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Muroetal. BMC Public Health (2023) 23:81
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Open Access
BMC Public Health
Nuestra Recuperación [Our Recovery]:
using photovoice tounderstand thefactors
thatinuence recovery inLatinx populations
Jordana Muroff1*, Daniel Do1, Cristina Araujo Brinkerhoff1, Deborah Chassler1, Myrna Alfaro Cortes2,
Michelle Baum1, Genessis Guzman‑Betancourt1, Daniela Reyes1, Luz M. López1, Maylid Roberts3,
Diliana De Jesus3, Emily Stewart3 and Linda Sprague Martinez1
Abstract
Background Photovoice is a form of visual ethnography intended to engage impacted communities in research
followed by action to ameliorate the injustices under study. Photovoice has increased in use, especially in collabora‑
tion with Latinx communities addressing health inequities. The Latinx population comprises nearly 18% of the overall
United States population and according to the census is projected to reach just under 30% by 2060. This diverse
panethnic community faces significant structural barriers in accessing services. Racism and the resulting marginaliza‑
tion, specifically, contributes to limited access to recovery services and treatment. Making meaningful advances in
substance use disorder training, intervention and policy necessitates learning alongside the Latinx community.
Methods We partnered with a Latinx serving integrated behavioral health and primary care setting in Boston Mas‑
sachusetts to explore barriers and facilitators to recovery using photovoice. Spanish‑speaking Latinx adults with a
substance use disorder participated. The group met for three photovoice sessions over a six‑week period. Together
group members critically analyzed photographs using the SHOWeD method.
Results Findings indicate a sense of purpose and meaning, security, faith and housing are important elements of
recovery. The results illustrated the importance of sources of connection in maintaining sobriety. Through this photo‑
voice project, Latinx Spanish speaking participants highlighted barriers and facilitators to their substance use disorder
recovery which spanned individual, community, and structural levels.
Conclusions The experiences and voices of the Latinx community are crucial to drive discussions that advance
policy (e.g., housing stability and access), enhance providers’ understanding of Latinx Spanish‑speakers’ substance use
disorder recovery, and inform culturally and linguistically appropriate services. This study demonstrated that photo‑
voice is highly acceptable and feasible among Latinx clients receiving substance use disorder services. Visual images
related to housing, faith, etc. communicate challenges, power structures, as well as hopes to policymakers at multiple
levels (e.g., institution/ agency, state).
Keywords Recovery, Latinx, Substance use disorders, SUDs, Photovoice, Social support
*Correspondence:
Jordana Muroff
jmuroff@bu.edu
1 School of Social Work, Boston University, Boston, MA, USA
2 School of Public Health, Boston University, Boston, MA, USA
3 Casa Esperanza, Roxbury, MA, USA
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Muroetal. BMC Public Health (2023) 23:81
Background
e perspectives and experiences of Spanish-speaking
Latinx people who use drugs are crucial to enhanc-
ing understanding and addressing factors contributing
to drug use [1]. Latinx populations, particularly those
who use drugs, are rarely engaged in program design or
decision-making. SAMHSA (2020) noted that centering
voices from the Latinx community is vital in addressing
the opioid overdose crisis. Although the Latinx1 popula-
tion comprises 12.4 percent of the Massachusetts (MA)
population, in 2021, Latinx individuals represented 36.3%
of opioid related deaths in the state, and not by chance
[2, 3]. In 2018, MA had the highest fatal overdose rate
among Hispanics in the United States (US) [4]. Yet the
experiences of Latinx communities are often concealed
and/or ignored and while non-Hispanic Whites are cen-
tered in the “opioid crisis” [5].
e combination of increased risk factors for substance
use disorders (SUDs) due to structural factors and lack of
access to high-quality, culturally relevant SUD treatment
contributes to inequitable outcomes and rising rates of
fatal overdose among Latinx individuals who use drugs.
Latinx populations are less likely to receive and com-
plete SUD treatment, and experience shorter treatment
duration and poorer quality of SUD services compared
to non-Hispanic Whites [6, 7]. Further, stigma related
to drug use discourages seeking of drug treatment, par-
ticularly among very low-income Latinx groups [8].
Moreover, there is a lack of linguistically appropriate and
culturally responsive services [1, 9–11].
Research studies utilizing qualitative methods with
persons in recovery have demonstrated the added ben-
efits of first-person perspectives in improving pathways
to treatment, prevention programs and institutional poli-
cies for engaging this population [12–14]. ese benefits
include challenging unconscious biases by treatment
providers, identifying barriers to care, and increasing
opportunities to repair community distrust in healthcare
institutions through actionable change [12–14]. Moreo-
ver, participatory research approaches such as photo-
voice, a qualitative method rooted in empowerment
education and feminist theory [15–18] can facilitate the
participation of minoritized populations in research as
well as in the decisions that impact their lives [19–21].
