Kubicek et al., 2012; Mamary et al., 2007; Simpson & Richards, 2018; Wilde et al., 2020) . Moreover, photovoice has robustly hosted an assortment of qualitative methodologies including intersectionality (Ferlatte, Oliffe, Salway, Broom et al., 2019) , ethnography (Oliffe et al., 2010) , grounded theory (Oliffe et al., 2021) , and interpretive description (Thandi et al., 2018) to inform avenues for promoting the health of men and their families.

Some 15 years ago, we published an article to discuss the benefits of using photovoice in men's health research (Oliffe & Bottorff, 2007) . Extending those early insights, we purposefully reflected on our experiences leading three photovoice studies spanning two decades to discuss some key learnings, front of mind issues and recommendations in the current article. Specifically, we highlight some gendered dimensions of photovoice in men's health promotion through studies addressing (1) psychosocial prostate cancer care, (2) fathers' tobacco reduction and smoking cessation (TRSC), and (3) male suicidality. In the psychosocial prostate cancer care example, we emphasize the plurality of masculinities (Connell, 2005) , and the implications for health promoters treating the common treatment side effect of erectile dysfunction (ED). Central to the fathers' TRSC work are gender relations whereby the well-being of partners and children strongly influenced men's photographs and behavior change efforts while contributing to smoke-free policies. The male suicidality example includes photographs to illuminate the interiority of mental illness and the destigmatizing powers in exhibiting those images and narratives. In reflecting on these project-specific insights, recommendations for future men's health promotion photovoice work are briefly outlined in the conclusion.

Similar to the wider field of masculinities and men's health, feminist theory influenced and informed our early (and ongoing) use of photovoice. Forefront was Caroline Wang's women's health work (Wang & Burris, 1997; Wang et al., 1998; Wang & Pies, 2004) , a participatory action research program that provided direction for our 2000-2004 prostate cancer study (Oliffe, 2003) . We also diligently polled experts about the feasibility of using photovoice in men's health (named and operationalized as photo elicitation in this early work), and the main caution expressed by numerous wise counsel was that males might be uncomfortable taking and talking about photographs that depicted their illness-and by extension exposed their vulnerabilities.

The warning was fair-indeed, some men who were willing to talk with us about their prostate cancer refused to take photographs. This reticence predominately related to men's concerns about their anonymity being compromised by who (and what) the photographs might "reveal" as well as challenges for conceptualizing the task (i.e., what to take photographs of?) let alone valuably talking about what were anticipated as mundane everyday images. Starkly contrasting these restraints were men who eagerly embraced the "photographic assignment" to vividly express their experiences of living with prostate cancer. The dissimilarities in men's openness to photovoice was interpreted as reflecting a plurality of masculinities and diversity in what could be comfortably self-disclosed and/or shown. Among the men who took and candidly talked to their photographs the richness of the visuals and conversational tone of the interviews was ever clear. Much was bared and with elixir qualities, photovoice seemed steroid-like for building many men's illness narratives. Moreover, both in terms of process and product, photovoice intensely mapped men's reliance, rejection and reformulation of idealized masculinities to their changing gender identities, roles, and relationships (Oliffe & Bottorff, 2007; Oliffe, 2009) .

Disarming stoicism and emotional restraints, many men, including Arthur, a 46-year-old man, exposed how prostate cancer really was for them. Changed and challenged in the aftermath of his prostatectomy, both by his ED, and the marginalizing avenues for treating that surgery side effect, Arthur shared a photograph (Figure 1 ), titled The Dreaded Brown Paper Bag (Oliffe, 2003; Oliffe, 2009) . He quipped that his urologist gave him the paper bag as a means to discretely carry his vacuum erection device-an appliance designed to manually draw blood into his penis for an erection that Arthur was no longer able to spontaneously achieve. Arthur explained his reason for including the photograph was "part annoyance and part embarrassment" because the bag implied his search for a remedy-and by extension his problem [ED]-should be hidden. However, rather than concealment, Arthur felt outed (and othered):

Like policeman in plain clothes stand out . . . it's like here's a brown paper bag "you can't get it up" that's what this bag says to you, and as you walk out through the waiting room there are half a dozen other men . . . sometimes with their partners . . . and they all look at you and see you walk out with a brown paper bag and even though it is meant to be anonymous it is . . . definitely a sign you are in the club.

