Arts-based approaches to promoting wellness in sub-Saharan Africa: a scoping review

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  1. http://orcid.org/0000-0001-6604-1305Christopher Bunn1,2,
  2. Chisomo Kalinga3,
  3. Otiyela Mtemaiv,
  4. Sharifa Abdulla5,
  5. Angel Dillip6,
  6. John Lwanda1,
  7. Emerge M Mtenga6,
  8. Jo Sharp7,
  9. Zoë Strachan8,
  10. Cindy M Grayness1
  11. Culture and Bodies' Team
    1. 1 College of Social Sciences, University of Glasgow, Glasgow, UK
    2. 2 Social Sciences, Republic of malaŵi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
    3. 3 Eye of African Studies, University of Edinburgh, Edinburgh, United kingdom
    4. 4 Zaluso Arts, Lilongwe, Republic of malaŵi
    5. 5 Section of Fine and Performing Arts, Chancellor Higher, Zomba, Malawi
    6. 6 Wellness Systems, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, United Democracy of Tanzia
    7. 7 School of Geography and Sustainable Development, University of St Andrews, St Andrews, United kingdom of great britain and northern ireland
    8. 8 Schoolhouse of Disquisitional Studies, University of Glasgow, Glasgow, UK
    1. Correspondence to Dr Christopher Bunn; christopher.bunn{at}glasgow.ac.uk

    Abstract

    Introduction Arts-based approaches to health promotion have been used widely across sub-Saharan Africa (SSA), particularly in public health responses to HIV/AIDS. Such approaches describe on deep-rooted historical traditions of indigenous groups in combination with imported traditions which emerged from colonial engagement. To date, no review has sought to map the locations, wellness problems, art forms and methods documented by researchers using arts-based approaches in SSA.

    Methods Using scoping review methodology, 11 databases spanning biomedicine, arts and humanities and social sciences were searched. Researchers screened search results for papers using predefined criteria. Papers included in the review were read and summarised using a standardised proforma. Descriptive statistics were produced to characterise the location of the studies, art forms used or discussed, and the health bug addressed, and to determine how best to summarise the literature identified.

    Results Searches identified a total of 59 794 records, which reduced to 119 later on screening. We identified literature representing 30 (62.v%) of the 48 countries in the SSA region. The papers covered xvi health issues. The majority (84.9%) focused on HIV/AIDS-related work, with Ebola (five.0%) and malaria (iii.3%) also receiving attention. Virtually studies used a unmarried fine art grade (79.0%), but a significant number deployed multiple forms (21.0%). Theatre-based approaches were nearly mutual (43.seven%), followed by music and song (22.six%), visual arts (other) (9.two%), storytelling (7.6%) and pic (5.0%).

    Conclusions Arts-based approaches have been widely deployed in health promotion in SSA, specially in response to HIV/AIDS. Historically and as evidenced by this review, arts-based approaches have provided a platform to facilitate enquiry, achieved pregnant attain and in some instances supported demonstrable health-related change. Challenges relating to content, power relations and evaluation have been reported. Future enquiry should focus on broadening application to other conditions, such equally non-communicable diseases, and on addressing challenges raised in research to engagement.

    • health education and promotion
    • wellness policy
    • review

    https://creativecommons.org/licenses/by/4.0/

    This is an open up access article distributed in accordance with the Creative Commons Attribution iv.0 Unported (CC Past four.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original piece of work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.

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    • wellness educational activity and promotion
    • health policy
    • review

    Key questions

    What is already known?

    • Arts-based approaches to health improvement have been used across sub-Saharan Africa (SSA), with some studies reporting positive outcomes.

    • No comprehensive scoping review of this work has been produced.

    • A rich array of approaches to using arts in support of health have been pursued in the global due north, but the decolonising methodology motility suggests nosotros should be careful not to import these into global south contexts.

    What are the new findings?

    • Our review suggests that an overwhelming bulk of studies have focused on HIV/AIDS, and that theatre-based approaches were the virtually common, but music and song, visual arts, storytelling and pic have received sustained attention in the research literature.

    • Arts-based approaches take facilitated enquiry enquiry, reach large numbers with wellness-promoting messages and initiatives, and in some instances supported demonstrable health-related change.

    • Challenges relating to the generation and suitability of content, power relations between researchers and target community and appropriate forms of evaluation have been reported.

    What exercise the new findings imply?

    • In SSA, arts-based approaches to health promotion have yet to be widely applied by researchers exterior of HIV/AIDS, suggesting that future research could develop approaches to non-infectious disease, neglected tropical diseases and communicable diseases other than HIV/AIDS.

    • There is great scope to develop theories of and methodologies for arts-based approaches to health in SSA that dialogue with, but practise not mimic, those developed in the global north.