All too often, people most impacted by public health and
social problems have the least amount of input in deci-
sion-making [22, 23]. Indeed, colonial structures con-
tinue to create policies and programming that exclude
impacted populations, centering expertise and decision-
making powers with institutions [9]. is expert-learner
or victim-savior model negates the knowledge and lived
experience of people in communities [24].
Photovoice has been used to challenge the power
dynamics that often exists between institutions and com-
munities as well as between physicians and patients by
showcasing the experiences of the patients in order to
change treatment policies and re-center the humanity of
the patients [17, 18, 25–32]. In addition, photovoice has
been used with Latinx communities to focus on a num-
ber of chronic health conditions including asthma, diabe-
tes, and mental health [31, 33–37].
e literature on photovoice with Latinx individuals
who use drugs is sparse. However, the few studies pub-
lished indicate it not only elicits insights from persons in
recovery, but also reduces stigma among treatment pro-
viders who view the final presentation [38–40]. We used
photovoice to engage Latinx persons with SUDs in an
exploration of the factors that influence their recovery.
is study adds to the literature by illustrating the ways
in which both cultural and structural factors converge
to influence recovery. To our knowledge this is the first
photovoice study conducted in Spanish with Latinx per-
sons with SUDs, a population that is highly impacted and
hardly reached.
Methods
is study was approved by the Boston University Insti-
tutional Review Board. e project was initiated in
response to client interest that emerged in a mHealth
relapse prevention smartphone intervention for Latinx
Spanish-speakers with SUD, CASA-CHESS [41], dur-
ing an in-person group meeting. CASA-CHESS clients
expressed the desire to use photos to share personal
experiences. is active larger CASA-CHESS smart-
phone project was comprised of Latinx Spanish-speak-
ing adult clients receiving bilingual/bicultural treatment
services for alcohol and other drug disorders along with
co-occurring mental health disorders through an inte-
grated behavioral health and primary care program, at
a community outpatient clinic in an urban northeastern
city in the U.S., between 2016–2019. Clients received
Android smartphones to access the CASA-CHESS appli-
cation. is Photovoice project occurred over a period of
6-weeks in 2019.
Sample
Non-random sampling was utilized to recruit adult cli-
ents in participating in CASA-CHESS. irteen (n = 13)
participants ranging in age from 35 to 58years old (mean:
48 years old, standard deviation: 8.2 years) enrolled to
participate. Participants identified predominantly as
1 e term Latinx describes a racially diverse panethnic population that is
immigrant, migrant and US born. In Massachusetts (MA), the segments of
the Latinx Community includes: Dominicans, Puerto Ricans and Salvadorans.
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Muroetal. BMC Public Health (2023) 23:81
Puerto Rican (n = 7), followed by Dominican (n = 3), then
Cuban (n = 2), and Mexican (n = 1). Participants were
Latinx Spanish-speakers (native and conversational), 85%
identified as Male, 69% considered themselves homeless,
54% were unemployed, and 46% had less than a 12th grade
education. Participants’ mean lifetime substance use was
20.54years (SD = 6.75) with a range from 10 to 30years.
Procedures
Participants were asked if they wanted to participate in
a photovoice project and share part of their recovery
journey.
Photovoice is an innovative community-participatory
action research (PAR) qualitative method rooted in
Freire’s popular education and feminist theory [17, 18,
37, 42, 43]. e photovoice process has three main goals:
1) to enable people to record and reflect their commu-
nity’s strengths and concerns, 2) to promote critical dia-
logue and knowledge about important community issues
through large and small group discussions of photo-
graphs, and 3) to reach policy makers [17, 18]. rough
the use of photography, participants document and
communicate their reality across cultural and linguistic
boundaries. e process encourages participants to criti-
cally reflect on the root causes of issues impacting them
and capture the essence through the storytelling tool of
photography. ese photos and potential resulting con-
versations may raise awareness for these issues, com-
bined with actionable steps viewers can take to advance
social justice.
is study intended to follow the original photovoice
methods, however, due to participant constraints such as
transportation, treatment meetings, and mobility, accom-
modations were made to adjust the photovoice method
to meet the needs of these participants. Modifications
included permitting web photos for a client who was
unable to take them outside their home, flexibility with
including clients who weren’t able to attend all sessions,
etc. [17, 18, 27, 30]. e case manager, research assistants,
and faculty members who facilitated the photovoice
process with the participants were bilingual, identified
as women and almost all as people of color. e faculty
member and staff co-facilitated each session, research
assistants took detailed notes during each session and
supported with group logistics. In addition, study team
research assistants and faculty also transcribed session
recordings, managed data, and drafted the manuscript.
is photovoice project consisted of three sessions
which occurred over a 6-week period in 2019, with four
weeks in between the first and second session and two
weeks in between the second and third session. e
sessions were recorded and transcribed. Participants
used the cameras in their cell phones (provided by the
larger study) to capture images related to their experi-
ences being Latinx in recovery. irteen participants had
enrolled, 7–8 attended the sessions, and 5 participants
submitted photos. Reasons for attrition included conflict-
ing appointments and therapeutic groups.