Craving distance from that emasculating milieu, a procession of ED devices and pharmaceuticals were carried through the waiting room by Arthur in that brown paper bag as he worked toward reestablishing his erections. Overtime, there were some improvements. However, Arthur's breakability and solidities rendered visible his uneasy embodiment of strength-based resiliencies for regaining his erectility with a littering of vulnerabilities (and shame) that he might ultimately be (and be seen by others) as less of a man. Multiple masculinities (and their intersections with other social determinants of health including culture and class) were ever present, and often contradictory, in Arthur's recovery work.

Photographs from our prostate cancer study (including the image and narrative shared here) have been featured in two publications (Oliffe & Bottorff, 2007; Oliffe, 2009) , numerous conferences, formal teachings (i.e., health trainees and continuing education for credentialed practitioners) and presentations at prostate cancer support groups. Making visible men's prostate cancer experiences in these varied ways afforded important advocacy opportunities that could reduce the aloneness of other similarly challenged men as well as prompt health promotion practice considerations amongst practitioners. In this regard, two key learnings emerged from Arthur's experiences. One, there were likely significant benefits to mapping a penile rehabilitation plan preoperatively, as most of what Arthur experienced surfaced as unanticipated loss and complicated grief. Moreover, amid being advised of his prostate cancer-free status postoperatively (prior to discharge), ED and its treatments became the focus, a long game with highly variable outcomes. Herein, some temporal staging of the penile rehabilitation plan might have also tempered Arthur's surprise and growing frustration. Second, that confidentiality, as the clinical rationale for providing the brown paper bag, so starkly contrasted with Arthur's experiences of carrying it, was an important reminder about the complexities, and contradictions, in men's ED help seeking. Key for health promotors here is that while Arthur's masculine self was clearly disrupted by the physical aspects of his acute ED (and focus on numerous seemingly failed treatments), identity threats, relationship concerns, and mental health challenges were also evident. In supporting Arthur's pursuit of an ED remedy, health promoters might initiate discussions about these (and other) psychosocial issues to address the many transitions that can accompany prostate cancer and its treatment[s].

The fathers' TRSC work afforded photovoice opportunities to address a significant blind spot in men's health promotion research. Specifically, smoking in pregnancy and the postpartum was restricted by the TRSC focus on mothers, and its framing as a women's health issue (Hemsing et al., 2012) . In heterosexual partnerships, the smoking practices of fathers had gone unchecked, despite strong potential for risking the health of women and children, as well as the men themselves (Bottorff et al., 2006; Oldereid et al., 2018) . Beyond second and thirdhand smoke, mothers who quit smoking during pregnancy were more likely to resume postpartum if their male partner smoked (Solomon et al., 2007) , and children had increased risk of smoking if they grew up in households where a parent smoked (Leonardi-Bee et al., 2011; Vuolo & Staff, 2013) . Within these gender relations frames, we invited dads who smoked to take photographs to orientate us to smoking through the eyes of fathers. Conducted 2004 Conducted -2007 in Vancouver, British Columbia, the study took place at a time when smoking cigarettes was increasingly stigmatized and policed. So, to recruit, let alone ask new fathers to include photographs of their favorite smoking places, was wrought with challenges. Indeed, we relied on new moms who participated in another arm of the study to recruit male partners, and among those predominately "new" dads who took part, their Within these TRSC contexts, the men's photographs revealed a strong emphasis on their cars with accompanying narratives suggesting that these vehicles were neither inside nor outside spaces, but rather ungoverned private spaces in which fathers could more freely smoke (Oliffe et al., 2008) . Most often commuting to and from work, and/or as a direct part of their job, the dads consistently linked their smoking to driving. All the participants assured us that they only smoked when they were in the car by themselves-and these practices were underpinned by the men's desire to protect their child from secondhand smoke. Illustrating these findings, Jimmy, a 31-year-old Indonesian Canadian dad, who had smoked 30 cigarettes a day for the past 16 years, narrated a photograph ( Figure  2) 

Nothing to do-just smoke, watch the view, think about something . . . you have to drive the car so you need to rest but keep sharp. Cigarettes are the same as coffee. Only by myself would I smoke when I drive the car-because of other people's health, especially for my kid, right?

