Latino Health Perceptions in Rural
Montana
Engaging Promotores de Salud Using Photovoice Through
Facebook
Violeta Nitzinger, MS; Suzanne Held, PhD; Bridget Kevane, PhD; Yanet Eudave, MS
The primary purposes of this study were to use photovoice with Facebook to explore health perceptions and
health needs among promotores living in rural Montana and to build community among geographically
dispersed promotores. Seven promotores participated in a photovoice project where they uploaded
photographs and shared comments in a private Facebook group. Emergent themes based on the promotores’
health perceptions, discussions, and interviews were transcribed and coded. Findings of this study will be
used to assess health perceptions and needs of the promotores and Latino community in rural Montana.
Key words: Facebook, Latinos, photovoice, Promotores de Salud
IN 2015, the Latino population was recognizedas the largest ethnic minority in the United
States, at 17.6% of the total population.1 Areas
where the Latino population is below 5% and
growing quickly are described as “new growth
communities.”2 Montana fits this definition, with
the Latino population growing from 2.9% in 20103
to 3.6% in 2015.4 As the Latino population con-
tinues to grow in Montana, it is important to have
an understanding of health perceptions and health
needs to develop and implement effective health and
other need-based programs.
Health disparities exist among Latinos,5 espe-
cially in rural communities where minorities are
Author Affiliations: Departments of Health and Human Develop-
ment (Miss Nitzinger and Eudave and Dr Held) and Letters and Sci-
ence (Dr Kevane), Montana State University, Bozeman.
This project was supported through funding provided by the Na-
tional Institutes of Health R25MD006791 and P20GM103474, and
the Montana Healthcare Foundation.
The authors express their gratitude to promotores Betty Nitzinger,
Kara Vasquez, Ana Nascimento, Yanet Eudave, Viridiana Nuñez,
Lety*, and Rafa* (*approved the use of first names only), student
researcher Dani Hess, Community Health Partners, and Healthy
Gallatin/Gallatin County Health Department.
The authors declare no conflict of interest.
This is an open-access article distributed under the terms of the
Creative Commons Attribution-Non Commercial-No Derivatives
License 4.0 (CCBY-NC-ND), where it is permissible to download
and share the work provided it is properly cited. The work cannot
be changed in any way or used commercially without permission
from the journal.
Correspondence: Violeta Nitzinger, MS, Department of Health
and Human Development, Montana State University, Bozeman, MT
59717 (vnitzinger@hotmail.com).
Copyright © 2019 The Authors. Published by Wolters Kluwer
Health, Inc.
DOI: 10.1097/FCH.0000000000000213
more likely to face health care discrimination,6 re-
ceive poor quality health care, develop a chronic ill-
ness, have poorer health outcomes, and encounter
other health challenges and health disparities.7,8
The use of promotores de salud (promotores) or
Latino community health workers (CHWs) is an ef-
fective method for bridging language barriers and
improving/increasing access to services, providing
support, and improving overall health and well-
being in their communities.9-11 Promotores are usu-
ally recruited from the communities in which they
live and work and are considered trusted and well-
known members of the community.10,12,13 Promo-
tores have inside knowledge of the strengths and
barriers of their communities, which allows them
to address health and social issues effectively.
Through a partnership between faculty members
(including the third author) and student researchers
(including the fourth author) at Montana State
University and a local community health center,
Community Health Partners, the Gallatin County
Promotores Program began in 2013. The pro-
gram transitioned to the Gallatin County Health
Department in fall of 2017 and continues at this
time. Participants were recruited based on status in
their community as someone others turned to for
support and advice, bilingual skills, and willingness
to participate. The researchers and health care pro-
fessionals traveled to the promotores’ communities
to offer monthly health trainings.
The goals of the program are to reduce health dis-
parities through prevention and basic health educa-
tion, connect the emerging Latino communities with
affordable health care and resources, and provide
support to community members.14 Research studies
with promotores/CHWs have used various meth-
ods for implementing, evaluating, and supporting
the work of the promotores. Among the methods
is photovoice.12,15
150 Family and Community Health April–June 2019 ■ Volume 42 ■ Number 2
V. Nitzinger et al. Latino Health Perceptions in Rural Montana 151
Photovoice was developed in 1992 with the goals
of identifying and documenting strengths and con-
cerns within a community, promoting critical di-
alogue and knowledge about these important is-
sues, and educating the public and reaching out
to policy makers.16 Typically, participants are pro-
vided with cameras and basic photography and
ethics training. The participants turn their lens
to issues that concern them, return the cameras
to the academic partners who develop the pho-
tographs, and the partners collaboratively review
photographs to identify common themes and cre-
ate action plans to address those themes. Previous
photovoice studies have worked with groups rang-
ing from 5 to 29 participants,17,18 ages ranging from
young children to the elderly,17,19,20 varying races
and ethnicities,18,20,21 genders,22,23 rural and ur-
ban communities,19,21 and international locations.21
Photovoice provides community members the op-
portunity to express their social, cultural, political,
and health concerns through photographs16 and en-
courages diverse perspectives, equalizes community
and academic voices, and emphasizes community-
level change.21
This study explored the benefits and challenges
of using of Facebook and photovoice together as
a new method to (1) explore health perceptions
and health needs among promotores living in
rural Montana and (2) build community among
geographically dispersed promotores. Face-to-face
communication between the promotores was diffi-
cult due to the distance between communities; the
longest being about 115 miles. We saw geographic
distance as a rationale for conducting the study
versus a limitation. The underpinnings of social net-
work theory show that interventions delivered via
social media had some of the strongest outcomes
of health-related behavior change.24 We found no
literature that used photovoice methods together
with Facebook with promotores, with CHWs, or
photovoice together with Facebook in other health
intervention research. Results of this study can be
applied to other rural or geographically dispersed
promotores/CHW programs.
