Keywords

1 Health, Health Promotion, and the Arts

Health involves the inclusion and combination of “circumstances / representations / elements related to biological, social, cultural, environmental, economical, political, etc. aspects”; as such, it is a dynamic notion that can only be comprehended and discussed in a contextualized way (Sanmartino 2015, p. 87). Thus, the field of health promotion, a discipline that seeks to enable people to increase control over and ultimately improve their health, is grounded in a complex understanding of health:

To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities. Therefore, health promotion is not just the responsibility of the health sector, but goes beyond healthy life-styles to well-being (WHO 1986).

Understanding health while acknowledging context and social determinants, and going beyond the absence of infirmity, is not a simple task. Beyond individual characteristics (personality traits, habits, genetics), people also face significant structural (social, cultural, economic, and political) barriers to health which are not easily solved as they involve multiple domains and ecological layers; i.e., dangerous employment conditions, social exclusion, inequitable distribution of public health programs, marginalization due to gender or race/ethnicity status, globalization and economic policy, and urbanization (CSDH 2008). Thus, the influence of these factors on health must be considered from the lens of intersectionality (Crenshaw 1990), recognizing that individual people and communities might live at the intersection of a variety of these social determinants which lead to compounding marginalization and oppression—especially along the lines of race, class, gender identity, sexual orientation, disability, citizenship, age, and other characteristics—and which may exponentially complicate their experience of health (Bauer 2014; Corbin and Bonde 2012). Similarly, historic experiences also impact health (Czyzewski 2011; Menzies 2008; Chandanabhumma and Narasimhan 2019), whether that be at the individual level of previous personal trauma (van der Kolk 2015), intergenerational trauma (DeGruy 2005), or at the national level with the historic experience of colonialism (Ward 2013; Chandanabhumma and Narasimhan 2019) and/or inequitable economic policy (such as structural adjustment programs) (Spencer et al. 2019). For instance, as we write this COVID-19 ravages the world and because of several overlapping facets of historic, economic, and structural oppression, the US has inequitable distributions of both the illness and access to care: for instance, 73% of the deaths in Milwaukee County, Wisconsin in the first 2 months of the pandemic—were African Americans— despite the fact that African Americans make up only 26% of the population in the county (Thebault et al. 2020).

Given these deeply individualized historically and community-based experiences of health, health promotion must seek to promote not only the physical experience of health but also social justice, agency, and self-determination through empowerment, participation, collaboration, and by reducing inequity (Chandanabhumma and Narasimhan 2019). It is in these efforts that the arts have a promising role. Indeed, Bell and Desai (2011) argue that art should have a central role in all social justice practice. To this end, the present book contributes to the wider social justice art field by introducing the specific role of art in health promotion efforts toward social transformation for health equity.

The Lima Declaration on Art, Health, and Development (PAHO 2009) underscores the inherent power of art in facilitating expression across cultural and social diversity and throughout the life course. The Declaration suggests key connections between art and health promotion, emphasizing art as “a powerful tool for promoting and repairing health, allowing individuals and communities to rework critical, painful or problematic situations and promote better and happier scenarios for their lives” (PAHO 2009, p. 3). The Declaration also points to art as a facilitator for active citizenship and social change through “creativity, imagination, critical thinking and love” (PAHO 2009, p. 3).

The opportunities afforded by incorporating a creative approach have been recognized as key to promoting individual and community health and well-being (Clift and Camic 2016; Craemer 2009; Davies et al. 2015; Jensen and Bonde 2018; Kilroy et al. 2007; Shand 2014; Stuckey and Nobel 2010; White 2006). Indeed, to date, there are numerous examples of how health promotion practice and research can incorporate the arts for health and social benefit in a range of settings (Daykin et al. 2008; Djurichkovic 2011; Fancourt and Finn 2019; Gussak 2007; McKay and McKenzie 2018; Raw et al. 2012).