    Introduction

    A long-standing critique of health promotion and intervention is that many practitioners uncritically impose categories and understandings from biomedicine on the communities with which they work.ane 2 Notwithstanding, efforts to facilitate improved health in a community are inevitably faced with the ideas, priorities and concerns that members of that community attach to health.3 Failure to acknowledge, respect and work with the situated cultural positions held past customs members tin can lead to cultural imposition,four introjection5 and symbolic violence,six which undermine the pursuit of better wellness. A range of researchers and practitioners take sought to address these problems by developing approaches to wellness promotion7 inspired past action research8 and dialogical theory.nine Such approaches treat health promotion and intervention as a collaboration between community members, healthcare professionals and researchers.10

    I way in which researchers have pursued collaboration with communities to improve health in sub-Saharan African (SSA) is by using artistic forms.eleven–xiii In SSA, creative processes have been harnessed to ask into local experiences and understandings relating to wellness,fourteen to intervene in drivers of health problems,15 to provide a discreet class of therapy for a range of conditions16 and to disseminate and validate wellness research findings.17 These four modes have indigenous roots in African communities.eighteen As Kerr notes, indigenous traditions such as the Gule wa Mkulu have long served equally a infinite for moral education (eg, the dangers of excessive alcohol consumption) and the negotiation of social alter in Chewa and Manganja communities.19 Members of this SSA enquiry customs make the merits that artistic forms and methods facilitate participants to footstep outside of their everyday lives to apply imagination and play to reconfigure how they understand and deed on an aspect of life, such as a disease.twenty They too point to the importance of the potential for art to appoint communities in embodied learning,21 to stimulate empathy22 and to provide vicarious experiences that shape collective and self-perceptions.23

    Edifice on indigenous performative traditions, arts-based methods have featured prominently in public wellness activeness across SSA. Kamlongera points to 3 phases in this action: during the precolonial era, artistic expression, or 'folk media', was central to cultural transmission and instruction in many communities across Africa; during the colonial era, these folk media were often appropriated for the purposes of 'moral pedagogy', notably through the 'propaganda play' and in the postcolonial era, in that location has been a resurgence of interest in art and folk media as media for education and development.12 Of the art forms, theatre has been widely used by governments in SSA in the postcolonial era, as it is seen equally a 'user-friendly instrument' through which to influence health-related practices in contexts of low levels of literacy, receiving pregnant funding.24

    Using the arts for health in the postcolonial era has been nearly visible in responses to the HIV and AIDS epidemic. Practitioners of theatre, song, storytelling, dancing, circus and many other artistic forms accept made substantial contributions to sensation raising, prevention, testing, destigmatising and counselling initiatives.13 In recent years, the Ebola epidemic has too received attention from the artistic community, notably in West Africa, which sought to communicate the danger posed by the virus and how to answer to symptoms.25 While the number of studies taking such approaches to HIV and AIDS and other health issues is large, no attempt has been made to systematically map the locations, wellness issues, art forms and methods relating to this body of work. Our review seeks to redress this gap in the literature and to provide researchers, practitioners and policy makers with an overview of the achievements and challenges identified in studies to date.

    In doing and so, we situate ourselves within the 'decolonising methodologies' movement26 and attempt to avoid imposing frameworks from the rich array of arts-based inquiry conducted in the global north.27 For this reason, our review is focused on the utilise of art in the pursuit of the World Wellness Organization's (WHO) widely accepted definition of wellness promotion, from the Ottawa Charter of 1986: 'wellness promotion is the process of enabling people to increase control over, and to improve, their health.'28 Our awarding of the WHO approach led u.s.a. to exclude arts-based approaches to research (except when part of a health promotion effort),29 therapy30 and knowledge translation.31 For, while these three traditions often overlap and intersect with health promotion, their primary aims are discreet.

    Methods

    We adopted scoping review methodology, as defined past Arksey and O'Malley32 and Levac et al,33 to enable an iterative and exploratory arroyo to knowledge gathering and synthesis. Specifically, nosotros followed the five stages proposed past Arksey and O'Malley:

    1. Identifying the research question.

    2. Identifying relevant studies.

    3. Study choice.

    4. Charting the data.

    5. Collating, summarising and reporting results.

    Unlike systematic reviews, scoping reviews exercise not seek to answer narrow questions with the best bachelor evidence, but instead map what is known nigh a topic, identify gaps in research literature and inform hereafter investigations.34

    Identifying the research question

    Although health promotion in SSA has often used artistic forms, an encompassing review of the bookish literature that these initiatives accept generated has never, to our noesis, been undertaken. To address this gap, we sought to answer the broad research question: how have arts-based approaches been used to promote wellness in SSA? Beneath this question, we as well set out to explore the achievements and challenges that the existing literature reports on, and to produce a synthesis of learning points from the corpus as a whole.

    Identifying relevant studies

    Arts-based wellness promotion frequently involves collaboration betwixt researchers and practitioners from the arts, social sciences and biomedicine. For this reason, nosotros searched a wide diverseness of databases representing the plurality of disciplines. Preliminary searches were conducted using the EBSCOhost and ProQuest platforms and the search strategy was refined iteratively to ensure that a selection of eight primal papers, identified through discussion among the authors, were returned past the strategy. The searches were limited to papers published in English and included search terms (see online supplementary file 1, table 1) that limited geography to SSA territories (using the World Depository financial institution's definition of the SSA region),35 applying both current and historical names for territories in the region. The final search terms were established in consultation with a librarian before ii researchers (CB and OM) searched eleven databases (see online supplementary file 1, table 2). Searches were carried out in May 2018, with no limitations placed on engagement of publication. Finally, the bibliographies of all papers that were included in the review were searched by hand for references not identified during the database searches.