METHODS
Setting and sampling procedures
This study was conducted in 4 communities in
Southwest Montana, where the promotores pro-
gram was located. There were 6 promotores in the
program and they all participated in this study.
One promotora who lived in a neighboring county
and who was not officially a part of the program
but who had many years of experience perform-
ing typical promotora activities also participated.
Recruitment was based on bilingual skills and ex-
perience working in the community in which they
were from.25 There were 6 females and 1 male with
an age range of 27 to 65 years. One promotora is
the mother of the first author. The institutional re-
view board at Montana State University approved
this study, and all subjects signed an informed con-
sent form. Each participant received a $50 Walmart
gift card upon project completion. Five of the pro-
motores who participated in this study approved
their full names to be used in this article, and 2
participants approved the use only of their first
names.26
Study procedures and data collection
We developed a private Facebook group in which
information and photographs could only be viewed
by the promotores and project team members. Af-
ter receiving consent, the promotoreswere added to
the Facebook group. All the promotores knew the
first author but not each other. This was a benefit,
as having these relationships and establishing trust
prior to starting the study facilitated the progress
of the project. To begin to create community and
build trust among the geographically dispersed pro-
motores, the first author prompted introductions on
the Facebook page, asking questions such as “where
are you from?” and “what do you and your family
like to do for fun?” She described that the goal of
the project was to allow the promotores to express
what health topics were important in their commu-
nities through photographs and discussions.
The promotores were instructed to use their
own smartphones/cameras to take and upload pho-
tographs. They were instructed to photograph and
upload anything of interest to them that spoke
about the theme of health and well-being. Detailed
instructions on how to upload photographs directly
to the Facebook group were uploaded as PDF files
to the Facebook group in both English and Span-
ish. For the 3 promotores who did not have a Face-
book account, a shared profile was available for
them to log in and participate. The promotoreswere
also provided with information about ethics in pho-
tography and the importance of being safe while
photographing and protecting the privacy of others.
Photographing public figures and areas was recom-
mended, but if a photograph showed any identify-
ing information, such as someone’s face or private
property, the promotores were instructed to obtain
a signed consent form. Example photographs and
descriptions were uploaded as a reference for the
promotores. All forms, materials, and discussions
were offered in both English and Spanish on Face-
book and as hard copies at monthly health trainings
for the promotores.
152 Family and Community Health April–June 2019 ■ Volume 42 ■ Number 2
Initially, the first author provided a photograph
upload schedule instructing the promotores to
share 1 photograph every other week for 10 weeks
during the spring of 2017. Only 1 promotora
shared a photograph the first week and 3 promo-
tores shared photographs the third week. In order
to increase the number of photographs uploaded,
the process was changed and the promotores were
asked to upload a minimum of 5 photographs and
a brief description of the photograph’s relation and
importance to health. They were also instructed to
comment at least once on another promotora’s pho-
tograph with their thoughts, experiences, and ideas.
After each photograph was posted, the following
prompts, based on the PHOTO method,16,27 were
posted to engage discussion among the promotores:
What do you see happening in this photograph?
What do you think or feel about this photograph?
Do you have experience with this or something
similar? What do you hope happens in the future?
How does this photograph provide opportunities
for us to improve? The first author and a student
researcher also contributed their own thoughts and
experiences to photograph discussions.
Each of the promotores received a photobook
with all 37 photographs, their descriptions, and dis-
cussion comments, as recognition and appreciation
of their participation and hard work. The photo-
book is a tangible representation of the promotores’
work in their communities that they can continue to
use as a resource and outreach tool. This was done
as an alternative to community meetings that are
frequently conducted with photovoice projects and
met the needs of the dispersed promotores.
After the 10-week photograph posting period, in-
dividual semistructured interviews were conducted
with each of the promotores by the first author to
gain insight into their experiences with the project.
A total of 7 questions asked the promotores what
they liked about the photo project, what could be
improved, how the project impacted their role as
promotores, how their relationships with the other
promotores changed, how the photo project im-
pacted the group, and what parts of the project they
would like to see continue in the future.
Interviews were recorded using QuickTime
Player. The promotores had the freedom to express
themselves in the language they felt the most com-
fortable with and were reminded that there were
no right or wrong answers. Each of the promotores
chose a convenient place and time for the interview
to take place and whether the interview was to take
place in person or over video chat. The interviews
ranged from 7 to 43 minutes; 4 interviews were
conducted in English and 3 were in Spanish, and 4
were done in person and 3 over video chat.
Data analyses
There were 2 types of data analyzed: photographs
and comments from the promotores on Facebook
and interviews with the promotores. Photographs
were downloaded and categorized into themes, and
comments were translated and coded by the first au-
thor, a bilingual and bicultural researcher.
Interviews were conducted, transcribed, and
translated by the first author. Each interview au-
dio recording was transcribed verbatim, and in-
terviews in Spanish were transcribed into Spanish
first and then translated into English. All interviews
were hand coded by the first 2 authors separately.
These authors then met to discuss and come to con-
sensus on codes and then the first author recoded
the interviews based on the consensus set of codes.
Coders allowed codes to cross-questions versus cod-
ing question by question.28
RESULTS
Photographs and comments posted to
Facebook
A total of 37 photographs and 95 comments were
uploaded by the promotores. The 37 photographs
and comments were coded into 5 themes: (1)
nutrition—la nutrición, (2) exercise—el ejercicio,
(3) healthy mind healthy body—mente sana cuerpo
sano, (4) healthy habits—los hábitos saludables,
and (5) helping our community—ayudando a nues-
tra comunidad.