Jimmy tied his smoking to the boredom associated with, and the stimulants required to survive the long hours he had to drive for his job. Bracketing his smoking as solitary (a strategy ensuring that his child was not exposed to secondhand smoke) in completing that paid work, Jimmy confirmed his alignment to highly prized masculine protector and provider roles. When asked about the deodorizer/air freshener on the dashboard Jimmy emphasized further his protection efforts, "I'm not the only one using the car, so I have to think about other people." Across the fathers' photographs it was also evident that most men had stopped smoking inside the family home amid retaining and/or retreating to their cars to smoke. These insights confirmed men's TRSC efforts as deeply tied to their child's (and partner) well-being.

In addition to publications (Oliffe et al., 2008; Oliffe, Bottorff & Sarbit, 2012b; Oliffe, Bottorff & Sarbit, 2012a ) and conferences, the fathers' TRSC photovoice work brought forward the centrality of gender relations for; (1) transitioning descriptive findings to tailored interventions, and (2) influencing smoke-free policies. In terms of tailored interventions, we drew from the men's photographs and narratives, and in consultation groups we also worked with fathers' who smoked to design a precontemplation and contemplation-based tailored TRSC booklet. Titled the right time . . . the right reasons, the goal was to affirm fathers in the TRSC challenges they faced while offering insights to the strategies employed by other dads who smoked but wanted to quit. Available in English, French, and Chinese the booklet has been widely distributed in hard copy and online. Regarding policy, our work coincided with legislated changes wherein smoking in a motor vehicle when a passenger is 16 years or under was prohibited, regardless of the use of windows or sunroofs to vent smoke (Government of British Columbia, 2008). While not espousing our findings as the primary influencer of this policy change, our photovoice work drew Ministry of Health and mainstream media attention contributing to the collective cultural shifts for TRSC in British Columbia.

Driven by wanting to better understand and address the high and rising male suicide rates in Canada (Oliffe, Rossnagel et al., 2019) , our most recent (2013-2017) photovoice work has focused on men's experiences of suicidality (suicidal thoughts, plans and/or attempts; Oliffe et al., 2017; Oliffe et al., 2021; Ferlatte, Oliffe, Salway, Broom et al., 2019) . A major challenge to preventing male suicide are stigmas that inhibit men from disclosing and/or seeking help for their mental illness challenges Han & Oliffe, 2016). The interiority of mental illness and suicidality can be especially arduous for men to express or explain to others (Ferlatte, Oliffe, Salway & Knight, 2019) . Photovoice provided a method for men to depict and discuss their suicidality experiences. Destigmatizing avenues were also possible through exhibiting a collection of the men's photographs and insights (Han & Oliffe, 2016; Creighton et al., 2018) .

Many men eloquently described their experiences, both in terms of risks and potential remedies for quelling suicidality (Oliffe et al., 2021) . For example, Gary, a 52-year-old gay man, recalled the months and moments leading up to his suicide attempt through a photograph (Figure 3) 

A depiction of the days that just keep passing, especially when you're in that head frame of what's my purpose? . . . The sun keeps rising the next day. Why not have the strength to go through with it? Why not have the courage to do what you're thinking all the time? I don't know. Fear? It might hurt. But that picture was just that, "is that all life is?" One sunrise to the next sunrise, to the next? And that's what I saw in the gaps between each one of those blocks-each one of those is a day. And they just keep passing, and passing, and passing. And my purpose doesn't seem to gain any more reality than it was the day before.

