Author: Andrew Oguntolu and Oluwatoyosi Adekeye
On 23rd May 2023, the LIGHT Consortium at Zankli Research Centre launched a photo voice enrichment exhibition titled "Gender-Responsive Ways of Improving TB Care", at the Masaka Health Centre, Nasarawa State. This event marked the culmination of participatory research work involving 25 primary participants impacted by TB, including those living with TB, family members supporting a person living with TB, and healthcare workers providing TB services at the community level. The photovoice project aimed to explore strategies for delivering TB services that respond to the needs of different genders in Nigeria and to generate learning for other high TB-incidence settings in Africa.
How was the study conducted?
The study employed “Photovoice” as a participatory approach to identify gender-specific TB services in peri-urban settings, specifically in Karu Local Government Area (LGA), Nasarawa State. Two primary health centres (PHCs) providing TB services, known as DOT clinics (Directly Observed Therapy), were the research study sites.
Participants were randomly selected from the TB Register, where people living with TB and their family members are listed. Inclusion criteria included individuals with TB who have been on treatment for at least 2 months or have completed treatment within the last 12 months; age 18 and above; living in Karu LGA; and registered at a selected DOT clinic. This information was validated with the help of healthcare workers. Healthcare workers working closely with people living with TB, in both health facilities, were asked if they would be interested in joining the study. The study included eight people living with TB, eight family members of people living with TB, and nine healthcare workers.
Prior to participant selection, the LIGHT Consortium Team at Zankli Research Centre (ZRC) held a two-day researchers' workshop, drawing various stakeholders from the Bingham University community. The purpose of the workshop was to train researchers and other stakeholders on the methodology.
The photovoice project kicked off with an ‘Inception Workshop’ which aimed to introduce participants to the project, outlining its expectations and overall goal. Participation was voluntary and participants were briefed about ethical issues including confidentiality, usage of data (including their photos), and their right to withdraw from the study. Consent forms were signed and cameras were distributed.
Participants took a few weeks to capture their own photos that represent their everyday experiences, challenges and inspirations in relation to TB and access to TB services. This was followed by a second workshop to check-in with participants, review their captured photos, and provide them with advice and guidance, in-line with the project’s guidelines. Prior to the third workshop, all photos and cameras were collected and thoroughly sifted to remove duplicates and blurriness. The third workshop engaged participants in group discussions to present and explain their photos and its significance using the SHoWED method. Participants then selected their three to four best photos, discussed them, and generated themes with guided support and instructions.
Key findings
The themes generated highlight the myriad challenges faced by marginalised communities in TB treatment, including stigma and discrimination, socioeconomic factors, healthcare infrastructure, economic constraints, nutrition, awareness and other cultural influences. Stigma and discrimination, particularly among marginalised groups, create barriers to accessing healthcare, leading to social isolation and treatment delays. Limited access to healthcare facilities and trained professionals in ethnic minorities and rural populations often compromises quality of care. Economic constraints further exacerbate these issues, hindering access to affordable healthcare services and contributing to delays and increased transmission rates. Cultural beliefs and perceptions also play a significant role in shaping attitudes and behaviours towards TB, sometimes conflicting with biomedical approaches and causing delays in seeking medical care.
Enrichment exhibition
The enrichment exhibition was attended by 140 people including 15 participants and some of their families and friends. Among the attendees were representatives of the Local Government, namely the Supervisory Councilor of all the Primary Health Centres in Karu and the Head of Masaka Health Centre, along with various Departmental Heads of the Centre.
Associate Professor Toyosi Adekeye and Mr. Andrew Oguntolu opened the event with a brief introduction about the participatory action research study and the photovoice approach. They explained the process of utilising photovoice as an innovative approach to empower individuals living with TB, their family members and health workers to document their lived experiences, including real-life challenges, motivations and achievements through photography.
The beauty of Photovoice lies in its ability to foster understanding and empathy, transforming visual narratives into powerful tools for knowledge sharing and advocacy. This was evident in the Photovoice Community Enrichment event where the images captured by participants served as compelling evidence for policymakers, urging them to address the socio-economic and health disparities exacerbating the burden of TB. Ultimately, Photovoice bridges the gap between lived experiences and policy, underscoring the importance of community engagement in driving meaningful change and improving the quality of life for people impacted by TB, while emphasising the urgency of implementing comprehensive solutions and support vulnerable populations.
Key feedback and insights
The exhibition stimulated significant feedback from various stakeholders. For instance, Hon. Idris Yusuf, Supervisory Council Primary Health Karu LG representing the Chairman of the LG, emphasised the need for government action to improve the quality of life for patients and health care workers.
All these pictures are very important, and the government needs to do more to improve the quality of life for patients and health workers, especially regarding that picture of beautiful health centers without TB drugs and health workers, I will push more to see that something is done about it… … If you look at our environment now, it is difficult for someone with a large family to feed them and a man goes to the hospital and has to wait for hours, what is he going to give his family? So, with awareness, they will understand health is wealth. [Hon. Idris Yusuf, Supervisory Council Primary Health Karu LG representing the Chairman of the LG]
Mrs. Dorcas Haruna, Officer Incharge of Office, Masaka DOT Clinic, appreciated the focus on awareness, nutrition and ventilation, highlighting the importance of protective gear for healthcare workers.
This is an eye-opener and sensitisation, especially on the issues of awareness, nutrition, and ventilation. The issue of hand gloves and face marks is very important because as a health worker if these things are not available then your health is in danger. I appreciate the organizers for coming and for giving us an insight on where to concentrate. [Mrs. Dorcas Haruna Officer Incharge of Office, Masaka DOT Clinic]
Other participants and attendees stressed the need for reducing patient wait times, increased awareness about free TB diagnosis and treatment, and encouraging young men to get tested to prevent family infections.
As a health worker, we need more hands honestly, because if there are more workers people won’t come and stay for hours. You have about 1 doctor attending to 40 patients and 1 nurse to 30 patients. So, if the government can employ more hands the work will be easier for us. [Magaret Obole, Health Care Worker, Uke Hospital]There is a need to create more awareness about TB as the diagnosis and treatment is free without paying anything, all they need to do is show up at the DOT centres. [Kasimu Aliyu, Community Mobiliser on TB]As a representative from the palace, we the women will continue to support our young boys and men to get tested so that they don’t infect the family so that they will have a culture of getting tested if they have symptoms [Magajiya Lami Bawa, Masaka Community, a representative from the Chief of Masaka] *translated from Hausa to English*
Conclusion
The Photovoice Enrichment Exhibition successfully showcased the importance of gender-responsive TB care. By empowering participants to share their stories through photography, the exhibition fostered a deeper understanding of the challenges faced by people living with and impacted by TB. It spurred critical conversations on the need for gender-equitable TB services and highlighted the vital role of community engagement in influencing policy and improving health outcomes.
The collective efforts of the community and stakeholders reflect a promising journey towards enhanced TB care and a brighter, healthier future for all. As we move forward, it is essential for the government and other stakeholders to act on these insights, ensuring that the voices of the community are heard and their needs addressed. The commitment demonstrated by the participants and officials is a promising step towards a TB-free future.