Using Photovoice to Promote Body Image Resilience in College Women

As a multidimensional construct, body image reflects affective, behavioral, and cognitive aspects of individuals' perceptions about their physical appearance (Cash & Smolak, 2011). One way that women construct their body image is through ongoing comparisons of their physique with the idealized sociocultural images promoted in mass media (Notman, 2003). The internalization of societal beauty standards propagated by popular media, including messages in magazines, music videos, and social networking sites, may lead to self‐objectification (Morry & Staska, 2001; Vandenbosch & Eggermont, 2012). Pervasive objectification is connected with increased body surveillance, decrease in desire for social connection, feelings of isolation, fragmented self‐acceptance, feelings of shame, anxiety, disordered eating, and depression (Breines, Crocker, & Garcia, 2008; Dakanalis & Riva, 2013; Fredrickson & Roberts, 1997).

College women are particularly at risk for the internalization of an ideal body image, which may contribute to a reduced satisfaction with their appearance, excessive dieting, lower self‐esteem, negative emotions, and disordered eating (Hendrickse, Arpan, Clayton, & Ridgway, 2017; Snapp, Hensley‐Choate, & Ryu, 2012; Stice, 2002). Studies have indicated that as many as 85% of college women report dissatisfaction with their body image (Neighbors & Sobal, 2007). These body image concerns are widespread and affect women of different racial, ethnic, and cultural backgrounds. In their study of weight perception and weight‐loss behaviors among university students from 22 countries, Wardle, Haase, and Steptoe (2006) found that compared with their male counterparts, college women across the world overestimated their weight despite having a lower body mass index and engaging in weight‐loss behaviors. With high rates of eating disorders and continuous pressure from the media and society (Dakanalis & Riva, 2013), developing strategies to promote positive body image and body image resilience remains a concern for college women.

Positive Body Image and Resilience

Wood‐Barcalow, Tylka, and August‐Horvath (2010) described positive body image as “an overarching love and respect for the body that allows individuals” (p. 112) to appreciate, accept, and feel comfortable with their bodies and emphasize body assets rather than imperfections.

Scholars described positive body image as a distinct multifaceted, holistic, and protective construct that contributes to women's overall well‐being (Tylka & Wood‐Barcalow, 2015). Avalos, Tylka, and Wood‐Barcalow (2005) found that body appreciation, which is an integral part of positive body image, related to participants' self‐esteem, optimism, and proactive coping. Researchers have also connected body appreciation with intuitive eating among diverse groups of women and men in the United States and other countries (Andrew, Tiggemann, & Clark, 2014; Avalos & Tylka, 2006). In a study of 284 undergraduate students, Gillen (2015) found that more significant positive body image was associated with higher self‐esteem, less depression, and greater intention to use sun protection. These findings suggest the importance of promoting positive body image as a critical component of mental and overall physical health of individuals.

Body image resilience, or the capacity to appreciate one's body despite societal messages, represents an essential aspect of positive body image (Choate, 2005). Resilience “connotes inner strength, competence, optimism, flexibility, and the ability to cope effectively when faced with adversity” (Wagnild & Collins, 2009, p. 29). Thus, examining creative ways to engage in discourse and activities to foster positive body image and body image resilience remains a critical prevention and treatment goal for mental health professionals.

Although a plethora of literature has investigated correlates, predictors, and consequences of negative body image concerns and pathology, fewer studies have examined creative prevention‐focused interventions to foster positive body image and body image resilience (Avalos et al., 2005; Madden & Breny, 2016). Furthermore, studies presenting approaches that promote elements of positive body image are lacking. Therefore, the purpose of this qualitative study was to explore a creative way that college counselors can promote body image resilience among college women.