Evident were the contests Gary endured wherein he was unable to mute nor distract himself from the monotony of, and rumination about, his unreasonable life. Symbolically illustrating his tedium and despair Gary digressed, "it was important to get back to work . . . it really has made a difference" in explaining how he continued to survive his suicidality. While career work is synonymous with idealized masculinity, Gary clarified that his job was deliberately "something menial" to afford purpose not pressure:

I just work at a grocery store, but you know what? It's something I've never done, and it's kind of cool to do something you've never done. And it's different . . . there's no stress. I mean, nobody cares what you do . . . how much you get done today. It's just whatever happens, happens. Not like in my former life. It was like, every day it was 16 hours. And you ran, and you ran, and you ran.

Contrasting challenges and strategies, Gary contextualized his suicidality to make available relatable insights to the interiority of and remedy work for his mental illness. Moreover, Gary's narrations of his vulnerabilities and resourcefulness emerged as strength-based projects. In addition to courageously admitting and addressing his suicidality, there was altruistic potential for helping others through his catharsis.

Recognizing the destigmatizing potential of Gary's and many other participants' photographs, we toured an in-person exhibition across Canada. Photographs and accompanying narratives featured in accessible and safe places hosting conversations about male suicidality, and lobbying tailored suicide prevention efforts. Some participants also collaborated with a local artist to produce and show art installations alongside the photographs. A photograph (Figure 4) , titled The Vancouver Exhibit Opening, hosted more than 300 guests, including Joe, a 50-year-old participant, who explained the destigmatizing value of his art installation (syringes in a glass case) with the following narrative:

Most people do not know that the back alleys of the Downtown Eastside are equipped with needle repositories as a means to prevent needle sharing among drug addicts. Normally hidden, this particular needle repository was the centerpiece of the room at the exhibit, commanding our awareness of it. It was also raised above eye height, asking us to look up at it rather than down or away.

The exhibits were especially powerful in facilitating conversations about wide ranging suicidality issues, with many attendees threading their own experiences in ways that bridged to aspirations for building male suicide prevention programs (Creighton et al., 2018) .

In addition to publications (Oliffe et al., 2017; Oliffe et al., 2021; Ferlatte, Oliffe, Salway, Broom et al., 2019) , presentations and in person exhibits, the men's photographs are available online. Across these advocacy efforts, the male suicidality work offers two key insights. First, photovoice methods strongly resonated with participants. Most men indicated their involvement as drawing therapeutic value from taking as well as talking about their photographs. Men's health promoters might usefully integrate photographs (and/or art therapy) to better understand and address men's mental illness. For example, many men disclosed traumas (e.g., bullying, abuse) and diverse self-management practices (i.e., alcohol use, self-isolating, exercise) when talking about their photographs in the interviews. Knowing and working with such contexts can be especially helpful for health promotors. Second, the community-based intervention value of photovoice was deeply evident in this work (Oliffe, Broom et al., 2020) . Health promotion has long worked to address agency and structure issues, and the community-based exhibits offered a unifying platform to destigmatize, raise awareness, and lobby prevention strategies for male suicide. That the men's photographs were intervention ready in their ability to directly message and engage others (rather than relying on our analyses and/or efforts for transitioning descriptive findings to prevention programs) is especially persuasive for intentionally building exhibits into photovoice projects from the outset.

The current article, in chronicling gendered dimensions of photovoice in men's health promotion, proffers an array of benefits and applications for the method. The plurality of masculinities, centrality of gender relations and destigmatizing potentials highlight the fit and influence of photovoice for advancing men's health promotion and practice. Moreover, photovoice processes and products can constitute interventions and avenues to guide clinicians, communities, and policy makers. That said, clearly, photovoice has shifted over the past 15 years, and cognizant of ongoing changes, we conclude by offering three recommendations for future work in men's health promotion.