Session 1
Participants (n = 8) attending the first session received an
introduction to photovoice, which described the method
and how it can support advocacy and legislative action.
Participants then had the opportunity to engage with
one another through an icebreaker activity. Facilitators
then led the group in an activity to explore factors that
influence recovery using a person in environment model
based on the Ecological model [44]. e goal of the activ-
ity was to engage participants in a critical exploration
of the ways in which living environments shape health
and ideology shapes environments and in turn behav-
ior. In small groups, participants mapped out on chart
paper factors at the individual, network, community and
societal levels influence recovery. During the session
participants engaged in a critical discussion reflecting
how people and institutions in the greater Boston area
influenced their recovery. Responses were shared with
the broader group which then engaged in a deeper dis-
cussion about the role of sociopolitical factors and how
the factors that shape community norms are different in
the US than in the Caribbean. Following the discussion,
facilitators explained how photovoice would be used to
further explore the factors that influence recovery. e
photovoice process was explained as were the activities
that would be involved in the subsequent sessions. Par-
ticipants were asked to capture images representing the
theme using their cell phones and to select 3–5 to submit
via text.
Session 2
e second meeting focused on analyses. After an ini-
tial icebreaker activity, participants shared their pho-
tos and analyzed the images they captured utilizing the
SHOWeD method [30]. e SHOWeD methodology [30]
features participants’ responses to the questions of: What
do we See here? What is really Happening here? How
does this relate to Our lives? Why does this strength or
concern Exist? What can we Do about it?
Five participants shared their photos explaining the
image and why they captured it. Two more did not share
photos yet participated in the process; one was not in
attendance. e group inclusive of the photographer
engaged with each SHOWeD question. e facilitators
and research assistants took notes for the group on large
poster-size paper which were stuck to the walls around
the room. After analyzing each photo, the participants
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Muroetal. BMC Public Health (2023) 23:81
reflected on the notes around the room, discussed themes
that emerged holistically and what resonated with them.
Key themes discussed were recorded on large paper and
synthesized by the group. e group then selected photos
that illustrated the key themes identified using dot poll-
ing. Each participant received dot stickers to indicate the
photos they wanted to include in the final project that
represented key themes. e group reviewed the top
voted photos and discussed the results. Four photos with
the most dots were selected. e groups then viewed the
photos again to construct the final narrative. ey viewed
the four photos and together generated words to give
meaning to each. e group ran out of time and this pro-
cess was completed in the final session. e session dura-
tion was about 2h. e group selected a meeting time
for the final session to complete the brief narratives and
decide who they wanted to share their photos with.
Session 3
During the final meeting, the group (n = 8) completed
their narrative and determined how they wanted to use
the project. e facilitator reviewed the process used at
the previous meeting and the group’s progress to date.
e group then finalized their narrative and determined
a name for their photovoice project. e facilitators then
encouraged participants to think about who needed to
experience their photovoice project and why, as well as
how, in what medium, they wanted to share the project
with members of the broader community.
Reexivity
After each session the research team (e.g., research assis-
tants, faculty, agency staff) met to reflect on the meet-
ing. e research assistants and faculty members typed
up the notes from the meeting and reviewed audio files.
ey kept a journal over the course of the project, which
was used to reflect on the meeting and to prepare for
subsequent sessions. In addition, recordings were used to
reflect on group processes and to ensure notes reflected
the meaning in participant statements.
Member checking
All themes were written in on the poster-size paper
onthe walls during sessions and reviewed with partici-
pants. As the facilitator was writing, they checked with
participants to ensure thatthey captured participant sen-
timent; and at the beginning of each session the facilita-
tor recapped themes from the previous session. e final
photovoice was developed by participants and reviewed
with them during subsequent sessions and before
printing.