Photovoice

Initially introduced by Wang and Burris (1994) in health research, photovoice represents a nonexperimental qualitative research methodology that documents visual information. With an overarching focus on advocacy and social change, photovoice represents a unique way to enable critical thinking around various aspects of individuals' lives through shared visual images and experiences (Wang & Burris, 1997). The traditional photovoice research process involves the following three stages: (a) the creation of images, (b) critical reflections on the photographs and the content using the SHOWeD method, and (c) the sharing of images with the broader community (Wang, 1999). The SHOWeD method includes questions that guide participants' reflections on their photographs (i.e., “What do you see here?” “What is really happening here?” “How does this relate to our lives?” “Why does this situation, concern, or strength exist?” “How can we become empowered by new social understanding?” and “What can we do about it?”). The method's theoretical foundation encourages individuals from diverse social backgrounds to express their unique experiences and concerns through the lens of visual art (Wang & Burris, 1997).

Supporting the core values of the counseling profession to engage in a critical dialogue about social issues, photovoice has been gaining attention in the counseling and counselor education literature as a viable pedagogical, social justice, and research tool (Koltz, Odegard, Provost, Smith, & Kleist, 2010; Lenz & Sangganjanavanich, 2013; Sackett & Jenkins, 2015). Furthermore, Sanon, Evans‐Agnew, and Boutain (2014) highlighted the potential for photovoice to be used as a social justice tool through focusing participants on identifying an outcome on one of three levels (individually raise awareness, ameliorate a condition, or engage in societal transformation). Thus, its potential as a participatory action research method is wide‐ranging. Sackett and Jenkins (2015) urged counselors to consider photovoice as a counseling intervention to discuss areas that hinder clients' growth and development. Healthy body image is a critical part of individuals' well‐being. Photovoice can offer a unique way for participants to share their experiences in developing body image resilience while raising their consciousness about societal norms that may inhibit their growth.

Method

The research team modified the traditional photovoice methodology to engage college women in critical discussion about body image resilience. Because the researchers were interested in piloting a group format for the sharing of participant‐produced photovoice project images, instead of having participants share their project images with the broader community, the researchers had participants share their project images in a group setting. Specifically, the researchers held two focus group meetings to engage the participants in critical reflections around the issue of body image resilience in response to media messages (i.e., raising awareness, per Sanon et al., 2014). Centered on group discussions and individual reflections, the data collection process was guided by the participants' photographs and visual images that represented their perspectives on body image resilience.

Researchers

The researchers in this study included five women. The principal investigator (the first author) is a counselor education faculty member, and the four other researchers (the second and third authors and two research assistants) included two doctoral students and two master's‐level students. The lead researcher has professional interest in and has researched the topics of body image, eating disorders, and self‐harm. The four graduate students expressed personal interests in the topic of body image.

Participants

Fourteen participants responded to the research advertisement posted on two campuses of a southwestern university. The research team secured written consent from the participants. Table 1 presents the demographic information of the participants in both groups. Group 1 was composed of six graduate students and two undergraduate students. Group 2 included three graduate students and three undergraduate students. Numeric identifiers (Group 1, IDs 1–8; Group 2, IDs 9–14) were used to keep track of the participant records and protect the use of potentially identifying information. Each participant received a $20 gift card for taking part in the study. The data collection process lasted 2 months.

Table 1

Participant Demographics by Group

Note. Numeric identifiers (Group 1, IDs, 1–8; Group 2, IDs 9–14) were used to keep track of the participant records.

Description of the Project

After receiving approval from the institutional review board, the research team recruited participants at a southwestern university in the United States using a recruitment video and flyers advertising the study. As described earlier, the researchers were interested in piloting the study in a group format. The final sample (N = 14) was divided into two groups of female graduate and undergraduate students. Participants in each group attended two 90‐minute group sessions over 2 weeks.

Group Session 1. The first session was structured to engage students in a critical discussion about body image and the media and to introduce them to photovoice. To stimulate the discussion, the research team put together an interactive presentation on body image ideals in the media to engage participants in a discussion about their perceptions of media messages and personal experiences related to body image resilience. The participants were then introduced to photovoice. After the meeting, the participants received instructions to take three pictures that represented their perspectives of body image resilience and provide written descriptions and reflections on these pictures following the described SHOWeD method questions. These pictures could potentially include objects that captured their experiences, locations, and people. The participants were advised not to take pictures of faces (their own or others) because they could serve as identifying information.