Theme 1: Nutrition—la nutrición
Twelve of the 37 photographs (32.4%) and 39 of
the 95 comments (41.1%) focused on nutrition. The
difference between healthy food and unhealthy food
was a popular discussion topic among the promo-
tores. Promotora Betty shared a photograph of a
colorful display of fresh fruits and vegetables and
described the benefits of eating a variety of fresh
fruits every day. She contrasted this with a pho-
tograph of processed and packaged food and de-
scribed the ingredients found in these foods that
may be harmful to one’s health. Ana shared a pho-
tograph of a frozen meal and its long, complicated
ingredient list and said, “When looking at the ingre-
dients, there are words that we do not know how to
say, ingredients that surely are bad for our health.”
Yanet shared a photograph of McDonalds and de-
scribed the importance of eating a balanced diet in-
stead of fast food containing simple carbohydrates
and processed meats. Yanet also shared a photo-
graph of a bottle of Coca-Cola and described that
it is “like water for most Mexicans” and suggested
not buying soda because “once you have it at home,
it is very easy to drink it instead of drinking water.”
V. Nitzinger et al. Latino Health Perceptions in Rural Montana 153
Promotora Lety shared a photograph of a healthy
lunch and described the importance of eating “ad-
equate portions of fiber, carbohydrates, and pro-
teins” for good health. Kara commented on Lety’s
photograph and observed that the meal had “a lit-
tle bit of each nutrition group: vegetables, meat,
and grains. It’s very healthy and it looks very tasty.”
Ana agreed and commented that “a healthy and bal-
anced meal can also be tasty and flavorful.”
Ana shared a photograph of her husband cook-
ing a healthy lunch (Figure 1). “We are trying to
eat healthier at home to be a good example to
our daughter.” Kara commented that “He is be-
ing a good example for men and children because
they too can make something tasty and healthy, not
only women.” Betty commented, “It is very impor-
tant that kids see their dads also helping out in the
kitchen to prepare food. Cooking is a family labor
where everyone can give ideas and be creative.”
Not having enough time to cook is one of the rea-
sons why it is hard to stay healthy. Kara shared a
photograph of protein drink mix and low glycemic
peanut butter that she described as options for
those with a busy schedule who want to maintain
a healthy weight. Lety also shared a photograph
of a nutrition shake, which she explained can help
people with diabetes maintain balanced blood glu-
cose levels. Promotora Viridiana shared her experi-
ence with meal preparation and explained its bene-
Figure 1. Healthy eating is a family responsibil-
ity. Photograph by Ana. Used with permission.
fits, which included saving time and money, being in
control of portions, and not having to stress about
cooking every day.
The promotores discussed the benefits of eat-
ing healthy. They shared their ideas about what
a healthy meal looks like, what to buy and what
to avoid when shopping at the grocery store, and
the importance of involving the family in making
healthy choices.
Theme 2: Exercise—el ejercicio
Eleven of the 37 photographs (29.7%) and 19 of the
95 comments (20%) focused on exercise. The pro-
motores shared their thoughts on the importance of
exercise related to good health, described how the
outdoors offer a range of free exercise options, and
expressed a need for more affordable and accessible
places to exercise throughout the year where long
winter months make this difficult.
Lety shared a photograph of a local gym and
described the various amenities they offer, including
different exercise classes, equipment, and a day care
center for those who need it. Ana commented, “I
am jealous of this gym. Here in West Yellowstone
we only have a small gym, with old equipment, and
no instructor to help us, and it is very expensive.”
Kara commented, “What West [Yellowstone] needs
is a bigger facility with more exercise classes for the
whole family.”
Promotor Rafa shared his experience with how
sports have helped him to stay active. He shared
a picture of himself running in the park. Viridiana
commented how important exercise is for improv-
ing overall health and explained its many benefits
including an increased heart rate and metabolism,
reduced unwanted body fat, and a reduced risk of
heart disease. She commented that it has helped her
sleep better at night and have more energy during
the day. Betty agreed and also commented on Rafa’s
photograph that it can be “hard for many of us that
work most of the day to be able to include an ac-
tivity like this into our schedules, but we should
make an effort. In the communities of Bozeman and
Livingston there are many places specifically where
people can go run or enjoy a hike.”Ana commented,
“I am always making excuses to not go out and
walk or run. But my husband, who is in a healthy
phase, is encouraging me to do more exercises.”
Yanet also shared her experience with sports and
said, “We Latinos love soccer. In our community of
Gallatin Valley, a lot of men practice sports during
the summers and they stay active by playing soc-
cer.” She described the outdoor activities Montana
can offer, even during the winter such as skiing or
snowboarding. “Not only do we move our body in
the outdoors but we can relax our mind in nature, in
154 Family and Community Health April–June 2019 ■ Volume 42 ■ Number 2
this gorgeous state we live in.” Lety shared a photo-
graph of a local playground and explained how im-
portant it is for children to be physically active on
a regular basis. Betty commented that even children
are suffering from chronic illnesses due to inactivity
and too much screen time.
The promotores shared their experiences with ex-
ercising and discussed the many outdoor activities
Montana offers during the summer. Staying active
in the summer is easier, but during the harsh winter
months this is difficult, especially when affordable
family fitness facilities in the community are limited.
Theme 3: Healthymind healthy body—mente sana
cuerpo sano
Five of the 37 photographs (13.5%) and 11 of
the 95 comments (11.6%) uploaded focused on a
healthy mind and healthy body. The promotores
discussed how the environment, alcohol, and stress
can all impact mental health.