Results
Participants discussed their recovery journey and iden-
tified the following narratives: 1) Security, Motivation,
Strength, Progress, Community, Quality of Life, Respon-
sibility, Order, and Discipline; 2) Life, Health, Motivation,
Hope, Faith, Responsibility and Humility; 3) Darkness,
Fear, Obstacles, Light at the end, New Changes, Clarity,
Hope, and Fight/ Struggle; and 4) Religion, Protection,
Unity, Motivation, Peace, Love, Faith, and Hope. Moti-
vation was an overarching theme that permeated their
recovery narrative. e sense of community and hope
shared in this photovoice project is represented in the
title chosen by the participants “Nuestra Recuperación”
or “Our Recovery.” While each recovery journey varied,
the group returned to this sense of shared experience.
e participants decided to share the photovoice results
at the community health center they attend in order to
help others, give hope and inspiration to people as they
start their recovery journey. Participants also wanted to
share the results on the mHealth app that they have been
using in order to reach the wider recovering community.
e meeting closed with the participants reflecting on
what they learned during the project and how this expe-
rience has impacted their lives. e photos and narratives
presented in the text that follow were printed and hung
up on the walls of central areas of the clinic. A digital
PowerPoint presentation of the photos was posted on the
app.
A participant talked about the struggle of not having a
place where "… you can open your door and close it and
you’re peaceful."
(Spanish) Male: Cuando uno no tiene un sitio donde
uno puede descansar por ocho horas… donde uno
tiene que estar en casa ajena levantándose para el
pase de hora. Yo tengo un proceso que es duro, esto
no es fácil. Este camino no es fácil. Porque yo estoy
luchando y te digo esta es la lucha más dura que yo
he tenido en mi vida…buscar mi responsabilidad, lo
que tiene el, eso es lo que yo estoy luchando… You
know what I’m saying? at’s what I want!
(English) Male: When you don’t have a place where
you can rest for eight hours ... where you have to be
at someone else’s house getting up for the pass every
hour. I have a process that is hard, this is not easy.
is path is not easy. Because I am fighting and I tell
you this is the hardest fight I have ever had in my life
... seek my responsibility, what he has, that is what
I am fighting ... You know what I’m saying? at’s
what I want!
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Muroetal. BMC Public Health (2023) 23:81
So, it was a great achievement when one of the par-
ticipants revealed that he had been approved for a stu-
dio apartment. e discussions that surrounded the
picture of the bedroom (Fig.1) displayed the founda-
tion of housing in a person’s journey towards recovery.
(Spanish) Male: Pero que es algo yo, es mío, todo
está trabajando bien. “I just got approved for a stu-
dio 1 bedroom“. So, la cosa se sigue poniendo mejor
todavía. Y… solamente me recuerda a la persona
que yo era, en el vicio. Y ahora digo: este soy yo. Así
quiero llevarte y no volver pa’ tras cómo estaba…y
no quiero volver pa’ atrás donde estaba. Me siento
alegre feliz, toda mi familia esta alegre.
(English) Male: But that is something for me, it
is mine, everything is working well. "I just got
approved for a studio 1 bedroom". So, things keep
getting even better. And ... it just reminds me of
the person I was, in the vice/addiction. And now I
say: this is me. I came back after how I was ... and
I don’t want to go back where I was. I feel happy,
happy, my whole family is happy.
Participants expressed their need for safety and com-
fort of having their own place and living on their own
terms.
(Spanish) Female: …va y mete la llave… y eso es
todo: “llegue mi casa”. No tengo que pensar que
metió la llave… y que: “Ay no! no te puedes acostar
porque nosotros estamos viendo televisión, porque
nosotros vamos a comer ahora y tú no te puedes
acostar. Tienes-tu-propio sitio. Yo gracias a Dios yo
también vivo en la facilidad de Casa Esperanza. Yo
vivo bien orgullosa de Casa Esperanza y de Maylid.
(English) Female: ... go and put the key ... and that’s
it: "my house comes." You don’t have to think that
you put the key in… and that: “Oh no! you cannot go
to bed because we are watching television, because
we are going to eat now and you cannot go to bed.
You-have-your-own place. ank God I also live
in the Casa Esperanza facility. I live very proud of
Casa Esperanza and Maylid.
Participants talked about their lives in recovery and
how they make meaning out of representational objects.
For example, the role of things such as the plants in the
picture that one of the participants shared (Fig.2) as a
source of Life, Health, Motivation, Hope, Faith, Respon-
sibility and Humility. One of the plants shown in the pic-
ture was given to the participant by her child, giving that
plant additional meaning to the participant.
(Spanish) Female: Y mira el palo (árbol) que me
regaló mi hijo, yo me siento tan feliz porque él me
lo regaló. Y él me pregunta ma, y cuando él me- y
cuando él me llama: ¿mami como esta? ¿Mami y el
palo todavía está, mami? Y yo digo: si papi. Wow
mami, tienes buena mano! Ese palo lleva, desde
que yo estoy en recuperación, el palo está conmigo.