Group Session 2. The second meeting for both groups involved the participants sharing and reflecting on their photovoice project images that symbolized their body image resilience. The meetings for each group began with the participants selecting a photovoice photograph that was most meaningful for them and that best represented the concept at hand (Wang & Burris, 1997). The researchers encouraged the participants to contextualize the selected images by sharing stories that accompanied their pictures (Wang & Burris, 1997). This process continued until each group member shared a picture and the accompanying reflection. In line with the participatory action research focus of the traditional photovoice methodology, the researchers invited the participants to make suggestions as to how to create social change around body image issues.

Data Analysis

Data analysis approaches vary in studies using photovoice research methodology (Cooke & Kathari, 2001). Because the research team was interested in exploring the participants' self‐perceptions of body image resilience, it wanted to see whether there were common elements and themes shared among the participants. Thus, coding followed Braun and Clarke's (2006) recommendations for thematic analysis. Thematic analysis encourages researchers to explore rich and complex data while engaging in a reflexive dialogue about emerging themes as categories of analysis. Thematic analysis and coding involve a multiphase process (Braun & Clarke, 2006). In Phase 1 of the analysis, the researchers began the process of familiarization with data and the preliminary identification of emerging ideas. During this early stage of theme identification, the research team's overarching goal was to understand the participants' relationship with the concept of body image resilience.

As mentioned earlier, during the second round of group meetings, participants were asked targeted questions following the SHOWeD methodology. In addition to their photovoice project images, participants' written (descriptions of visual images) and verbal (focus group debriefing) reflections on their photographs, their feedback about the group sessions, and the researchers' reflections (verbal and notes) on group dynamics were used as data sources. All of the researchers immersed themselves in the data (including the participants' photovoice project pictures, accompanying reflections, and the shared dialogue that emerged during the group meetings).

During thematic data analysis, Braun and Clarke (2006) encouraged making several decisions about the data transformation process. First, researchers should agree upon the level of data transformation (i.e., inductive or theoretical). Accordingly, in the current study, the research team applied an inductive or data‐driven approach to data familiarization, avoiding the application of a predetermined theoretical framework to theme coding (Boyatzis, 1998). This approach allowed the emerging themes to be closely related to data collected through the identified sources (e.g., photovoice artifacts, personal reflections, group discussions). The initial codes included as many potential themes as possible related to the topic of body image resilience (Braun & Clarke, 2006). This process occurred during Phase 2 of the thematic data analysis (Braun & Clarke, 2006).

During Phase 3 of the analysis, the research team had to make another decision regarding the level of theme identification. Accordingly, a combination of the semantic and latent levels of theme identification was applied in this study, which means that identified themes emerged from the participants' accounts, as well as the analysis of underlying assumptions and ideas shared by the participants (Braun & Clarke, 2006). The team also analyzed the relationship between different levels of themes that emerged. This iterative process resulted in the creation of a map with the three themes and subthemes (see the Results section). In Phase 4, repetitive and overlapping themes were condensed into the final thematic analysis. During this phase, themes were also named and organized by presented narratives and visual images related to body image resilience. The research team viewed participants as coinvestigators in the project and sought their feedback on the themes that emerged.

Rigor

Recognizing that a certain level of subjectivity is present in all studies, the researchers attempted to remain objective by using the following trustworthiness methods: triangulation of investigators, member checking, field notes, the bracketing of their own experiences and assumptions throughout the study, and prolonged engagement with participants (Creswell, 2013; Hays & Singh, 2012). Triangulation of data sources helped the researchers to include various points of data in the analysis process. The entire research team reviewed notes from group discussions and photovoice artifacts. Qualitative scholars view member checking as an essential strategy of trustworthiness (Hays & Singh, 2012). All participants were emailed the map of the initial themes and were asked to provide their opinions related to the findings. Asking members to check data transcriptions ensured that the researchers did not distort or misinterpret the participants' messages. This process also allowed the researchers to engage the participants in the process of theme construction. The researchers took notes during the second meeting with each group. These notes helped the researchers to compare their group experiences during the subsequent bracketing and data analysis meetings. The researchers conducted member checking following the second‐round meetings. Hays and Singh (2012) suggested that because researchers play an integral role in a qualitative inquiry, they should engage in extensive note‐taking and reflections. This process encouraged the research team to engage in self‐examination, thereby promoting their reflexivity through the process.