The social dimension of health is emphasized in the Ottawa Charter for Health Promotion (WHO 1986), which argues that health is created in our everyday life contexts where we “learn, work, play and love” (WHO 1986, p. 4). Similarly, art is created in these same settings and may contribute to the promotion of health, well-being, and social change. We argue that the arts can be transformative for the field of health promotion not only by helping us to do the work that we have traditionally done-- better, but by also providing unique avenues to address and redress issues impacting health disparities that we have neglected or failed to consider. That is, scholars have noted that health promotion might be limited by its positionality and framing, and that it may suffer from being situated in a postcolonial context, originating primarily from a Northern/Western perspective (McPhail-Bell et al. 2013). From a critical standpoint, art not only serves as a tool for health promotion but can also be an important bridge toward equity in both health and knowledge exchange. Again, this aligns with social justice art practice, which considers and uses arts to identify and challenge systems that maintain inequity and injustice. Similar to how we in this book argue for the role of art in critical health promotion, social justice art is concerned with amplifying voice and position to other ways of knowing and facilitate alternatives to the dominant discourse and structures (Bell and Desai 2011, see also Chap. 21, this volume).

This book draws together 19 contributed chapters with examples of arts-based health promotion initiatives in over 17 countries. In this chapter, we begin to describe how these projects serve to promote health through the Ottawa Charter action areas, and suggest how the arts can provide further opportunities for research and practice to work toward social transformation. Through this first chapter we hope to establish the value of art for health promotion in the efforts toward health equity and social justice, and to inspire a wide readership and application of the book: practitioners, researchers, artists, and communities worldwide.

2 Arts to Address the Five Health Promotion Action Areas

The Ottawa Charter (WHO 1986) defines the core of the field of health promotion and underlines the need for active engagement by all sectors and at all levels of society to fulfill individual and community potential for health and well-being across five action areas: (1) strengthening community action, (2) developing personal skills, (3) creating supportive environments, (4) reorienting health services, and (5) building healthy public policy. These action areas require concentrated and intentional efforts, and the arts can be easily adapted in many ways to work toward achieving change in each of them.

2.1 Strengthen Community Action

Health promotion encourages a bottom-up approach in which individuals take control of their individual and community health (WHO 1986). The creative arts, specifically those coming from community art initiatives, often hold this same perspective in the way that they encourage individuals’ free expression of experiences. This is exemplified in the critical literature review on community arts for research presented by Lombardo in Chap. 13. Merging participatory art with health promotion initiatives can also create synergy when aiming to strengthen community action. In line with the Ottawa Charter’s conceptualization of community development, which involves drawing on “existing human and material resources” (WHO 1986, p. 3), community arts can build capacity to enable health or social transformation while also facilitating “constitutive capacity” as an end in itself, building on existing community strengths and assets (Carson et al. 2007, p. 367). In Chap. 16, Stoneham and colleagues discuss how Indigenous community members used the local custom of storytelling to revise negative stereotypes of their communities in Western Australian media by telling positive stories and showcasing achievements. Through this common and culturally appropriate approach, the program aimed to strengthen community action to improve community well-being.

Indeed, many public health projects including the arts often have explicit goals of strengthening communities by bringing individuals together to collaboratively and creatively address specific social or health problems (Carson et al. 2007). Furthermore, the act of collectively experiencing and witnessing art may also generate a deeper shared understanding among community members of the problems they face and opportunities for addressing them. For example, in Chap. 11, Madsen and colleagues explore how several community groups from Australia and the Pacific created a theater production based on experiences of local women to raise social consciousness on the issue of domestic and family violence in their community.

From a social justice perspective, art can also be used to instigate and facilitate social change by providing communities with opportunities to take action (Boal 1995; Freire 1970). In Paulo Freire’s Pedagogy of the Oppressed (1970), learners are viewed and met as co-creators of knowledge. Through this approach, critical consciousness in individuals and communities can be achieved, which in turn facilitates action for social change. Inspired by Freirian thinking, Augusto Boal’s Theatre of the Oppressed uses different forms of participatory theater to allow the contribution of new voices and provide space for change to individuals and communities (Boal 1995; Österlind 2008). Combining art and education enables the creation of awareness of individual and community situations, as well as the tools with which to express them. Through acting out situations of oppression, social injustice, liberation etc., Boal’s theory posits that individuals and groups will be equipped to act out the same situations in real life (Boal 1995; Österlind 2008). In Chap. 6, Ramirez and colleagues describe how Encuentro CuidarNos—a collaboration between the Puerto Rican Coalition Against Domestic Violence and Sexual Assault and the University of Puerto Rico—employed a combination of art forms (theater, music, drawing, dance) to process the primary and vicarious trauma experienced by gender-based violence service providers and advocates throughout Puerto Rico in the aftermath of Hurricane Maria. Throughout the different phases of the initiative, the participants were guided through ways of processing the trauma at multiple levels simultaneously to process their own experience of the trauma, and to increase their ability to continue their important work through their organizations and within the broader community.