    Supplemental cloth

    During preliminary searches, we constitute that our search strategy returned papers relating to television (TV) and radio productions, triggered past the inclusion of the term 'drama' in the search. While at that place is a polarising and long-continuing debate about whether Telly and radio can be considered 'art', nosotros settled on an inclusive strategy that included these cultural forms.36

    Study choice

    Titles were screened for records that appeared to stand for efforts to employ artistic practices to promote health in SSA territories. 3 researchers (CB, CG and OM) screened record titles in separate EndNote libraries. These libraries were then combined to class a second library containing the records selected for abstruse screening. The post-obit inclusion and exclusion criteria for abstract and full texts were applied:

    1. Papers set in SSA.

    2. Papers that report using arts.

    3. Papers with a focus on wellness promotion/intervention.

    Not

    1. Papers from non-SSA territories.

    2. Papers that use arts to recruit to clinical interventions or disseminate research findings.

    3. Papers that focus on customs art without relating this to health.

    The database of records was divided betwixt eight researchers (Advertising, CB, CMG, CK, JL, OM, SA and SM), who worked in pairs to screen the abstracts for inclusion. 2 researchers (CB and OM) reviewed the decisions fabricated by the paired researchers and created a listing of records for full-text review. These records were and so provided to seven researchers (AD, CB, CMG, JL, JS, OM and SA) who read the papers in full and proceeded to extract data from those papers that met the review inclusion criteria. Decisions and extractions were reviewed by two authors (CB and OM).

    Charting the data

    Given the interdisciplinary nature of the enquiry and the multiple disciplines from which the records were fatigued, we used a template that was broad enough to comprehend approaches that did not fit the 'headings' under which traditional biomedical/public health research is conducted. The template included the following fields:

    • Writer(s), yr of publication, written report location and study elapsing.

    • Study customs, target group and/or sample.

    • Aims of the written report or paper.

    • Art forms used/discussed, and wellness issue focused on.

    • Methodology/approach

    • Activities/interventions.

    • Analysis undertaken/upshot measures.

    • Study results, key arguments, central messages.

    The researchers attempted to ensure that a uniform arroyo to data charting was achieved, but in exercise the variety of approaches taken in this cross-disciplinary literature meant that some information was not available for all records. Two authors (CB and OM) reviewed and supplemented the content captured during the charting stage.

    Collating, summarising and reporting results

    The content generated during charting phase was combined in an Excel database, which was used to generate descriptive statistics relating to the location of the studies, yr of publication, art forms used or discussed and the health bug addressed. Graphs and visualisations were produced at this stage, to assist estimation of the data.

    After consideration of potential approaches to summarising and reporting the information, we chose to nowadays the data by fine art grade, as to do and so past health issue or location would have led to clumping in the HIV/AIDs category. Our initial arroyo to categorising art forms was grounded, following the labels applied past the authors of the papers we reviewed. During the process of summarising the data, we maintained these grounded labels, with the exception of three groups of art forms: theatre, visual arts and digital arts. These groupings amass a range of author-practical labels. Our reporting combines multiple groupings (indicated by the use of a comma in the subheading).

    Our approach to reporting the results below draws on the narrative review tradition, which is a common and accepted approach to reporting findings of a scoping review.37 Adopting narrative-based reporting enabled our multidisciplinary squad to participate in the analysis and presentation of the diverse ready of methodological and disciplinary traditions present in the literature nosotros identified.38

    Patient and public involvement

    No patients or members of the public were involved in the design of this literature review.

    Results

    Scoping review search and initial screening

    Online supplementary table ane details the database search, which identified 59 794 records. Subsequently de-duplication, 51 921 records remained. Screening of tape titles excluded 50 941 records. The abstracts of the remaining 980 articles were screened and differences of opinion relating to 9% of records were resolved through give-and-take. Equally figure 1 shows, 763 records were excluded at the abstract stage, and 217 records included for full-text screening. During the total-text screening stage, 113 records were excluded, leaving 104 for data extraction. A farther 15 papers were identified in the references lists of included papers, bringing the full number of records reviewed to 119.

    Description of included papers

    Our review identified work representing 30 countries in the SSA region (see figure 2). Of the 119 studies, 52 (43.7%) related to South Africa, 9 (7.6%) to Tanzania, 8 (6.vii%) to Uganda, vii (v.9%) each to Kenya, Republic of malaŵi and Zimbabwe, 6 (5.0%) to Nigeria, 5 (4.2%) to Botswana and Republic of ghana, 4 (3.3%) each to Ethiopia, Liberia, Swaziland and the Gambia, and 3 (2.5%) to Zambia and Namibia. The remaining fifteen (12.half-dozen%) countries were associated with two studies (Benin, Burkina Faso, Cameroon, Lesotho, Mali, Mozambique, Senegal and Togo) or one study (Cape Verde, Guinea, Guinea-bissau, Republic of madagascar, Niger, Rwanda and Sierra Leone).

    The studies addressed sixteen different health problems (run across effigy three). A significant majority related to HIV/AIDS (101 (84.9%)). Ebola was the discipline of half-dozen (5.0%) studies, malaria four (3.3%), and cholera, reproductive health and gender-based violence two (1.7%). The remaining 10 (eight.four%) wellness bug were covered in unmarried papers (breast feeding, cervical cancer, childhood cataracts, cardiovascular illness, immunisation, measles, stroke, tuberculosis, water, sanitation and hygiene, and 'women's health').