Results

In all, the participants produced 26 images and photographs reflecting their ideas of and personal experiences with body image resilience. Data analyses revealed three key themes (i.e., connection, social gender norms, and self) and several subthemes. Each of the themes and subthemes is discussed below. Participants' written reflections on their photovoice projects are used as illustrations.

Connection

The connection theme was reflected in several images presented by the participants. During the group sessions, the participants spoke about the role of supportive connections with others in their lives. The participants identified these connections as empowering women to overcome not only struggles associated with their body image but also other life struggles. One participant spoke about feeling empowered being in connection with others:

Girls‐Friends! Your life is so much richer if you have the right girlfriends. Who support you no matter what! Who lift you when you're down. Who laugh with you, cry with you, and lend a caring hand when you need it. I would not be the same without my girlfriends.

Another participant described the complexity of connections and women's abilities to navigate adversity in the world. In her reflection, the SHOWeD method is highlighted:

In this picture, I see a woman who is complex and full of life. She is lifted by those around her. She is taking in the beauty of life…. This relates to our lives because it is a testament to no matter what situations we may find ourselves in, we can still rise above them. No matter what society tells us we have to look like, we can still be strong in who we are and embrace what we look like as being beautiful and strong.

Social Gender Norms

The second theme of social gender norms echoed throughout the participants' images and their reflections. In addition, a subtheme of intersectionality related to the domain of social gender norms emerged. In this study, the subtheme of intersectionality reflected the participants' positions on their intersecting and multidimensional identities and related to systems of dominance and oppression (i.e., race and gender). For example, during the group meeting, participants spoke about the role of the media as a system of dominance and influence. One participant wrote the following reflection about her photovoice project (a picture of an African American female in the traditional Wonder Woman outfit):

This shows that we can all be wonder woman because we all have strength. This relates to our lives because it turns the idea of what a female superhero is. She also gives a great image for more girls to look up to. This situation exists because people were tired of the comic industry promoting only one type of superhero, if they even dared to show a female superhero. What we can do about it is put our money behind multicultural comics and stories. We can promote in society that all types of people can be superheroes.

Another participant stated,

My generation, or older it was normal for a woman to take care of the chores inside of the house. And the man takes care of the outside chores. I think it's time to switch that kind of thinking. Man can cook, and clean, and wash … etc. Women can mow, and fix things if they so choose…. I would like our society not put any label on what a woman can or cannot do, or should or shouldn't do. What is a “man's job,” vs. a “woman's job”? Who gets to decide that? We should all have the opportunity to do what we want to do … step outside the box.

Self

The final theme, self, included participants' photovoice pictures and reflections that related to their ideas about themselves and various aspects of their bodies, particularly how their perspectives and experiences were influenced by media messages. The two subthemes in this domain reflected participants' struggles and triumphs that were related to self‐acceptance and self‐criticism.

Self‐acceptance. The following narrative highlights the participant's ideas about specific aspects of her body, particularly related to images in the media:

My stomach does not have abs of steel, it is more like a flabby pit. However, I am not ashamed of this. In fact, I love my stomach because one day it will hold inside it another life. It will be the home and shelter of another human being. It will guard and protect and grow another person. One day, I will have a precious baby growing inside my stomach, and the extra flab will help to protect the innocence of my baby. I love my stomach because it gives me the ability to love unconditionally a child who has not yet been conceived, but that will one day need me. I love my stomach because it is a part of my past and will be a part of my future.