Betty shared a photograph of Livingston and de-
scribed how it reflects the loneliness of the long win-
ters. “The freezing environment and lack of color
makes me feel sad. This is a very small community
and doesn’t offer much for entertainment during
winter. People are more secluded and it makes
it hard to be active and social” (Figure 2). Ana
commented on a similar experience in West Yellow-
stone. “When winter comes, many Mexicans with
work visas return to their country and our town is
left empty. Restaurants and hotels close and there is
nothing to do. A lot of people are depressed during
these times.”Rafa shared a photograph of Bozeman
in the summer and explained the difference of emo-
tional effects of the environment. “Make an
agreement with your family and friends and tell
depression goodbye.” The promotores explained
that having a hobby can help stay busy and improve
Figure 2. Livingston winter. Photograph by
Betty. Used with permission.
mental health during the winter months. Lety also
commented on the need for a community group
that offers classes, games, and a space to unite.
Rafa shared a photograph of a margarita and
described the secondary effects of alcohol, not
only on one’s health but also on family and other
relationships, and explained that drinking in
moderation is best. Betty commented on society’s
acceptance of alcohol and explained that if abused,
alcohol use can turn into an addiction and can
have the harmful effects on the body. Yanet shared
a photograph of a bottle of Corona and described
the act of drinking as “a mask for people that suffer
from stress or depression.” She described that “a
healthy mind equals a healthy body” and explained
the importance of learning new ways to cope
with stress, anxiety, and depression. She suggested
trying meditation or yoga and also emphasized
the importance of helping family and friends seek
professional help when needed.
The promotores shared their thoughts on how
Montana’s different seasons impact the mental
health of Latinos, specifically during the winter, and
as a result, many suffer from seasonal depression.
They suggested organizing events for the commu-
nity to meet, talk, play cards, and participate in
other indoor activities to stay busy during the win-
ter. The promotores also described how alcohol is
accepted culturally and how its abuse can impact
health and relationships.
Theme 4: Healthy habits—los hábitos saludables
Five of the 37 photographs (13.5%) and 13 of the
95 comments (13.7%) focused on healthy habits.
The promotores discussed incorporating healthy
habits such as hand washing and regular doctor and
dentist visits into daily routines to prevent illness
and stay healthy.
Betty shared a photograph of dental care prod-
ucts and discussed the importance of dental hygiene.
She recommended regular teeth brushing and floss-
ing, avoiding sugary foods, and seeing a dentist reg-
ularly. Betty also shared a photograph of one of her
students washing her hands with soap and warm,
running water and explained that this is another
form of basic hygiene that can help avoid the spread
of infections and germs. She emphasized the impor-
tance of promoting appropriate healthy habits at
home, school, and work.
Lety shared a photograph of Bozeman’s hospital
and expressed the importance of having a family
doctor “to have regular health checkups and de-
crease the surprise of diseases that in many occa-
sions could have been prevented with lab exams
and other types of tests.” Ana commented that her
husband was very sick, overweight, and his blood
V. Nitzinger et al. Latino Health Perceptions in Rural Montana 155
glucose levels were at 253, an abnormally high level.
About 6 months later, everything changed. By exer-
cising, eating healthy, and eliminating alcohol, his
glucose levels decreased to 89. The other promo-
tores shared their support and congratulated him
for making this big change. Rafa commented, “This
is an excellent example that by eating a healthy and
balanced diet, anyone can achieve this.”
The promotores discussed how many health is-
sues can be fixed and even avoided simply by
implementing healthy habits and preventive mea-
sures into daily routine, such as hand washing,
exercising, and regularly going to the doctor and
dentist.
Theme 5: Helping our community—ayudando a
nuestra comunidad
Four of the 37 photographs (10.8%) and 13 of the
95 comments (13.7%) uploaded focused on help-
ing the community. The main goals of the promo-
tores de salud are to provide accurate information
to allow community members to be informed and
take control of their health and advocate for their
communities in many different ways. One way pro-
motores help their community is through bridging
language barriers. Yanet shared a photograph of
English-learning resources and described the chal-
lenges of not speaking English in rural Montana.
She explained that not being able to communicate
in English can negatively impact one’s health and
that it is important to make an effort to learn.
Kara and Ana shared a photograph of themselves
standing in front of the HealthCare Connections
van, a mobile health service that provides routine
checkups and other medical examinations for free
(Figure 3). Kara explained that this is an important
resource in the community, especially for those who
do not have health insurance. Viridiana shared a
photograph of herself standing in front of the van
Figure 3. Promotores Kara and Ana. Used with
permission.
helping community members to fill out forms,make
appointments, and interpret their visit. Ana com-
mented, “It feels great to be able to help others.
We should always take advantage of everything our
community offers us to take care of our health.”
Rafa commented that “if everyone could help those
who need it, the world would be easier and dif-
ferent. We continue to support our community to
move forward. It is our goal as Promotores de
Salud.”
The promotores’ goal is to continue support-
ing their communities by improving their language
skills as well as promoting the various free health
services and resources offered in their communities.
INTERVIEWS
The promotores’ responses fit under 9 main themes:
(1) a simpler way of understanding health, (2) a
picture is worth 1000 words, (3) new awareness
through photography, (4) learning about health and
community needs through photography, (5) shar-
ing experiences and perspectives among the promo-
tores, (6) photobooks, (7) freedom of expression, (8)
a new experience, and (9) longing.
Theme 1: A simple and cost-efficient way of
understanding health
The promotores described how the process of shar-
ing photographs through Facebook was simple and
easy. Lety shared that “it was a way to capture
[ideas] more clearly, visualizing each photo.” Even
the promotores who did not have a Facebook pro-
file mentioned that the instructions were easy to fol-
low. Betty said, “It was very straightforward and we
[had] all the rules or expectations, instructions on
how to do the project, how to take the pictures, how
to download them, and put them in your computer,
so I think that was easy.”
Using Facebook was a cost-efficient way to com-
municate. Betty described how “you can just have a
simple camera or your iPod [to take photos] and
it doesn’t cost money.” Yanet explained that us-
ing Facebook is easy and “everybody knows Face-
book, especially the Latino community,”and “when
working with rural communities, [using social me-
dia] is so beneficial because you can communicate
through your phone.”
