Applying Photovoice to uncover fundamental causes of health inequality in local health contexts.

Introduction: Participatory action research methods like Photovoice are uniquely equipped to identify structural determinants of health based on lived experiences of how they influence proximal and distal population health outcomes. This study uses Photovoice data to examine how structural determinants impact community health needs. Methods: Qualitative thematic analysis used focus group discussion data (25 transcripts) from four Kentucky counties that embedded Photovoice into their local health department community health assessment processes. Coded excerpts were examined for ways in which participants' community health concerns reflected structural issues rather than individual health behaviors. Results: Participants perceived issues such as houselessness, food insecurity, and transportation as resulting from structural factors beyond the scope of local public health departments. Rather than individual interventions to improve health, participants often discussed the need for system changes in health promotion. The findings show that while local organizations can contribute to addressing health disparities, violence prevention and health promotion require larger policy decisions to reduce health disparities. Conclusion: Highlighting the roots of health disparity as lived and understood by community members through Photovoice may indicate specific areas where cross-sector engagement and government intervention is most critical to improve community health outcomes.