    The studies employed or addressed the use of 17 different categories of art forms (see figure 4). Theatre was present in 52 (43.7%) studies, music and song in 27 (22.half dozen%), Boob tube/radio in 14 (11.7%), visual arts in 11 (9.two%), storytelling in 9 (vii.6%) and film in 6 (5.0%). Digital art and photovoice were referred to in 5 (iv%); papers, comics, craft and folk media in four (3.3%); dance and photography in three (ii.v%); verse in two (1.7%); and circus arts, comedy and puppetry in one. Of the 119 studies, 25 (21.0%) used or referred to more than one artistic course. In the balance of the newspaper, we refer to these studies equally 'multiform'. Effigy 5 visualises the proportional distribution of fine art forms by health bug.

    Theatre

    Amid the papers identified in the review, the well-nigh common art class used to promote wellness was theatre. Of the 52 papers we identified,fifteen 17 xx 39–87 14 (26.ix%) presented theatre as part of a multiform approach. Beneath the category of 'theatre', many studies located themselves with reference to specific traditions or techniques: theatre for development,82 participatory theatre,85 forum theatre,58 image theatre,57 customs theatre59 and appreciative enquiry.73 Papers often described an extended period in which facilitators worked with community groups to develop a performance by eliciting narratives relating to experiences and perceptions of wellness conditions (usually HIV/AIDS), before putting on a operation for the community.49 51 54 55 64

    A subgroup (9 (17.3%)) of the theatre-based papers presented evaluations of interventions that included statistical assessments of outcomes.fifteen 40 41 45 50 55 77 78 83 A big-calibration randomised community trial of a school-based drama programme in Southward Africa establish meaning improvements in HIV/AIDS-related knowledge and attitudes, likewise as rubber use among those who were sexually agile.45 Another South African study plant that public theatre performances produced in collaboration with community members, working within the Xhosa educative storytelling tradition of intsomi, were significantly associated with large increases (172%) in self-referrals to HIV/AIDS voluntary counselling and testing services.fifteen

    In some instances (19/52 (36.five%)), studies used theatrical techniques to help participants explicitly explore potential solutions to wellness-related struggles or dilemmas.17 41 43 44 49 57 58 61 64 66 71 73 74 78 84–86 Ane paper presented role-play techniques and Boalian paradigm theatre to human activity out HIV/AIDS-related scenarios, such as pressured situations in which women are expected to accept unprotected sex activity, consider strategies for managing these situations and and so part-play alternative responses, with the aim of helping participants to program ahead for such difficult situations.57 Another paper described using torso sculpture, epitome theatre and role-play to help healthcare workers explore and mitigate their risk of contracting tuberculosis (TB) while at work.85

    Critical reflections on working with theatre-based art forms were likewise present in the corpus. One writer questions the extent to which 'participatory' methods referred to in some work are truly participatory, suggesting that some invoke the term without in fact providing a space for empowerment or agency.80 Some other paper, reflecting on community theatre approaches to HIV/AIDS prevention in Tanzania, noted that audiences sometimes reacted negatively to the open depiction of sexual matters, and that post-operation word were oftentimes shunned, especially by men.59

    Music and song, trip the light fantastic

    We identified 27 papers that considered music, song and/or dance as mediums through which to engage in health promotion,25 39 l 53 60 61 77 83 88–106 11 (40.seven%) of which were part of multiform work. I body of work (7/27 (25.9%)) nosotros identified explored how pop artists take incorporated wellness-promoting messages in their songs, specifically in relation to HIV/AIDS and Ebola.25 92 94 96 102 103 105 A study in Tanzania used interviews to explore young peoples' engagement with popular music and emphasised the utility of metaphor to communicate the nature of HIV/AIDS, the important function songs tin can play in confronting stigma and for addressing myths virtually who is afflicted by the condition.94 An ethnographic study in Liberia documented how pop musicians, sometimes deputed by non-governmental organisations (NGOs) such as UNICEF or WHO, responded to the Ebola outbreak in 2014–2016 with a series of songs and 'jingles' which communicated preventative measures, as well equally basic information virtually the status.25

    Other studies (6/27 (22.ii%)) worked with members of communities to produce music and song with wellness-improving or preventative intentions.90 93 95 98 101 104 In the The gambia, 1 newspaper reports how songs that encouraged bed net repair for malaria prevention were crafted past customs members in response to a focus group give-and-take exploring malaria and prevention.90 The researchers leading this report facilitated the recording and circulation of these songs, accompanied by locally crafted posters, and found statistically significant improvements in bed internet repair after communities were exposed to them. In South Africa, researchers explored the use of djembe drumming circles every bit an intervention to promote low-intensity to moderate-intensity physical activity.98 The written report constitute that drumming was safe for hypertensives and was associated with a statistically significant reduction in blood pressure.