Theme 2: A picture is worth 1000 words
The promotores described the visual depth a pho-
tograph can show. Betty explained that photogra-
phy “can be a very simple thing and then it can tell
you a lot about health issues.” Lety explained that
using photographs was “a good option because the
photos that you visualize are interesting and clearer.
It’s not the same as when someone tells you and
156 Family and Community Health April–June 2019 ■ Volume 42 ■ Number 2
you listen. I think when you look at a photo the
information stays clearer. It was one of the main
things that the community let us know about when
we would hand out information and gave them fly-
ers with photos.” Yanet believed the photographs
shared on Facebook “added more value to every-
thing [and] to the project.”
Theme 3: New awareness through
photography
The promotores explained having a new personal
awareness of health and the environment through
photography. Many of the promotores described
how they stopped to think about what their pho-
tographs represented. Betty described that pho-
tographs “reflect everyday life, the things we do ev-
ery day, like for instance going for a walk around
the park or riding your bicycle.” Ana said that the
photographs showed “the things that we go through
every day and I don’t stop to look, so I think that
was the most beautiful part.” Ana expressed that
“it’s like stopping to look at a part of the world
you see every day but you don’t notice the details.
I think photography does this.” She expressed that
she was grateful for “the opportunity to slow down
and have a new perspective, to stop and think about
the things we do to photograph them.” Yanet de-
scribed that she would take a photograph and later
identify its significance. She said, “You really start to
analyze the photo and think about [why] this came
up and then overall what it really means to you and
your community.”
Kara shared that the photo project opened her
eyes to different health topics. “I have two kids and
so I’m always open to new ideas with feeding them
and trying to give them the right nutrients because
sometimes you just want to buy the cheapest thing,
[but] I’ve learned that even though it’s the fast way
out, it’s not the best way.”
Theme 4: Learning about and taking action
for health through photography
Through photography, the promotores learned
about health and other needs among the communi-
ties they were working in andwere able to share that
with the broader community through photographs.
Lety said, “People have questions but if we do not
have the answer, we can visualize a photo and I
think that is our best way to share it.” Ana ex-
plained that the information she gained from the
photo project “helped me a lot as a promotora to
be able to pass on the correct information.” They
talked about the importance of building trust with
the community, especially when approaching peo-
ple about health, prevention, and culturally taboo
topics.
Yanet described the project as a reminder “to re-
alize the importance of why you’re there” and that
sometimes the small interactions can have the most
impact. She said, “[I’m] planting a seed every now
and then and that’s my mission.” The photographs
portray different lifestyles and health habits, and
Yanet expressed that “if you really take charge and
make the decision [that] you want to be a health-
ier person, have a healthier mind, have a healthier
body, you can do it.”
As a promotora, Yanet described herself as a
“powerhouse” for someone to offer encouragement
to make an appointment, go to the doctor, and
make healthier decisions in general. She explained
that resources are limited and people “don’t know
who to go to or what to do” if they are new in
the community. Using photography “gives a promo-
tora the power to speak up, especially [for] people
that can’t really represent what they’re feeling. You
can represent that for them. Not everyone gets that
opportunity.”
Theme 5: Sharing experiences and
perspectives among the promotores
Using Facebook was an efficient way to explore the
health perceptions of the growing Latino popula-
tion in rural Montana, share health information,
and build trust among the promotores. Using pho-
tography through Facebookwas helpful for the pro-
motores to express their own health concerns and
ideas, as well as understand the other promotores’
experiences.
The promotores discussed the power of team-
work, collaboration, and supporting each other.
Betty described that the Latino population in her
community is very small compared to other sur-
rounding areas and that through this project she felt
connected to a bigger community. The promotores
taught each other how to work in the community
and overcome challenges.Kara explained that “Lety
in Bozeman has more experience with people there
because there’s more people interested in the pro-
gram, so I learned a lot from [her].”
Using Facebook was also beneficial because the
promotores could access the group when it was
most convenient. Lety explained that “we could
open the Facebook page and we could find new
ideas, new questions, messages from the other pro-
motores. We didn’t all have to be there exactly at
the same time. I think it was a good choice because
not all of us have the same schedule.”
Through the Facebook group, the promotores de-
scribed how the project brought them closer to-
gether. Ana shared, “After this I felt, not necessar-
ily like a friend, but closer and more comfortable
[with the other promotores].”Betty also shared that
V. Nitzinger et al. Latino Health Perceptions in Rural Montana 157
“even though I didn’t really know them in person, it
was a good way to get acquainted.”Kara expressed
that she learned from the other promotores about
their lifestyles and she “shared things that you nor-
mally don’t share with people every day.” Ana en-
joyed being able to share her “vision” and expand
her thinking by seeing the others’ perspectives. Betty
shared that it was “interesting to know about the
challenges that everybody faces by being a promo-
tora because we all have jobs, families, and we vol-
unteer doing this because we want to help.” Yanet
said there was “a lot of work to be done, and that
with all of us together, much more can be accom-
plished” and the photographs represented “what is
going on [in the community], what we care about,
and why we’re here [doing the work].” Rafa ex-
pressed that “as long as we are all in a promotores
team, we will be able to continue supporting our
community.”
Theme 6: Photobooks
Many of the promotores commented on sharing
their photobooks with family, friends, coworkers,
and other members of the community. Kara said,
“I thought [the] photobook was awesome, it was
lovely. I showed my family, everyone loved it.” Ana
received positive responses about the photobook
and shared that it was a great success for her per-
sonally. She appreciated being able to show people
“what kind of project it was, how we participated,
[and] how it all happened.”
Another benefit of sharing photographs is that
one photograph may represent similar experiences
among different people and can create critical dis-
cussion. The ideas that arise through the pho-
tographs can be a reminder to some, raise aware-
ness, and provide information to those whomay not
have a similar experience or knowledge of the topic.