Y esta verdecito porque mi hermana me lo cambio
para la ventana, porque mi hermana me dijo que es
de sol. Y entonces ahora se está poniendo más verde,
Fig. 1 “Seguridad, Motivación, Fortaleza, Progreso, Comunidad,
Calidad de Vida, Responsabilidad, Orden, Disciplina” (Security,
Motivation, Strength, Progress, Community, Quality of Life,
Responsibility, Order, Discipline)
Fig. 2 “Vida, Sanidad, Motivación, Esperanza, Fe, Responsabilidad,
Humilde” (Life, Health, Motivation, Hope, Faith, Responsibility,
Humility)
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Muroetal. BMC Public Health (2023) 23:81
está echando hojas…. Y yo me siento bien feliz con
mi mata. Porque vuelvo y te digo, para mí son una
compañía.
(English) Female: And look and the-and the branch
(tree) that my son gave me, I feel so happy because
he gave it to me. And he asks me, and when he calls
me and when he calls me: Mommy you like this?
Mommy and the small tree/plant/cutling is still
there, mommy? And I say: yes son. Wow mommy,
you have a good hand! at small plant/cutling has,
since I am in recovery, the small plant/cutling is
with me. And it’s green because my sister changed it
for the window, because my sister told me the plant
likes sun. And so now it’s getting greener…. And I am
very happy with my plant. Because I come back and
tell you, for me they are a company.
Other participants shared a similar sense of purpose,
commitment and responsibility related to the picture as
another participant shared similar feelings for his dog.
Participants could bridge the connection between these
feelings and their path toward recovery.
(Participant spoke in English)
Male: Yeah like the plant…taking care of a plant,
that’s like showing-showing like, it’s spiritual in a
way you are taking care of. It is your responsibility,
taking care of your recovery is your responsibility. It’s
your responsibility to make sure you’re clean.
Participants identified the words Darkness, Fear,
Obstacles, Light at the End, New Changes, Clarity, Hope
and Fight to describe the picture of the tunnel (Fig.3).
ese words reflect how hope is a consistent theme
during a recovery journey that is complex and filled
with challenging feelings during recovery. Participants
reflected on how places like this tunnel would represent
both places they could sleep at night and also bad memo-
ries about where they would use drugs. at just like this
tunnel where above the surface it was positive because it
could be used for transportation, just beneath the surface
a different struggle existed out of public view.
(Spanish) Female: Para mi yo lo veo de esta manera:
positiva, por un lado, sí porque es la vía de trans-
portación de-de vehículos o lo que sea. Pero abajo
me trae unos recuerditos no muy buenos… que me
acuerdan cuando yo estaba antes, yo me metía en
los puentes…así me metía.
Male: Aha….si
Female: ¿Usted también?
Male: Si.
Female: Así mi tipo… los puentes… y dormía hasta
en esos puentes…. ¿Tú…?
Male: Para mi yo lo veo, si yo quisiera la claridad de
atrás… yo tengo que pasar por ese puente a la larga
voy a cruzar ese túnel-ese túnel lo voy a cruzar y
allá va haber cosas maravillosas.
(English) Female: For me, I see it this way: positive,
on the one hand, yes because it is the vehicle’s trans-
portation route or whatever. But downstairs brings
me some not very good memories ... that remind me
of when I was before, I used to get on bridges ... that’s
how I got involved.
Male: Ah.... yes
Female: You too?
Male: Yes
Female: So my type ... the bridges ... and I even slept
on those bridges ... You…?
Male: For me I see it, if I wanted the clarity behind ...
I have to go through that bridge, in the long run I am
going to cross that tunnel-that tunnel I am going to
cross and there are going to be wonderful things
Participants discussed the obstacles in their way to
recovery. Despite these obstacles, the participants spoke
of the hope they had that there would be light at the end
Fig. 3 “Oscuridad, Temor, Hay Obstáculos, Luz al Final, Nuevos
Cambios, Claridad, Esperanza, Luchar” (Darkness, Fear, Obstacles, Light
at the end, New Changes, Clarity, Hope, Struggle)
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Muroetal. BMC Public Health (2023) 23:81
of the tunnel. e narratives described difficult past and
some possible present hurdles along the way; however,
participants were confident that they had support and
could provide support to others to fight together to main-
tain their recovery.
(Spanish) Male: Y cada vez que-que me vienen
tentaciones- que me vienen bastante- por eso yo
la entiendo a ella cuando digo eso. Yo cuando
empecé… son 7 días a la semana- y fíjate- yo tan
siquiera como 3 o 4 días de la semana peleando con
esas cosas. Porque yo me crié por aquí y a donde
quiera que voy son amistades… y-y no son amista-
des positivas, todos están usando.
