“A photo can change everything”: Photovoice as a tool for social change and decreasing health inequities in a community based primary health care (CBPHC) program in rural Nicaragua

Purpose: Health inequities in Nicaragua result in higher rates of morbidity and mortality for women and children, especially in rural areas characterized by extreme poverty and difficult geographic access to health care. We describe a program protocol using photovoice as a tool for building capacity so communities can determine their own strengths and needs, prioritize problems, and make action plans to improve their health in a CBPHC program serving 5000 people in a rural Nicaraguan municipality. Data Used: Participant photos, stories, interviews of local lay health workers and leaders from 11 rural Nicaraguan communities; community action plans. Methods Used: Four photovoice sessions included training, taking digital photos about health and community, critical analysis of fotos via inductive questioning (SHOWED method), and action planning. Major Results: The themes that emerged included poverty as a cause of illness and disability; difficult access to health care; and resilience and hope despite extreme poverty. Participants presented their pictures and stories to their own communities, program donors, and the government Ministry of Health (MINSA) with the following impact: 1. Development of community action plans to improve health 2. Strengthening of donor support of the CBPHC program 3. Support from MINSA to coordinate health interventions with the network of CBPHC lay health workers. Recommendations and/or policy implications: Photovoice can strengthen CBPHC programs by promoting critical dialogue, facilitating issue selection and the development of community action plans to decrease health inequities.