Another participant described her journey toward self‐acceptance in the following reflection:

In this picture, I see a girl who has freckles. I am trying to convey that this girl is happy letting her freckles show. I feel like a lot of girls in society that have freckles are embarrassed by them and think that they look unattractive so they choose to cover them up with makeup. I personally feel like freckles are adorable and I think it is horrible that girls feel as though they can't appreciate them because for some reason society as a whole portrays them as unattractive.

Self‐criticism. In this study, participants spoke about self‐criticism related to certain body parts, and how women hide and modify their body image using technology. The following narrative provides examples of these concerns:

My entire life I have had major self‐confidence issues because of it [psoriasis]. It was a lot worse when I was younger, but I hardly ever wear shorts or dresses or anything that risks showing my skin where the psoriasis is. I get so self‐conscious…. Society or the media depicts women who are very thin yes, but they also depict women who have PERFECT skin…. It looks smooth, shiny, and flawless, which makes “normal” people feel as though they have to have flawless skin as well…. I hate seeing my roots, but I like to look at it as a reminder of my entire family have darker hair and blue eyes…. I want to learn to embrace my natural hair.

Social Change: Promoting Body Image Resilience

According to participatory action research methods, one of the goals is to enact social change (Greenwood, Whyte, & Harkavy, 1993). Studies using photovoice seek to do this in one of three ways: awareness, amelioration, or transformation (Sanon et al., 2014). In their reflections, group discussions, and member checks, participants shared ideas and suggestions to challenge the way body image is promoted in contemporary society. One participant stated, “I think the focus should be less on the outward, but empowering people to find self‐love and how to have awareness around being in touch with our bodies so we know what we need to be healthy instead of thin.” Urging the creation of social change around the focus on the ideal body image, another participant mentioned, “I think the only way we can create social change is by changing what society values/what is seen as the ideal woman. We also have to get rid of the proliferation of body shaming.”

Another participant noted,

As a society, we can promote body image appreciation by not always having … certain stereotypical “attractive, good looking” models being portrayed in social media. Every person is unique in his or her own way, but as a society there is such a focus on everyone trying to fit one certain image stereotype. By showing a wide variety of different types of people, it will hopefully help everyone to appreciate who they are and appreciate their own uniqueness.

Finally, one participant had the following advice: “The most important thing we can do is love our bodies and be thankful for them. Loving your flaws will also make you less likely to judge other people.”

Discussion and Implications for College Counselors and Researchers

The participants in this study produced 26 images and photographs that reflected their ideas and experiences related to body image resilience. The participants were creative in selecting visual images to represent their realities. For instance, one participant sketched an image of herself, highlighting particular features she wanted to embrace; another used images from a comic book; and other participants chose pictures from magazines or took pictures of their surroundings and their body parts. Concerns around various body parts represented in some of the photovoice projects reflected the persistent focus on images of ideal bodies portrayed in the media. For example, in one of the above quotations from the self‐acceptance subtheme, the participant stated the following: “My stomach does not have abs of steel, it is more like a flabby pit.” The media influenced her ideas about her stomach (e.g., comparing her abs with “abs of steel”—a home workout program advertised in the media). Other participants commented on different aspects of technology, such as Photoshop (which allows individuals to visually correct and perfect pictures for media consumption), and their effect on their body image resilience.

As stated earlier, studies have implicated the media in objectifying and socially denigrating women (Madden & Breny, 2016). The participants' narratives reflected that these messages are seen and internalized—with both positive (leading to self‐acceptance) and negative (leading to self‐criticism) outcomes. The participants in this study were also aware of the gendered nature of media messages. Jordan (2010) maintained that growth‐fostering connections are vital to the healthy development of women, and the theme of connection that emerged from this study appears to underscore this idea. This theme also supports Choate's (2005) assertion that a supportive social environment is foundational for developing and promoting body image resilience. Thus, counselors can link a connection between college women using photovoice in group or presentation settings. The women in this study also touched on a critical feature of Wood‐Barcalow et al.'s (2010) definition of positive body image—respect for their bodies—by highlighting valued aspects of their bodies rather than classifying them as imperfections. For this reason, college counselors should view the use of photovoice not only as a method to normalize and validate the role of the media in body dissatisfaction but also as a way to encourage self‐love and self‐compassion. Self‐compassion has been linked to psychological well‐being in students pursuing higher education (Saricaoglu & Arslan, 2013).