(English) Male: And every time that - that tempta-
tions come to me - that comes to me enough - that’s
why I understand her when I say that. Me when I
started ... it’s 7 days a week- and look- I even like 3
or 4 days a week fighting with those things. Because
I grew up here and wherever I go, they are friends ...
and-and they are not positive friends, everyone is
using.
Participants discussed their faith and the role of reli-
gion and spirituality, as well as feelings of love, hope and
inner peace in their recovery process (Fig.4). For some,
religion was a strong motivator to remain sober. ese
institutions out in the community represented a place
where participants could go for support.
(Spanish) Female: Que uno se apoya en esa creencia-
en ese algo como uno sabe- cuando uno está en la
iglesia uno no quiere hacer cosas malas porque sabe
que a Dios no le agradan esas cosas. Y es un- un
temor que uno le tiene. Una confianza y un temor
a la vez, porque uno sabe que si está haciendo cosas
malas- vamos a recibir cosas malas que uno no
quiere en la vida. Y eso me mantiene siempre- es- yo
tengo a Dios presente, pero me mantengo siempre en
eso-
Male: Enfocada.
Female: Enfocada. Que sé que, si me salgo de allí,
voy a ir para la calle de nuevo.
(English) Female: at you rely on that belief - on
that something as you know - when you’re in church
you don’t want to do bad things because you know
that God doesn’t like those things. And it’s a - a fear
that you have. A trust and a fear at the same time,
because you know that if you are doing bad things-
we are going to receive bad things that one does not
want in life. And that always keeps me- is- I have
God present, but always keeps in that-
Male: Focused.
Female: Focused. I know that if I get out of there, I
will go to the street again.
Some participants talked about church as a place of
hope where they have been able to be supported as they
made big changes in their lives. Others concentrated on
spirituality and positivity. All participants shared a con-
nection with a higher power that offered spiritual sup-
port during difficult times.
(Spanish) Female: Y para mí la iglesia me ha ayu-
dado mucho, yo-yo cuando-cuando a veces, porque
como estamos diciendo ahorita, en la vida uno
tiene momentos, ¿verdad? A veces presentamos
situaciones que uno- que uno tiene la necesidad
de llamar a alguien. Yo puedo llamar a mi pastor
y decirle: “pastor me pasa esto”. Y él me dice: “pues
mira corre para acá vamos a orar por ti, ven pa’ aca
para que no te sientas sola. Y yo encuentro que eso
es unidad. Unidad también, mucha unidad.
(English) Female: And for me the church has helped
me a lot, I-I when-when sometimes, because as we
are saying right now, in life you have moments,
right? Sometimes we present situations that one-
that one has the need to call someone. I can call my
pastor and say, "Pastor, this is happening to me."
And he says to me: "Well, look, run over here, let’s
pray for you, come over here so you don’t feel alone.
And I find that is unity. Unity too, lots of unity.
Discussion
is study utilized the photovoice methods as a partici-
patory qualitative approach to explore and contextualize
factors that facilitate recovery among Latinx Spanish-
speakers with SUD. e findings from this study provide
additional context for understanding the structural and
Fig. 4 “Religión, Protección, Unidad, Motivación, Paz, Fe, Amor,
Esperanza” (Religion, Protection, Unity, Motivation, Peace, Faith, Love,
Hope. (AFP Agencia, 2018) With authorization to publish from AFP
Photo)
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 8 of 11
Muroetal. BMC Public Health (2023) 23:81
community factors, outside of a treatment facility envi-
ronment, that impact recovery.
is study supports existing literature that photovoice
is both a method and intervention that empowers par-
ticipants [16–18, 27, 30, 43], especially those who are in
recovery [38]. is study indicates photovoice is highly
acceptable and feasible among Latinx clients receiving
SUD services.
Previous studies have documented the importance of
addressing the lack of culturally responsive treatment
options as they have contributed to lower rates of treat-
ment completion among Latinx individuals [6, 45]. Racial
concordance between patients and providers is corre-
lated with increased treatment retention and moderate
improvements in treatment outcomes [46–49]. Partici-
pants in this study currently receive treatment at a center
that has bicultural and bilingual treatment teams.
e participants’ themes are not so focused on individ-
ual level cultural competency or access to treatment per
se. e resounding theme from the participants’ photos
was that their recovery was centered in the community.