    Research on HIV/AIDS activist choirs in South Africa has been conducted in Zulu-speaking communities. Through ethnographic written report, two papers present how such choirs provided both support networks for people living with HIV/AIDS and a platform for activism and preventative advice.97 100 In republic of the gambia, researchers too used ethnographic methods to examine a government-funded Ebola initiative, which engaged local kanyeleng female fertility societies to compose and perform Ebola communication and prevention songs and dances. The studies debate that the initiative fostered trust in the messaging and provided reach that conventional methods would not have accomplished.101 104

    All iii of the papers which nosotros identified as working explicitly with dance were part of multiform approaches.46 81 83 Two addressed HIV/AIDS46 81 and i focused on cholera and malaria.83 Given the lack of distinction between music, vocal and dance in many African traditions,107 it is probable that the obviously small number of dance-related studies identified in this review masks the extent to which trip the light fantastic toe was present in music and song-based studies.

    TV/radio

    The third largest group of papers identified in the review related to piece of work that used TV or radio platforms for health promotion purposes. Of the xiv papers in this group,103 108–120 4 (28.vi%) described multiform interventions. The dominant paradigm operating in this trunk of literature is 'entertainment-pedagogy', which describes fabric that self-consciously seeks to embed educational messages within mass art forms.121 A mutual study design involved the airing of a TV or radio series containing HIV/AIDS-related story lines, followed by a survey amidst target communities to assess potential impacts on HIV/AIDS-related practices. For instance, ane written report explored the issue of a radio drama which aimed to increase HIV/AIDS testing rates in Botswana. In a random-sample survey of 555 people across vii districts, researchers found that most one-half of respondents listened to the drama, and that listening to the drama was positively associated with lower levels of stigma toward people living with HIV/AIDS, stronger intentions to become tested and increased discussions with partners about getting tested.115

    In South Africa, researchers conducted a nationwide evaluation of the 'Soul City' drama serial, which was broadcast through both TV and Radio and supported by booklets distributed through national newspapers.111 The drama integrated health-promoting messages with stories from daily life in South Africa, with the aim of reducing infection rates, stigma and risky behaviour in teenagers. In a random sample national survey of 1981 people, 82% reported being exposed to Soul Urban center via TV, radio or booklet. The survey information also suggested that both the Television and radio drama were associated with significant positive shifts in perception of social norms relating to HIV/AIDS stigma. Exposure to Soul Urban center material was also associated with requesting the employ of condoms during sexual practice, talking about HIV/AIDS with partners, friends and family, and with supportive and help-seeking behaviours.

    A Kenyan report used content analysis to explore whether an entertainment-education drama called 'Shuga' conveyed its intended letters.120 Shuga was intended to promote prophylactic sex activity by encouraging safety use and monogamy and to destigmatise HIV/AIDS. Content analysts coded 138 min from half-dozen episodes of Shuga and found that the series conveyed potent and consistent destigmatising and condom-promoting messages. All the same, the analysts' findings suggest that messaging promoting monogamy as a component of condom sex practice was neither strong nor consequent, with few direct statements of this message, a majority of characters engaged in multiple concurrent partnerships, and a lack of a function model couple engaged in monogamous sexual partnership.

    Visual art (other), digital art, comics

    Visual arts were nowadays in eleven of the identified references.90 122–131 Ane newspaper described a 3-phase slice of work which used sculpture as an HIV/AIDS sensation-raising and prevention strategy in Republic of uganda.128 In each stage, a professional sculpture artist created pieces of sculpture that sought to reflect on and challenge taboos surrounding the word of HIV/AIDS, sex and death. The study culminated in a series of soap-based sculptures, a medium chosen for its portability, allowing the sculptures to be moved, exhibited and handled in communities across Republic of uganda. This sculpture-based approach was evaluated through interviews and focus groups with members of the customs in which the sculptures were exhibited. The qualitative information gathered suggested that the sculptured imagery was seen to be readily intelligible, evoking lots of interpretations that 'fit' with the health-promoting calendar: the vulnerability of the trunk, which diminishes with employ, like lather; the linking of ballocks, sex and infection; embedding objects in ballocks evoke repulsion at the invasion/infection.

    We plant five papers which used a course of digital art.117 129 131–133 With the spread of video-capable mobile phones, ane grouping of researchers used this platform to explore the use of digital animations equally a medium for providing health didactics and prevention letters relating to insect control, and cholera and malaria prevention in Benin.132 A 3D animated video, presented in local language, was created for each target topic and shown twice to participants using mobile phones, who then completed a brusk survey. Of the 83 participants, 100% 'liked' the video, and all but 1 rated the 'message' equally 'articulate'. The authors conclude that this arroyo to wellness promotion is feasible and, as mobile technologies continue to spread, could also provide an arroyo that is scalable.

    Comics were deployed in four of the studies we identified.109 134–136 Ane study of Swahili language HIV/AIDS prevention comics uses a case-study approach to contrast the content of a UNICEF-funded comic to that of a locally funded and produced comic.134 The study'due south author'south discourse assay claims that the UNICEF-funded comic relies on a simplistic 'goodies' versus 'baddies' narrative structure, while the locally produced comic uses ambivalence to enable readers to identify with the characters. The writer concludes that the UNICEF comic underestimates both the medium of the comic and the immature East-African readers information technology is aimed at, and that until its shortcoming are addressed, information technology is not a suitable arroyo to HIV/AIDS prevention.

