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When a picture is worth a thousand words

Participative map detailing where new urban migrants in Nepal seek healthcare. Living in the city: Building collaborations to strengthen health systems to respond to the needs of newly urbanised populations in Africa and Asia

Participative map detailing where new urban migrants in Nepal seek healthcare. Image courtesy of the Living in the city: Building collaborations to strengthen health systems to respond to the needs of newly urbanised populations in Africa and Asia project.

Published: 19 January 2023

How our funded projects are using visual participatory methods to address local needs in global health research.

NIHR is committed to engaging and involving communities from low and middle income countries (LMICs) in all aspects of global health research we fund. Enabling patients and communities to have a genuine voice in research is vital to achieving long-term sustainable impact. We encourage researchers to engage communities at all stages of the process, from funding to study design, delivery and dissemination.

Actively involving communities at the start of a project can generate invaluable knowledge that shapes the project’s priorities. This process also fosters genuine co-production of research – a topic that was explored by our community engagement and involvement (CEI) team and other colleagues in a recent article for the BMJ.

NIHR’s vision and goals for CEI in global health research are set out on our website and examined in our new podcast series. This feature focuses on one interesting and important aspect of CEI: the use of visual participatory methods.

Involving young people as ‘citizen scientists’

The use of visual aids such as drawings, paintings, photos or videos - can be an effective way of engaging people in research. They can help overcome language barriers and enable two-way communication. This is very important in global settings, where people may have low literacy or a limited understanding of healthcare and research.

Visual participatory methods take the use of such images a step further. They use visual aids to understand a topic from a particular point of view, or to prompt a response or opinion. By enabling people to make and share , researchers can spark discussion and empower groups to express their views.

The NIHR Global Health Research Group on Nepal Injury Research used visual methods to involve young people in their work on road safety. Teenage participants were given cameras to capture examples of dangerous versus safe road practices during their school journeys. This prompted further discussion during interviews. It also created a powerful body of evidence to engage with policymakers about road safety.

The NIHR Global Health Research Group on Global Diet and Activity Research (GDAR) used a similar approach with young people in Cameroon, South Africa, Kenya and Jamaica. They trained teenagers as ‘citizen scientists’, encouraging them to create photo and video diaries of their daily journeys, food and health environment. Their insights have helped to inform policy on healthy diets and physical activity across Africa and the Caribbean.

Empowering marginalised people in research agendas

Empowering communities to express themselves in pictures can encourage people to discuss sensitive issues more openly. It helps level the power balance between communities and researchers and gives a voice to people who may not otherwise be heard. Equally, it brings community voices to the fore when engaging policymakers to raise awareness and advocate change.

Over the past four years, the NIHR Global Health Research Group CLEAN-AIR Africa has used visual methods to engage women from disadvantaged communities in Cameroon and Kenya. These women spend a lot of time cooking with smoky fuels such as charcoal and dung in enclosed spaces. They and their children suffer from respiratory illnesses caused by household air pollution.

By taking time to build relationships with local communities, the CLEAN-AIR Africa team empowered women to share their experiences of household air pollution and illness. They also supported them to switch to cleaner cooking methods. Find out more about the study on the NIHR YouTube channel: The Killer in the Kitchen: How CLEAN-Air Africa is tackling household air pollution.

Researchers from Living in the city: Building collaborations to strengthen health systems to respond to the needs of newly urbanised populations in Africa and Asia, used a similar approach to empower newly urbanised communities in Nepal. 

The team encouraged people who had recently moved from rural to urban areas to take photos of the healthcare challenges they face. They also asked participants to interview and video fellow community members. They explored two main questions:

  • what new health threats/challenges do they face in their new urban environment?
  • how do they 'navigate' the complex urban health system?

Together, participants drew maps detailing where they travel to seek healthcare. Researchers used these maps in group discussions to understand why people make particular choices. They explored the importance of convenience, cost, accessibility and other factors.

Professor Simon Rushton at the University of Sheffield led this project with partners in Nepal, Bangladesh and Ghana. He said: “Many developing countries are experiencing rapid and unplanned urbanisation, and people can find it difficult to access health services. We were able to capture the experiences and perceptions of both newly-urbanised people and providers of health services, to bring these into dialogue with health planners and policymakers.”

The researchers hope to expand this work with a larger project using similar visual methods. If successful, they will work in four countries: Nepal, Vietnam, Bangladesh, and Ghana.

Communicating health messages

Visual imagery is not only an effective way of involving communities in research, but also communicating health messages. As the old saying goes, a picture is worth a thousand words – and sometimes many more.

For example researchers from the ‘One for All, All for One’ project, created a comic book and film to raise awareness of immunisation in Malawi. NIHR and Malawi-Liverpool-Wellcome Programme funded the research, developed in collaboration with local communities.

Rodrick Sambakunsi, Head of Public Engagement and project manager, said: "Working with different community groups on this project has been a game changer. Our ambition was to 'listen' rather than 'tell'. We used workshops with participants that included communities, village and faith leaders and policymakers in Malawi to co-create the narrative of the comics.

“The final comics reflect the questions and discussions that took place in the workshops. They are informed by evidence from science communication and social science research, and their different insights and perspectives have contributed greatly to the project." 

To find out more about CEI, check out our new podcast series, Spotlight on community engagement and involvement. It brings together guest speakers from across the world to explore how meaningful engagement with local communities is improving global health research.

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