For example, at places of spiritual significance or with
family members and friends, reinforcing current empha-
sis on the social determinants of health (e.g. neighbor-
hood resources such as churches, economic stability such
as housing and social and community contexts such as
places and people to be able to talk about recovery with).
e participants’ narratives highlight and address a gap
within substance use treatment research that predomi-
nately focuses on individual factors impacting treatment
engagement and completion [50]. e themes from the
participants guide the discussion towards policy rec-
ommendations that address more structural issues.
ese findings challenge individually oriented treatment
approaches for SUDs and exemplify the importance of
including community voice in treatment program devel-
opment and policy in order to address the increased rates
and heightened negative effects of SUDs on adult Latinx
Spanish speakers [4, 51].
Although participants felt housing was critical, when
asked, they felt like animportant action was to put mes-
sages in the environment to inspire their peers and give
them hope. is focus on their peers in the community
speaks to cultural values associated with collectivism as
does their title “nuestra recuperación".Agency leaders,
saw the photovoice projectas an opportunity to also ele-
vate the housing crisis experienced by clients.
Multi-level outcomes for this photovoice project also
include resulting organizational changes such as the
increased use of photovoice as a therapeutic tool and
approach for social change with more clients at the
agency. Clients voiced preferences for group processes
that included photovoice leading to organizational
change and greater application of these methods as group
interventions.
Our findings support the current emphasis on address-
ing the structural factors that negatively impact sub-
stance use recovery, and addressing social determinants
of health like housing, food insecurity, and job opportu-
nities in contextualizing substance use. e participants’
findings demonstrate the need to further address the
underlying systemic and structural racism that contribute
to the disproportionate rates of substance use disorders
in Latinx communities. Ongoing stigma, perpetuated
and exacerbated by structural racism that impact both
use of substances and willingness to engage in care, is an
example of an oppressive structure to be dismantled [9].
Policy makers and healthcare providers should address
the question of: “How do policy makers make it easier for
individuals to engage in their own recovery?”.
Listening to our participants and valuing their experi-
ence means to recognize the various structures and fac-
tors that contribute to substance use and develop and/or
strengthen policies that dismantle such oppressive struc-
tures while incorporating community-based strengths
that exist in the midst of these challenges.
Recommendations
One recommendation is to include pathways to housing
and/or housing as an integral part of the SUD treatment
process. Stable housing reduces stressors, and increases
hope and motivation for recovery and, more impor-
tantly, a safe place to focus on recovery. Programs have
demonstrated that financial support for housing along
with mental health and case management are effective
in maintaining recovery and maintaining housing after
rental assistance ended for women with substance use
disorders [52]. Policy makers need to address access to
sustainable affordable housing and evaluate barriers to
participation in housing programs due to a history of
SUD, current drug use, and/or history of incarceration
due to SUD. Participants engaged in deep discussions
around the hope of housing and a place to rest. Given the
existing structural barriers to housing due to historical
laws that resulted in inequitable distribution of home-
ownership [9, 53], housing should be a priority area for
policy makers.
Participants utilized the words motivation, responsi-
bility and hope to describe multiple photos. e under-
standing, compassion and wisdom demonstrated through
their discussions for cultivating hope and overcoming
barriers to recovery exemplifies why a key recommenda-
tion is the prioritization of Latinx leadership and voices
when increasing funding and opportunities to address
the multifaceted challenges driving the disparities in
Latinx SUD prevalence rates and treatment engagement.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 9 of 11
Muroetal. BMC Public Health (2023) 23:81
One way institutions can accomplish this recommenda-
tion is through paid community advisory boards (CABs)
that have the power to change institutional policies as it
relates to SUD treatment and recovery. CABs can provide
expertise and insight into priority areas for engagement,
building on hope and strengths, and foster meaningful
connections with community partners [54]. Institutions
can demonstrate how they value the expertise of per-
sons with lived experience by amending their own inter-
nal policies to be responsive and responsible to enact
changes recommended by these paid experts [51]. e
key components of this recommendation are 1) paying
a thriving wage to persons with lived experience in rec-
ognition of their expertise and 2) changing internal poli-
cies to grant the Boards’ true power (e.g. decision making
capacity on programmatic and budget decisions) to effect
change [51, 55–57]. is project underscored the impor-
tance of engaging the “end users” of programs (program
participants) and those more impacted by policy in the
research and policymaking processes, as well as inter-
vention efforts designed to promote their health and
wellbeing.
ese are some tangible steps agencies can make to
truly embody the mission of including community voice
in treatment. e hope is that the recommendations
and changes made by these Boards will inform policies
to develop both SUD treatment and SUD prevention
interventions.
ese recommendations are informed by the hope and
community assets that the participants displayed, even
in the face of a variety of challenges. Recognizing that
the systems and structures that participants encounter
daily put them at a disadvantage in recovery, social work-
ers must then work towards their professional values of
social justice, by dismantling these systems. It may also
serve as a reminder to policy makers, agency leaders, and
SUD treatment providers of the humanity of the indi-
vidual and that the implementation and embodiment of
a strengths-based approach means believing and having
confidence in the clients that seek treatment. We must
work together to ensure we break the cycles of harm
caused by structural racism.