2.2 Develop Personal Skills

Facilitation of life-long development and learning to ensure individual and community agency for health and well-being is a core action area in health promotion. Engagement in creative arts has been connected to the development of a range of personal skills in addition to or besides arts-specific skills at the individual level (Cameron et al. 2013; Chatterjee et al. 2018; Chilcote 2007; Kilroy et al. 2007; White 2006). Kilroy et al. (2007) emphasize the “arts in health” field as a holistic approach that recognizes and responds to the whole person, and as such lays foundations for an active personal development through experiencing flow, gaining new expectations and perspectives, and increasing well-being. Indeed, building personal self-esteem and confidence are among the most cited benefits of community-based arts projects (White 2006), which can further lead to leadership and responsibility taking (Cameron et al. 2013). For example, in Chap. 3, Zarei explores the use of poetry to empower Iranian women experiencing divorce to make meaning from their experiences. Similarly, in Marx and Regan’s contribution to this book (Chap. 8), researchers undertook a youth participatory action research project with trans- and gender-non-conforming youth to design, film, and edit a documentary about their experience in the United States. Youth wanted to portray both their unique challenges and their strengths through this work, and they were encouraged to learn new technical and advocacy skills as part of the entire project.

Arts have also been presented as very promising for effective health education, especially when developed in a participatory way (Frishkopf et al. 2016; McDonald et al. 2007). Many arts-based approaches offer alternative (non-language) ways to present knowledge and information; as such, they may mitigate barriers to health knowledge, such as illiteracy. For example, as Caman discusses in Chap. 10, photovoice is used as a social connection tool for Syrian youth displaced in Turkey, as well as to identify and communicate health issues facing this vulnerable population. Furthermore, in the aftermath of a disaster, art can function as a tool for “retrieval and reprocessing of traumatic memories that are often encoded in images rather than in words” (Huss et al. 2016, p. 1), a process which contributes to individual emotional development and healing. In Chap. 2, Katisi and colleagues describe their work with youth in Botswana who had lost caregivers to AIDS, exploring the use of a drawing-narrative approach to facilitate emotional recovery from traumatic experiences in children, who oftentimes may not have the appropriate words they need to talk about their experience.

2.3 Create Supportive Environments

A third action area for health promotion as defined in the Ottawa Charter is to ensure environments that are supportive for health—from immediate contexts like family, school, and work environments, to the larger community and across natural and built environments (WHO 1986). Indeed, arts-based activities have been shown to be a viable approach to developing supportive environments for a variety of health-related outcomes in a range of settings, including schools (McKay and McKenzie 2018), prisons (Djurichkovic 2011; Gussak 2007), communities (Shand 2014), and elderly care (Kilroy et al. 2007). For example, in Chap. 4, Ruge describes the use of a variety of art (drawing and graphic design) and cooking activities that engaged children, teachers and kitchen personnel and supported discussion of nutrition and healthful eating in schools in Denmark.

Several arts-driven projects have an explicit objective of creating arenas and safe(r) spaces for physical and mental health promotion among diverse groups including recent immigrants, the elderly, and young people (Clift and Hancox 2010; Cohen et al. 2007; Hallam et al. 2011; Jackson et al. 2010; Kilroy et al. 2007; McKay and McKenzie 2018; Shand 2014). Also, for communities that have experienced a disaster event, the use of art for recovery can help mobilize individuals to take control of their lives again while also creating a group narrative of the disaster experience (Huss et al. 2016), and in this way promote social connection and meaning. Related to this action area, in Chap. 7, Sandhu and colleagues present a historic overview of the use of drama to create supportive environments for health in the Nagano Prefecture of Japan in the 1940s.