    Film, photography, photovoice

    Half dozen studies explored the use of film to promote wellness,103 137–141 i of which used a multiform approach. In Tanzania, a inquiry team used participatory research methods to create video content to reflect on and challenge the reproductive health bug faced by adolescents.140 The study team worked with gender-counterbalanced groups of school-going children aged 15–nineteen years, to place and prioritise reasons why teenagers go pregnant, then writing scripts that worked with the prioritised reasons to create screenplays. Participants and so worked with the research team to shoot and edit footage of their screenplays to produce films which were shown to policy-makers, broadcast on local telly and shared through YouTube. Reflecting on their work, the author suggested that participatory video approaches can exist a useful ways of engaging young people in wellness issues, providing vocalism to their experience and empowering them. Still, the author too noted that the researchers experienced considerable challenges relating to the power dynamics between the research team and the participants. Specifically, the participants argued that they should be paid a salary, equally they saw their involvement in the project as work. This issue was resolved by providing a leisure event at the cease of the project.

    Photography and photovoice approaches to wellness promotion were used in viii papers.135 142–148 Researchers in Mozambique used photographs in combination with vignettes to elicit social norms relating to multiple concurrent sexual partnerships, with the aim of contributing to HIV/AIDS prevention efforts.143 The authors report that by using projective techniques, they were able to elicit rich narratives relating to sexual norms, HIV/AIDS manual and chance perception, and that this method tin exist particularly useful during the development phases of interventions, assuasive researchers to admission local constructs and terminologies without imposing external assumptions.

    In S Africa, Mitchell et al used a photovoice and participatory enquiry methodology to facilitate customs health workers and teachers to represent and respond to HIV/AIDS in their communities.144 Over the course of 4 sessions, participants formed groups, were taught to utilise cameras, encouraged to take pictures of the challenges and potential solutions for addressing HIV/AIDS-related issues, and gathered together to view and talk over the pictures that had been taken. The pictures and discussions provided insight into local experiences of HIV/AIDS but were also a platform for community organization and mobilisation, with participants using their newly formed social networks equally a platform to instigate stigma-reduction initiatives and education programmes.

    Storytelling

    Of the nine papers that worked with storytelling,60 127 129 133 149–153 ix (55.5%) approached the method independently, and 4 (44.iv%) every bit function of a multiform approach. 2 studies describe a storytelling competition, in which immature people were invited to submit HIV/AIDS-related narratives designed for transformation into short films.150 153 The competitions reached 63 327 immature people and received 22 894 screenplays, and the researchers suggested that the narratives conveyed that HIV/AIDS stigma was mutual, the virus is associated with sexual promiscuity, that antiretrovirals (ARVs) are viewed with ambiguity, and that social support networks for those living with the virus are limited. A further study presented a critical analysis of the Zimbabwean HIV/AIDS intervention strategy for schools, revealing that non-fictional texts dominated and argued that fictional texts should be included to assist pupils grapple with the social and emotional dimensions of the epidemic.149

    In a workplace setting, and using participatory workshops, South African researchers collaborated with employees of a large mining company to tackle HIV/AIDS myths using stories developed with peer educators.151 A total of lxxx variations of myth were identified in the initial workshops only in later on workshops, the researchers found that some of peer educators struggled to create appropriate stories to counter these myths. The researchers concluded that while not all peer educators found it easy to create alternative HIV/AIDS narratives, those who did created richer stories, more suitable to their context, than the storytelling experts could on their own.

    A academy in S Africa was also the site for testing storytelling-based HIV/AIDS awareness and prevention messaging.152 Using a small sample of 21 students, researchers tested the effect of a prerecorded 'storytelling stimulus' on self-reported intentions relating to HIV/AIDs-related risks. The written report found statistically significant relationships betwixt participants' levels of interest in the story and their power to recall its content, and between their levels of absorption in the story and their intention to carry out at least one positive behaviour.

    Multiform approaches that used storytelling tended to include digital or visual arts. In one Southward African study, which was office of a narrative therapy initiative for women living with HIV/AIDS, participants combined storytelling with the creation of trunk maps, through which they narrated experiences and histories relating to their status.127 Two school-based studies, one in Tanzania129 and one in Due south Africa,133 used a combination of storytelling, visual arts and digital arts to support students to produce stories layered with images, drawings and spoken words. These stories were used to facilitate HIV/AIDS pedagogy and social-behavioural change, including challenging stigma.

    Folk media, arts and crafts

    Folk media56 65 81 108 and craft75 123 124 154 were each referred to in iv papers. All but one154 of these papers discussed multiform work. Folk media was mostly used as an umbrella term to refer to art and expressive forms derived from the specific community in which the work was being conducted. One study in Malawi highlighted the complexities of this approach, demonstrating that what researchers may assume to exist a 'local' form of expression can, if non advisedly negotiated with target communities, in fact turn out to be external and alienating.81 The paper notes that folk dances are specially problematic in this regard, as the meanings and practices that environs specific dances tin can vary greatly, even within cultural groupings that are assumed to accept a caste of homogeneity.

    In South Africa, one study presents a project that worked with rural women to produce beaded craft works and phone wire imbenge (pot covers and baskets) carrying HIV/AIDS messaging conceived of past participants.123 Aslope work on mural and billboard campaigns, the paper presents bead-based craft as a means to challenge social taboos. The women who participated in the craft project produced objects, such every bit tableaux, depicting promiscuity or that emphasised unprotected sex, which challenged traditional Zulu taboos relating to explicit communication almost sexuality and love. The author defends investment in arts every bit a ways of preventing and raising awareness of HIV/AIDS, suggesting that they are more acceptable to local populations than traditional education programmes, adding that such investment can as well adorn the environment, provide employment and encourage activism.