Limitations
e current study had several limitations. e partici-
pants from this study had all completed residential treat-
ment and/or were engaged in outpatient treatment at the
same integrated primary care and substance use clinic,
staffed primarily by bilingual and bicultural staff and
treatment team members. Participants had all also par-
ticipated in the same mHealth research program that had
offered additional services, supportive resources, and
ways to communicate with the treatment team members.
Additionally, the possibility of response bias may have
affected participants’ responses, such as the tendency
to respond to questions in a socially desirable manner
whether or not it aligns with one’s personal experience
and/or perspectives [58].
Methodological limitations include that the final rec-
ommendations noted in this paper are driven more by the
researchers in response to the participant’s social action
process (rather than the participants specifying these rec-
ommendations). e research team interpreted the client
experiences and derived themes to name the broader pol-
icy implications and the intersection of the participants’
lived experiences with structural racism. e participants
focused on instilling and providing hope for others from
their community who may be struggling with recovery,
emphasizing that they too can live and work through the
obstacles impacting their recovery. is social action step
was both meaningful and powerful for these participants
and future patients at the treatment center.
e goal of photovoice is to advance social change
through participant voice, which hopes to challenge the
oftentimes extraction focused research relationship with
communities. is project was successful in advancing
participant driven change at the organizational level.
e researchers hope to continue these change efforts
through their recommendations based on participant
driven concepts and themes, derived throughout the
photovoice process.
Conclusions
Engaging community members in participatory research
methods, like photovoice, results in better informed rec-
ommendations for training and policy solutions to address
issues like substance use disorders. For example, the par-
ticipants’ photovoice discussions strengthened policy rec-
ommendations to support pathways to stable housing in
geographic areas that are in close proximity to client’s natu-
ral support systems and faith systems. ese participants
still face the realities of interpersonal and structural racism
in their daily lives, and yet are able to find hope to maintain
their own recovery and support the recovery process for
other Latinx persons in recovery. Researchers and provid-
ers of care can utilize the tools and resources at their dis-
posal to dismantle some of these racist structures, to help
“make the light at the end of the tunnel” brighter, instead of
contributing to the “darkness” of this journey. e goal then
for researchers, practitioners and policy makers is to inter-
vene and challenge the traumatic and oppressive structures
that would make recovery that much easier for these indi-
viduals, instead of exclusive reliance on individual-level
resiliency in response to such structures. Researchers and
providers can be aware of the inherent power structures
due to colonialism such as the punitive ideologies when
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 10 of 11
Muroetal. BMC Public Health (2023) 23:81
it comes to recovery (e.g., strict institutional discharge
policies that disregard systemic barriers contributing to
relapse) as they work alongside historically marginalized
and minoritized communities.
Future community participatory research studies should
aim to engage the participants in all levels of the research
project from design to implementation. Researchers con-
ducting participatory action research should continue to
practice reflexivity and address how their own institutional
policies limit active engagement of persons with lived
experiences from the community in the research process.
Future studies addressing issues related to recovery, relapse
prevention and SUDs among Latinx communities should
focus on the impact of community-based investments in
infrastructure like housing and workforce development.
Abbreviations
mHealth Mobile Health
SUD Substance use disorder
Acknowledgements
We express our sincere gratitude to the CASA‑CHESS clients.
Authors’ contributions
JM, LSM, and DC designed the study. LSM, MB, GGB, DR, and MR implemented
the photovoice. JM, LSM, GGB, MAC, MB, and LML contributed to the analysis
and translation of quotes. JM, DD, LSM, and CB framed the article and drafted
the text. All authors contributed to the writing of the text. The author(s) read
and approved the final manuscript.
Funding
This article was supported by Substance Abuse and Mental Health Services
Administration–Center for Substance Abuse Treatment grant no. TI026433.
The content is solely the responsibility of the authors and does not necessarily
represent the official views of SAMHSA.
Availability of data and materials
Data generated or analyzed for this photovoice study are included in this
published article. Data are not publicly available. Additional requests may be
made to the corresponding author.
Declarations
Ethics approval and consent to participate
The Boston University Charles River Campus Institutional Review Board
reviewed and approved this photovoice project (protocol 4195E). Informed
consent was obtained from all the participants. All methods were carried out
in accordance with relevant guidelines and regulations in the declaration.
Consent for publications
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Received: 8 June 2022 Accepted: 3 January 2023
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