Creating supportive environments through art can promote social connection by building new relationships among participants (Shand 2014) or by strengthening bonds between family members, such as by involving parents and children in a project together (Jackson et al. 2010). Gold-Watts and colleagues (Chap. 9) attended to linking the school and community environment in rural Tanzania and India by engaging youth in initial arts-based research (including drawing and mapping), which was later presented to their families and the larger community through a community science fair and a community event day.

When considering the neighborhood as another setting in which close relationships are woven, de Araújo Jorge and colleagues (Chap. 15) describe the development and use of ArtScience-based activities with multiple artistic languages and production of materials for health care communication (including photography, handicraft production, and song composition). The aim was to train community agents living in socio-environmentally vulnerable areas to address health awareness related to social, environmental, and biological determinants involved in the transmission of dengue, Zika, chikungunya, and yellow fever by the Aedes aegypti mosquito in urban areas of Rio de Janeiro in Brazil.

2.4 Reorient Health Services

In agreement with the argument that health is more than the simple absence of disease, the Ottawa Charter argues that “the role of the health sector must move increasingly in a health promotion direction…” (WHO 1986, p. 3). This means acknowledging the contextualized nature of health, and connecting health services to the broader societal levels in culturally sensitive ways (WHO 1986). Although this is a challenging endeavor, a broader approach to health service provision, treatment, and healing is indeed being taken in health sectors around the world, also incorporating the use of arts (McDonald et al. 2007). Several examples exist of health care settings (hospitals, senior homes, etc.) that take a holistic approach to patient treatment and care through art, both using the more traditional art therapies (Fraser et al. 2014) and also adapting art therapy by moving away from a clinical/expert approach to patient participatory approaches (Kilroy et al. 2007; Preti and Welch 2011). In Chap. 5, Barton describes an initiative within a long-term care facility in Scotland that engaged residents, their families, and its staff in a community art project that aimed to build a sense of community, provide an avenue for self-expression, and beautify the clinical space (using clay tiles). Further, in Chap. 18, Deleo and colleagues, describe the experience of a self-managed social movement to promote mental health and reduce stigma around mental illness through the use of dance (Biodanza) and art therapy in the Psychosocial Hospital of Managua, Nicaragua.

Art can also reorient health services by acting as a bridge between the health care sector and other sectors. For example, the use of live music as therapy for hospitalized children seeks to use art as a “cultural bridge between the hospital and the wider community” by introducing a familiar “outside” into the unfamiliar hospital environment often associated with pain and stress/fear (Preti and Welch 2011). In Chap. 14, written by Gomez i Prat and colleagues, the members of a health team in Barcelona share the way in which they work collaboratively with community stakeholders to co-create innovative resources that allow them to work on affective sexual health issues with migrant populations in international health care services using different art forms, including music, documentary films, videos, and more.

2.5 Build Healthy Public Policy

Incorporating arts in health promotion and public health in systematic ways requires attention at the policy level—locally, nationally, and perhaps globally. In this regard, the conclusions of the WHO Regional Office for Europe report point to the need to develop effective strategies for synergized collaboration between health and arts sectors to “realize the potential of the arts for improving global health” (Fancourt and Finn 2019, p. 57).

In this sense, the experience shared in Chap. 12 by Amieva and colleagues is a good example of how such work could inform discourse and lead to changes at the policy level, if appropriate advocacy efforts were undertaken across sectors. In their project, an interdisciplinary team of researchers, practitioners, and artists used workshops and literary productions from those workshops to examine the rhetoric around Chagas disease in Argentina and Brazil, with the ultimate aim of improving advocacy and treatment for this complex condition. The proposal of the National Academy of Medicine (USA), discussed by Alexander and colleagues in Chap. 19, could be considered within the same line of reflection. The Academy has begun to use various forms of art, including images, paintings, and street art, as a way to expand its impact and intentionally include underrepresented voices by asking communities to share their understanding and perceptions of health equity and its role in supporting the well-being of all people. In addition, their recent projects ask artists to explore clinician well-being and its connection to quality patient care and a thriving health system.