Yanet explained that “you’ll have the bookwith you
[and] maybe someone will take a look at it and read
about it and it will get them thinking.”
Theme 7: Freedom of expression
Promotores were free to take photographs of any-
thing related to health. Yanet expressed, “I liked
that we had the freedom to have open themes about
how health impacts our Latino community.” Betty
expressed that there was “not a wrong answer
or right answer, so there’s always that flexibility.”
Yanet also shared, “We had the opportunity to com-
ment and see everybody’s opinions. [It was nice] that
you allowed for that opportunity [instead of saying]
post your pictures and what do you think about it
and that’s it.”
The promotores also described how using pho-
tographs was a fun and enjoyable way to express
health concerns and ideas. Betty said, “I like to take
pictures. I am not a professional, but I enjoyed to
just get creative and think about ways to promote
health using simple pictures.”
Theme 8: A new experience
Many of the promotores also described how par-
ticipating in this project was a new experience for
them.Yanet shared, “I had never thought about tak-
ing photos or had never heard of a project about
this before.” Rafa said, “[I] had never been part of
a project like this.We learned so much and I think it
was excellent.” Lety said, “I had never participated
in anything like this and I really liked the experience,
and the ability to learn and share with everyone. I
think it was a beautiful experience.”
Theme 9: Longing
Many of the promotores expressed how they wished
they would have contributed more photographs
and comments and participated more on the Face-
book page. They also expressed their hopes that the
project would continue into the future.
Ana explained that she was hesitant to post pho-
tographs at first because she was focused on sharing
quality photographs and was “embarrassed” if she
had to ask for a participant’s photograph consent
but later decided that was not necessary for her to
feel that way because “it is something you are look-
ing at. I could have taken advantage of it more. It
wasn’t an obligation of something I had to do. If
there’s another opportunity, I won’t wait so long.”
Kara shared, “I was kind of stressed out at first, [but
I liked it at the end].” She also thought that “it was
a good start to the program” and wished she would
have had more time to participate. “I’ll do it again
and I’ll be more detailed next time.”
DISCUSSION
This study expands the literature by providing a
combination of promotores de salud, photovoice,
and Facebook, 3 methods that have not been ap-
plied simultaneously. We found that this combina-
tion is effective for exploring health perceptions
and for building community among geographically
dispersed promotores. The private Facebook group
was a safe and respectful space for promotores to
ask questions, express concerns, and learn about
each other.
Most of the posted photographs and comments
from the promotores centered on nutrition. The
promotores shared their experiences with healthy
meals, what foods to look for and to avoid, and
the importance of family involvement in making
healthy nutrition choices. Exercise was the second
most popular topic, and the promotores shared how
158 Family and Community Health April–June 2019 ■ Volume 42 ■ Number 2
they stay active, how the lack of a fitness facility can
make it difficult to exercise, especially during the
winter months, and the importance of affordable
access to an exercise facility for the whole family.
Simultaneously, the promotores discussed how the
environment impacts mental health and that many
Latinos in the area deal with seasonal depression.
The promotores also described the cultural use of
alcohol and the impacts alcohol abuse can have on
health, as well as relationships. Another topic with
multiple photographs and comments was the pro-
motores’ responsibility and goal of helping the com-
munity by learning English and taking advantage of
the opportunities and resources the community of-
fers to improve one’s health.
The promotores described the benefits of using
photography to share perspectives and health infor-
mation and that using Facebook was an easy and
efficient way to communicate with each other and
with the community. The methods were beneficial
because it gave the promotores an equal opportu-
nity to express their perspectives among themselves
and is a safe method for reaching undocumented
community members. The photo project was a new
experience for the promotores and they felt it was
a creative and productive way to share ideas. Fre-
quent examples of photographs with descriptions,
reminders, and encouragement were needed and im-
portant for the study’s success.
Using Facebook was an efficient and low-cost
way to promote health, share resources, and build
trust among the geographically dispersed promo-
tores. All of the promotores had a smartphone/
camera they could use to take photographs, had a
basic understanding of how to navigate Facebook,
and had access to the Internet; Internet connectivity
was not considered a limitation in this study. The
promotores created an online community where
they became acquainted with and supported each
other as a team.
Limitations to this study include a small sample
size, the short duration of the intervention, and the
discomfort of one promotora to using Facebook.
Having a larger sample size, including both women
and men, could have provided a broader portrayal
of the context of health among Latinos in rural
Montana. The short duration of the intervention
was due to the timeline of the first author in com-
pleting a master’s degree. Some of the promotores
said that at first they felt stressed, that they saw
it as another task added to their busy schedules,
but that in the end it was educational and worth-
while. The promotores discussed that they wished
they would have shared more photographs and par-
ticipated more on the Facebook group. A longer du-
rationmay have facilitated this. Three of the promo-
tores did not have a Facebook profile,which seemed
to have impacted participation and access to discus-
sions, resources, and other information for 1 pro-
motora. In a discussion after the intervention was
complete, this promotora recommended use of an
alternate social media platform such as Instagram.
A future study could compare Facebook and Insta-
gram or use the 2 platforms together.
Previous photovoice studies discussed potential
limitations of using photographs to share informa-
tion, including how participants were challenged
with expressing the meaning of their photographs
with words.19 However, in this project, the promo-
tores discussed the power of photographs and that
the photographs can lead to discussion with com-
munity members about health, including topics that
are potentially sensitive.
Most photovoice projects conclude with a photo
exhibition to share ideas and concerns with the
community and reach out to policy makers.16,19,21
Instead, the promotores received photobooks and
used them to promote community discussion
around health topics. This is a method that could be
used in communities where CHWs are dispersed.