Considering the prevalence of body image dissatisfaction among college women, mental health professionals have an essential role in assisting students in developing body image resilience. Although the presented issues may not be directly expressed as body image concerns, college counselors need to be aware that some of the symptoms, such as low self‐concept and self‐esteem, may be connected to dissatisfactory body image. Thus, creatively exploring these concerns within a safe therapeutic environment is encouraged. Sustainable prevention programs can be critical in forestalling the development of negative body image and disordered eating among college women (McVey et al., 2010; Piran, 2015; Schwitzer, Rodriguez, Thomas, & Salimi, 2001). College counselors are encouraged to organize creative educational programs and workshops on the topics of the media, societal norms, and body image resilience (McVey et al., 2010). Incorporating media literacy materials in counseling college women can be a useful preventive approach to working with this population (Piran, 2015). College counselors can promote awareness by organizing media awareness days on college campuses. The use of online campaigns through social media platforms is also encouraged. College counselors can create their hashtag and promote body image resiliency and dismantle the normalcy of objectification and denigration of women in the media. Online campaigns have the potential to reach past targeted audiences, thus maximizing the connections created between women in college.

Photovoice can be a valuable adjunct for college outreach programming and counseling and has the potential to expand media literacy and prevention efforts. Photovoice can be useful when working with various groups who may not be able to or feel comfortable with openly expressing themselves and discussing concerns related to body image (Nash, 2014). For example, a timid individual or someone who experiences language barriers may feel more inclined to share through the use of photos rather than in verbal expression. Photovoice allows individuals to express themselves beyond traditional methods and empowers them to create meaning from their experiences through storytelling (Loewenthal, 2013). Thus, counselors can use photovoice to gain a richer understanding of the client's experience that can be missed through the use of traditional counseling. In this study, the photovoice method empowered participants to engage in media literacy and reflect on their body image resilience by critically examining and deconstructing societal messages related to images of ideal bodies portrayed in the media. Not only did participants describe having greater awareness of and respect for their body image resilience, they discussed specific solutions that can create change on the micro‐ and macrolevels. Thus, the use of photovoice in this study promoted participants' awareness, as recommended by Sanon et al. (2014).

Limitations and Directions for Future Research

This study has several limitations. First, the study was conducted on a college campus, and the participants were members of its community. Second, all participants lived in the southwestern region of the United States. Third, a different group of women may have offered different perspectives on the topic. For example, several of the participants were pursuing a degree in counseling, psychology, or social work. Fourth, the study focused solely on female participants. Finally, because generalizability is not a goal in a qualitative inquiry (Creswell, 2013), the results of this pilot study cannot be generalized to explain the experiences of all college women. Therefore, future studies should examine the body image resilience experiences of diverse participants, including males and those who are transgender or gender fluid. In addition, researchers should seek to replicate the method used in this study with other populations (e.g., younger girls, adolescents, older adults, men and women from various backgrounds).

Conclusion

The central purpose of this study was to examine photovoice as an intervention and as a prevention tool for understanding, expressing, and encouraging body image resilience among college women. Photovoice presents a unique way to allow participants to express their voices and self‐empower (Budig, Diez, Conde, Sastre, & Franco, 2018). In this study, participants explored their body image resilience through photovoice. Three overarching themes emerged from the data analysis: connection, social gender norms, and self. These themes reflect increased self‐awareness and an appreciation of intersectionality and connection. Considering the limited amount of research that has used photovoice with respect to positive body image, this study has value. On the basis of the results of this study, photovoice holds the potential as an intervention and as a prevention approach for promoting increased understanding of body image resilience in a group setting. As a creative tool, photovoice can be used to engage women in critical reflections and discussions about body image.