Finally, considering the indisputable link that should exist between social mobilization and changes in public policies, “artivism” is an essential tool in health promotion. Understanding “artivism” as activism for social change through art, we agree with the words of Salazar and Olivos when they affirm that:

ARTIVISM configures a collective action developed predominantly in public spaces. It is confrontational because it challenges and questions directly through the symbolic manifestation; and it is culture as it has to do with the change of meanings and shared representations. However, reflection is important because it constitutes a stop along the way, a moment to think about what assumptions we start from, where we are, what we have achieved and how we continue (Salazar and Olivos 2014, p. 5).

Chapter 17 by Leitch focuses on an eloquent example in this regard: the “Silent Silhouettes” project, a roving installation, in the form of wooden sculptures that aim to visualize—in various public locations—the fatal effects of gender-based violence in Trinidad and Tobago.

3 About This Book

Given the many opportunities for using the arts in health promotion efforts to address the five action areas of the Ottawa Charter, this book presents and examines the incorporation of arts in three primary ways: as a dynamic and participatory approach to health promotion practice, as a method to enrich and drive research, and finally as a unique avenue to reflect on and pursue social transformation.

Our intention with this book was to provide a broad overview of the potential for incorporating the arts in health promotion practice and research in a concrete way to enable readers to experiment with these ideas in their own work. As we were inviting contributions to the volume, we established foundational criteria to ensure that the resulting work constituted a diverse, inclusive, and representative contribution in the field of arts and health promotion. We sought to include diverse art forms and initiatives that addressed a broad array of health issues and were implemented in a variety of settings and work contexts. We also strove for gender balance among the invited authors, and geographical diversity in the locations of the projects. As a result, this book has 19 contributed chapters spanning projects from Asia, Africa, Latin America, Australia, Europe, and North America. These projects represent a variety of collaborative arrangements including south-south partnerships, north-south partnerships, and smaller-scale national projects. The chapters also describe programs that support diverse populations, including older adults, young people, professionals, whole communities, schoolchildren, divorcees, transgender and nonbinary youth, displaced people/migrants, teachers, and Indigenous peoples. It is this broad relevance of art in so many contexts for so many people—the sheer accessibility and tradition of it—that provides the promise for how art might be a pathway to redressing power structures that influence and cause health disparities and impact the field of health promotion and its means of knowledge production.

There are a variety of models in health promotion that could serve to frame the role of arts in promoting health and equity. In the final chapter (Chap. 21), we employ the Bergen Model of Collaborative Functioning (Corbin et al. 2016) to synthesize and analyze the diverse experiences presented in the volume and propose a way of theorizing how arts-based initiatives might contribute to synergy in health promotion research and practice. We use this model given its flexibility in approaching health promotion projects with multiple stakeholders and its attention to both positive outcomes (synergy) and negative outcomes (antagony). Using examples from across the 19 contributed chapters, we argue that the incorporation of arts can facilitate deeper engagement with one’s self and with others, as well as support the process of making sense of context. We also argue that art can promote social justice and contribute to social transformation by amplifying voice, leveraging power, and honoring multiple ways of knowing.

Finally, this book is a milestone for us. The project began long before we ever considered editing a book on the topic. Chapter 20, written by Ayele and colleagues, gives an account of the central axis of this journey: the art and health promotion sessions held at international conferences on health promotion organized by the International Union for Health Promotion and Education (IUHPE). These sessions saw their beginnings when we turned a perceived obstacle into an opportunity and asked ourselves, “How could we talk about health without using words?” It was in these sessions that we began to glimpse the metaphor of “tools and bridges” to explain how the arts might provide unique opportunities for health promotion. Tools enable and support action, they make tasks easier, they smooth challenges, and they file rough edges. Bridges allow us to access hard-to-reach places, cross rough terrain, and reduce distance. Through our own diverse collaboration in planning and facilitating these sessions, we saw the potential for arts to act as precise tools to address complex health promotion issues, and to act as bridges—across language and connecting people to one another in their humanity—to promote health and to fight inequity and health disparities. We hope this book reflects this journey while inspiring critical, creative, and transformative practices.