    Circus, comedy, puppetry

    Single papers each described the use of circus arts,60 comedy61 and puppetry40 in combination with other art forms. Due south Africa's 'Clowns Without Borders' organization used circus arts in combination with theatre, storytelling and song with the aim of improving the well-existence of children orphaned by HIV/AIDs in South Africa, Lesotho and Swaziland.60 This multiform intervention was initially deployed equally a brief intervention, before the organisers moved to a residency-based programme in collaboration with local NGOs to improve sustainability. The writer of the study reports that while monitoring and evaluation work is underway, no formal evaluation is beingness conducted.

    One-act was used equally part of some other multiform intervention in Republic of ghana.61 Following the Ghanaian functioning tradition of 'concert party', the researchers worked with a combination of popular Ghanaian artists and people living with HIV to present an HIV/AIDS education event. Comedy acts were used to 'break the ice' with audition, by openly joking near relationships, sexual activity and condoms; topics which, in the Ghanaian communities that participated in the research, are non normally spoken of publicly.

    During the early 1990s, researchers in South Africa used a combination of puppetry and street theatre to deliver an HIV/AIDS instruction programme in South Africa.40 Larger than life, puppets told the story of how a single person with HIV transmits the virus to multiple others earlier dying. The report aimed to inculcate a realistic fear of HIV/AIDS, communicate that changes in behaviour can be protective, and encourage audience members to exist supportive of those who contracted the virus. The researchers used pre- and mail service- functioning questionnaires to assess the programme and detected statistically significant brusque-term improvements in knowledge and intention.

    Word

    Our review has identified the broad range of arts-based approaches that have been used within health promotion research in SSA. Theatre-based work was the most prominent among these approaches, merely music and vocal, TV and radio, visual arts, storytelling and film-based work accept all been explored, amid others. The majority of these approaches have been mobilised equally part of public wellness responses to the HIV/AIDS epidemic, merely Ebola and malaria have also received some sustained attention. Other health weather and bug take been explored with arts-based approaches, just in a more desultory and isolated manner. The geographical spread of the research work is broad, with 30 of the 48 countries in the SSA region represented. Even so, as found in reviews of literature on other health-related topics in the region, South African-based research dominates.155

    A central feature of art-based methods for wellness is their capacity for apply during enquiry enquiries.xiv 156 Reflecting debates that began as far back as aboriginal Greece,157 arts are positioned by some researchers equally an alternative mode of cognition generation that tin can reveal dimensions of human experience that are difficult to represent with words.158 Papers included in our review suggest that this arroyo has been used with some success in the SSA region. Storytelling through the drawing of body maps, as presented by Horne, enabled Xhosa-speaking women living with HIV to envisage their bodies and represent histories that had often remained untold.127 Similarly, Molesante et al'southward school-based report in South Africa demonstrates how photovoice techniques tin can elicit and reveal experiences of HIV/AIDS-related stigma.145 In both of these papers, withal, art as enquiry is coupled with explorations of the effect the research had or could take for participants and their communities. In doing so, the authors acknowledge the long-held position that art cannot be contained inside a representational framework lonely and can set alter and transformation in motion. In future studies in the SSA region, there is an opportunity to deepen understandings of how arts-based enquiries affect those who participate and the actions such enquiries might facilitate, intentional or otherwise.

    1 of the significant achievements of arts-based approaches in SSA has been to achieve and engage large numbers of people in health-focused reflection and action. The amusement-education approaches applied in Television and radio take proven to be particularly capable of reaching big numbers with HIV/AIDS-related materials.111 115 Theatre-based work has too been shown to attract large numbers of people, both as audiences and equally participants in organisations and initiatives, which have been characterised as a social movement.57 During Ebola outbreaks, popular25 and traditional101 music has also been used to reach large audiences. With the SSA region continuing to confront a double burden of infectious diseases and non-communicable diseases (NCDs),159 these findings suggest that TV, radio, theatre and music are important tools for reaching populations and engaging them to reflect on health-related practices.

    As well as offering novel modes of inquiry and reaching big populations, some arts-based approaches have been able to succeed in engaging their participants in changes which are beneficial for health. Street theatre performances have been strongly associated with large increases in self-referrals for HIV/AIDS screening15 and both TV111 and radio115 edutainment approaches show positive associations with a range of self-reported HIV/AIDS-related measures. While some studies take suggested that identifying with characters is a cardinal pathway through which alter might be inculcated in story-based art forms,152 few papers in the review theorise and report how modify takes place in response to arts-based interventions. Panter-Brick and colleagues' song and poster-based malaria prevention work is an exception and highlights how an approach grounded in indigenous cultural forms and musical traditions can support significant improvements in bed net repairs.90 The authors argue that past working with their participants' musical and visual traditions the arroyo was not only culturally 'acceptable' or 'competent' simply also culturally 'compelling.' Future research in the SSA region has the opportunity to build and test theories of arts-mediated health-related alter.