Although this project has finished, the promo-
tores are still working together in their communities
and using social media to communicate with each
other and with the general community and continue
to promote well-being and healthy lifestyles in their
communities.
Future recommendations
Sharing health information and photographs
through social media is an accessible and efficient
method that allows for all community members’
voices to be heard and can empower community
members to share their stories and make last-
ing changes in their lives and their communities.
Feedback provided from the promotores about
the project was overwhelmingly positive. When
asked what could be changed to make the project
better, most of the promotores said “nothing.”
Rafa shared that the project was organized and
led professionally. Lety expressed how the first
author prompted the promotores in a positive and
encouraging way. “I liked the way you asked for
information. You asked with [a good] attitude and
overall in a way that motivated us to keep going
and continue to support you. You shared your
enthusiasm for us to continue participating.”
Based on the interview responses, all of the pro-
motores expressed that they would like to con-
tinue taking photographs and sharing them online
publicly. Viridiana suggested that they should con-
tinue posting photographs so the community can
see “what we’re doing and the difference it can
V. Nitzinger et al. Latino Health Perceptions in Rural Montana 159
make.” Social media is an efficient and accessi-
ble method of reaching and interacting with the
general community, especially those who are new
to the area. Since this study ended, the first author
became a promotora and has been posting health
information and photographs of community events
on the Facebook page. The group has been dis-
cussing the use of Instagram to share photographs
as an additional method for reaching community
members.
Community organizations can benefit from us-
ing social media methods to engage their audi-
ences, improve communication, and reach a larger
social network.29 Reports suggest that the use of
social media can encourage health promotion, as
well as “increased social support, benefit-finding, or
positive peer-modeling.”30 While many people use
Facebook, and its popularity is increasing among
Latinos,31 some people do not use Facebook. By in-
cluding the use of a public Web site or blog to share
photographs, it would be easier for other commu-
nity members to participate, as suggested by Virid-
iana. With approval from the promotores, the pho-
tographs and comments have been made available
through a public Latino Facebook page. In addition,
the general community was invited to post pho-
tographs and comments regarding topics important
to them. We recommend that a health care profes-
sional monitors posts and comments to ensure that
accurate health information is being shared.
Although this project focused on health topics,
it could be expanded to other topics explored in
other studies such as the “physical environment, so-
cial norms, and behaviors of communities.”32 Ana
suggested one way to improve the project would be
to broaden the topics to other issues beyond health
such as “Hispanic life in small communities.”
Betty shared that “sometimes some of the pro-
motores didn’t download their pictures on time,
then a few days later you have 6 pictures that you
need to comment on,”which was “time consuming,
but doable.” Kara also expressed that having more
structure would be helpful and suggested “a subject
of the week, and [have] people submit one photo
per week.”
Yanet explained the importance of sharing the
results of the project with the community and de-
scribed that sometimes “with different projects you
get the information you need and then forget about
showing the results, especially going back to the
community.” Along with the successful photobook,
Yanet suggested sharing the photographs in a video.
Future goals of the promotores include to continue
sharing photographs, questions, and resources on
Facebook and to continue helping and supporting
the community.
REFERENCES
1. US Census Bureau. Hispanic or Latino Origin by Race:
Total Population of US. 2011-2015. US Census Bureau.
2015. https://factfinder.census.gov/faces/tableservices/
jsf/pages/productview.xhtml?fpt=table. Published 2015.
Accessed November 30, 2018.
2. Cunningham P, Banker M, Artiga S, Tolbert J. Health
Coverage and Access to Care for Hispanics in “New
Growth Communities” and “Major Hispanic Centers.”
San Francisco, CA: Kaiser Commission on Medicaid
and the Uninsured, Kaiser Family Foundation; 2006.
https://kaiserfamilyfoundation.files.wordpress.com/2013/
01/7551.pdf. Accessed December 7, 2016.
3. US Census Bureau. Hispanic or Latino Origin by Race:
Total Population of Montana. 2006-2010. US Census
Bureau. https://factfinder.census.gov/faces/tableservices/
jsf/pages/productview.xhtml?pid=ACS_15_5YR_B03002&
prodType=table. Published 2010. Accessed November
30, 2018.
4. US Census Bureau. Montana Quickfacts. US Census
Bureau. 2015. https://www.census.gov/quickfacts/fact/
table/mt,US/RHI725217#viewtop. Published 2015. Ac-
cessed November 30, 2018.
5. Elder JP, Ayala GX, Parra-Medina D, Talavera GA. Health
communication in the Latino community: issues and ap-
proaches. Annu Rev Public Health. 2009;30:227-251.
doi:10.1146/annurev.publhealth.031308.100300.
6. López-Cevallos DF, Harvey MS. Foreign-born Latinos liv-
ing in rural areas are more likely to experience health
care discrimination: results from Proyecto de Salud para
Latinos. J Immigr Minor Health. 2016;18(4):928-934.
doi:10.1007/s10903-015-0281-2.
7. Bolin JN, Bellamy GR, Ferdinand AO, et al. Rural Healthy
People 2020: new decade, same challenges. J Rural
Health. 2015;31(3):326-333. doi:10.1111/jrh.12116.
8. Guzman A. Exploring the chronic illness experience
of rural-dwelling Latinos of Mexican origin. Hispanic
Health Care Int. 2016;14(4):177-183. doi:10.1177/15404
15316677720.
9. Davidson K, Kos P. Bending the Arc [documentary film].
USA. Impact Partners; 2017.
10. Medina A, Balcázar H, Hollen ML, et al. Promotores
de salud: educating Hispanic communities on heart-
healthy living. Am J Health Educ. 2007;38(4):194-202.
doi:10.1080/19325037.2007.10598970.
11. Early JO, Burke-Winkelmann S, Joshi A. On the front lines
of prevention: Promotores de Salud and their role in im-
proving primary care for Latina women, families, and com-
munities. Glob J Health Educ Promot. 2016;17(2), 58-86.
doi:10.18666/GJHEP-2016-V17-I2-7130.