First, our photovoice work reveals men taking photographs to express themselves as increasingly normative, a trend reflecting (in part) high and rising male smartphone ownership (Rowntree et al., 2020) . To grow men's photovoice work, we suggest researchers affirm (and where needed direct) men taking photographs to waylay their fears about image ascetics and/or creativity while assuring participants about the centrality of their narratives and commentaries. Opportunities should be seized to do more with the analyses of men's photographs. Building semiotics analyses, for example, might provide an avenue to more fully investigate meanings and mobilize participant-produced photographs in men's health promotion. Transitioning analyses to focus on the men's images as a collection to distil and share themes and interventions would be especially progressive. Second, COVID-19 has shifted qualitative work to virtual audiovisual-based platforms. These adjustments are well-suited to efficiently doing photovoice work and disseminating related findings and interventions, especially in the global north. Irrespective of the pandemic's run, we suggest that the ripple effects will garner new ways and means to do photovoice in men's health promotion work, notwithstanding the unique challenges in, and potential barriers for the global south. Third, discussed in detail elsewhere (Creighton et al., 2018; Tarrant & Hughes, 2020) digital and virtual platforms have forever changed ethics considerations regarding the use and reproduction of photovoice images. Working iteratively to educate and align with ethics boards is a critical means to ensuring photovoice work empowers participants who are fully aware of and agreeable to such caveats. Together, these three recommendations offer openings to thoughtfully consider next steps for further advancing photovoice to boost the health of men and their families.

Critical issues in men's mental health

Men's constructions of smoking in the context of women's tobacco reduction during pregnancy and postpartum

Hegemonic masculinity: Rethinking the concept

Constructions of masculinity and their Oliffe and Bottorff / PHOTOVOICE IN MEN'S HEALTH PROMOTION 323 influence on men's well-being: A theory of gender and health

Photovoice ethics: Critical reflections from men's mental health research

Using photovoice to understand suicidality among gay, bisexual, and two-spirit men

Stigma in the bereavement experiences of gay men who have lost a partner to suicide

Bill 36-2008: Motor vehicle (banning smoking when children present) amendment act

Partner support for smoking cessation during pregnancy: A systematic review

Photovoice as a tool to adapt an HIV prevention intervention for African American young men who have sex with men

Exposure to parental and sibling smoking and the risk of smoking uptake in childhood and adolescence: A systematic review and meta-analysis

Our lives: An examination of sexual health issues using photovoice by non-gay identified African American men who have sex with men

The effect of paternal factors on perinatal and paediatric outcomes: A systematic review and meta-analysis

Prostate cancer: Anglo-Australian heterosexual perspectives

Positioning prostate cancer as the problematic third testicle

Further than the eye can see? Photo elicitation and research with men

Fathers: locating smoking and masculinity in the postpartum

Analyzing participant produced photographs from an ethnographic study of fatherhood and smoking

Mobilizing masculinity to support fathers who want to be smoke free. What a difference sex and gender make: A gender, sex and health research casebook

Supporting fathers' efforts to be smoke free: Program principles

Help-seeking prior to male suicide: Bereaved men perspectives

Injury, interiority, and isolation in men's suicidality

How to Save a Life: Vital Clues From Men Who Have Attempted Suicide. Qualitative Health Research

Stigma in male depression and suicide: a Canadian sex comparison study

Community-based men's health promotion programs: Eight lessons learnt and their caveats

Men's depression and suicide

Understanding men and health: Masculinities, identity and well-being

Connected women: The mobile gender gap report 2020

Using photovoice with working-class men: Affordances, contradictions and limits to reflexivity. Qualitative Research in Psychology

Healthy masculinities? How ostensibly healthy men talk about lifestyle, health and gender

Predictors of postpartum relapse to smoking

The ethics of technology choice: Photovoice methodology with men living in low-income contexts

Engaging older men in physical activity: Implications for health promotion practice

Parent and child cigarette use: A longitudinal, multigenerational study

Photovoice: Concept, methodology, and use for participatory needs assessment

Family, maternal, and child health through photovoice

Photovoice as a participatory health promotion strategy

The real me shining through M.E.": Visualizing masculinity and identity threat in men with myalgic encephalomyelitis/chronic fatigue syndrome using photovoice and IPA