    The content of arts-based approaches to health promotion has non always been 'compelling' in the manner described past Panter-Brick and colleagues. Indeed, some studies report that addressing sex and related practices through theatre can exist met with negative responses relating to taboos.59 Some other challenge relating to content is well-illustrated in a report of the edutainment soap Shuga, which suggested that the show reinforced rather than challenged the practice of taking multiple concurrent sexual partners.120 Finally, as highlighted by Abdulla, arts-based approaches take to pay careful attending to the specificity of cultural forms, such every bit trip the light fantastic toe, used during health-promoting activities.81 What is causeless to be 'of' a community may in fact be alien, and therefore be treated as a spectacle and not met with participation. Researchers considering how to work with arts-based approaches to wellness promotion in SSA should reflect on these content-related challenges and conceptualize how to address them.

    While many studies nowadays positive accounts of arts-based approaches that have enabled participation in health agendas, some sound notes of caution and point to issues of ability. Papers such as Beck'southward study of comic-based approaches to HIV/AIDS prevention demonstrate that, while acting with good intentions, international agencies take imposed narratives which are unsophisticated and unappealing and lack the subtly and realism of local comic forms.134 Such top-downwardly approaches have too been taken via popular music and Idiot box, and run a risk presenting narrative which fail to resonate with audiences, or worse, inculcate resistance to appointment with information and issues of nifty importance for health. When arts-based approaches practice piece of work with local communities to produce minimally directed content, issues of inequalities between researchers and participants can arise. Specifically, participants can feel that the modest allowances they receive from researchers inadequately compensate them for the time they invest in producing fine art works. Such power struggles can be heightened and intensified when the researchers working in SSA territories are white Europeans, Americans or other from other counties associated with wealth.140 Drawing on the work of Ellsworth, Kennedy Chinyowa encapsulates issues of power in arts-based approaches to health promotion past exploring participation as a form of 'repressive myth'. He argues that when artists and researchers fail to put participants 'at the centre of the intervention process', they place their ain interests first, silencing instead of empowering them.80 Such perspectives serve as a stark alarm to researchers engaging in arts-based wellness promotion in contexts riven with memories of biomedicine's impositions.160

    A concluding challenge identified in the literature relates to how arts-based approaches to wellness promotion have been evaluated. This claiming is by no means peculiar to the SSA region and has been highlighted by researchers from the global north, and very few studies employ research designs capable of producing the types of show conventionally accustomed by medical and policy professionals.23 161 While our review has shown that statistical assessment of arts-based wellness promotion has been conducted in SSA territories, these assessments are usually express to self-report earlier-and-later on designs.45 Evaluation via qualitative approaches to data collection often renders extremely positive accounts of arts-based initiatives, but these accounts sometimes appear overstated, particularly when they fail to consider negative and unintended consequences. Innovative approaches to evaluating futurity arts-based approaches to health promotion in SSA are clearly needed and while experimental and statistical assessments should be considered, researchers should recollect critically most the tools they use to assess the impact of methods that champion aspects of experience and life oft considered to exist intangible, yet vital.162

    Strengths and limitations

    The review we have presented here is limited by four factors. First, the searches we conducted were restricted to English language outputs. As a consequence, our findings predominantly relate to the Anglophone territories of SSA. 2d, we chose to confine our searches to articles published in peer-reviewed journals. This choice facilitated international collaboration, assuasive all retrieved articles to exist shared electronically across the grouping. In this review, we accept engaged with some of the many volume-based contributions to the field, but we acknowledge that we have not done justice to the breadth of these contributions and have completely omitted grey literature. Third, the narrative approach we have taken to reporting our findings limits the systematicity of our reporting but enabled a multidisciplinary squad to participate deservedly in the review process.

    Quaternary, while the pick to locate our review inside the WHO-defined tradition of health promotion is defensible in the context of our research question, a consequence is that nosotros did non capture studies with a primary focus on fine art-based research, therapy or knowledge translation. Futurity piece of work should explore how these other traditions take been approached in the SSA region and how practitioners and researchers in these traditions might enter into productive dialogue with African researchers. Finally, following the scholarship of authors such as Okagbue107 and Kerr,19 we note that the categorisation of fine art forms we accept employed is derived from the Western cannon, and does not reflect African conceptualisations of performance, which tend non to brand as many distinctions between forms.

    Conclusions

    Information technology is clear from this review that arts-based approaches to health promotion have generated a rich academic literature relating to a broad range of SSA territories. The overwhelming bulk of studies have focused on HIV/AIDS, pursuing prevention, testing and destigmatisation agendas. The learning contained in these studies has significant potential to inform public wellness responses to the growing burden of NCDs in SSA, every bit well every bit other health-related problems. Specifically, the literature we have identified suggests that there is potential for time to come enquiry efforts to use arts-based approaches to reach large populations, drive enquiries into health-related problems and facilitate reflection on and change in health-related issues. While often championed by participatory researchers, arts-based approaches are not immune to the problem of imposition, can transmit content and letters that are inappropriate or offend, and pose challenges for evaluators. With care and focus on the communities with which engagement is sought, arts-based approaches to health promotion clearly have a useful role to play in improving public health in relation to both catching illness and NCD in SSA and present opportunities for researchers to develop and evaluate innovative theory-informed work.

    Acknowledgments

    The lead author wishes to thank Megan Vaughan and Phillip Kapulula for their guidance in the build-up to conducting this research.

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