12. Baquero B, Goldman S, Siman F, et al. Mi Cuerpo,
Nuestra Responsabilidad: using photovoice to describe
the assets and barriers to sexual and reproductive health
among Latinos in North Carolina. J Health Disparities
Res Pract. 2014;7(1):65-83. http://digitalscholarship.unlv.
edu/cgi/viewcontent.cgi?article=1245&context=jhdrp.
Accessed September 20, 2016.
13. Villa-Torres L, Fleming PJ, Barrington C. Engaging men
as promotores de salud: perceptions of community health
workers among Latino men in North Carolina. J Com-
munity Health. 2015;40(1):167-174. doi:10.1007/s10900-
014-9915-x.
14. Promotoras de Salud MTHCF. Promotoras de Salud:
Bridging Latino Health Disparities in West Yellowstone
and Belgrade. Bozeman, MT: Montana Healthcare Foun-
dation; 2017. http://www.mthcf.org/grantee/promotoras-
de-salud-bridging-latino-health-disparities-in-west-yellow
stone-and-belgrade. Accessed November 30, 2018.
160 Family and Community Health April–June 2019 ■ Volume 42 ■ Number 2
15. Postma J, Peterson J, Ybarra-Vega MJ, et al. Latina
youths’ perceptions of children’s environmental health
risks in an agricultural community. Public Health Nurs.
2014;31(6):508-516. doi:10.1111/phn.12112.
16. Wang C, Burris MA. Photovoice: concept, methodology,
and use for participatory needs assessment. Health
Educ Behav. 1997;24(3):369-387. https://www.ncbi.nlm.
nih.gov/pubmed/9158980. Accessed September 5,
2016.
17. Wright JA. Through the looking glass: a case study of pho-
tovoice and digital storytelling with fourth grade English
learners. In: Dissertations, Theses and Capstone Projects.
2015. Paper 669. https://digitalcommons.kennesaw.edu/
etd/669. Accessed February 10, 2017.
18. Foster-Fishman P, Nowell B, Deacon Z, et al. Using meth-
ods that matter: the impact of reflection, dialogue, and
voice. Am J Community Psychol. 2005;36(3/4):275-291.
doi:10.1007/s10464-005-8626-y.
19. Vaughn LM, Rojas-Guyler L, Howell B. “Picturing”
health: a photovoice pilot of Latina girls’ perceptions
of health. Fam Community Health. 2008;31(4):305-316.
doi:10.1097/01.FCH.0000336093.39066.e9.
20. Hou J. Speaking images: a case study of photovoice
application in community design. Paper presented at: Vi-
sualizing Change: Association of Community Design Con-
ference; March 30-April 1, 2005; New York, NY. https://
www.academia.edu/7137935/Speaking_Images_a_Case_
Study_of_Photovoice_Application_in_Community_Design.
Accessed February 10, 2017.
21. Aslam A, Boots R, Link S, et al. Effective community
listening: a case study on photovoice in rural Nicaragua.
Int J Serv Learn Eng. 2013;8(1):36-47. http://ojs.library.
queensu.ca/index.php/ijsle/article/viewFile/4535/4716.
Accessed February 10, 2017.
22. Moya EM, Chávez-Baray S, Martinez O. Intimate part-
ner violence and sexual health: voices and images of
Latina immigrant survivors in southwestern United States.
Health Promot Pract. 2014;15(6):881-893. doi:10.1177/
1524839914532651.
23. Kamouyerou A. Insights Into an Invisible Community: A
Photovoice Project With Latino Immigrant Men in Al-
legheny County [doctoral dissertation]. Pittsburgh, PA:
University of Pittsburgh; 2011. http://d-scholarship.pitt.
edu/8604/1/AKamouyerou_etd2011.pdf. Accessed Oc-
tober 3, 2016.
24. Laranjo L, Arguel A, Neves AL, et al. The influence of so-
cial networking sites on health behavior change: a system-
atic review and meta-analysis. J Am Med Inform Assoc.
2015;22(1):243-256.
25. Trochim WK. Nonprobability sampling. http://www.
socialresearchmethods.net/kb/sampnon.php. Published
2006. Accessed March 9, 2017.
26. Banks S, Armstrong A, Carter K, et al. Everyday ethics in
community-based participatory research. Contemp Soc
Sci. 2013;8(3):263-277. doi:10.1080/21582041.2013.
769618.
27. Simonds V. Guardians of the Living Water Program Photo
Analysis Form. Bozeman, MT; 2017.
28. Padgett DK. Qualitative Methods in Social Work Re-
search.2nd ed. Thousand Oaks, CA: Sage Publications;
2008.
29. Ramanadhan S, Mendez SR, Rao M, Viswanath K. So-
cial media use by community-based organizations con-
ducting health promotion: a content analysis. BMC Public
Health. 2013;13(1):1129. http://www.biomedcentral.com/
1471-2458/13/1129.
30. Yi-Frazier JP, Cochrane K, Mitrovich C, et al. Using
Instagram as a modified application of photovoice for
storytelling and sharing in adolescents with type 1 di-
abetes. Qual Health Res. 2015;25(10):1372-1382. doi:
10.1177/1049732315583282.
31. Pew Research Center. Social media fact sheet.
http://www.pewinternet.org/fact-sheet/social-media/.
Published 2018. Accessed November 30, 2018.
32. Strack RW, Orsini MM, Fearnow-Kenney M, Herget
J, Milroy JJ, Wyrick DL. Developing a Web-based
tool using information and communication technolo-
gies to expand the reach and impact of photovoice.
Am J Health Educ. 2015;46(4):192-195. doi:10.1080/
19325037.2015.1044585.