Keywords

1 Introduction

This volume, Arts and Health Promotion: Tools and Bridges for Practice, Research, and Social Transformation, has presented 19 chapters illustrating how the arts have been incorporated into a variety of health promotion programs, research projects, and social mobilization initiatives. In this final chapter, drawing from examples shared throughout the book and using the Bergen Model of Collaborative Functioning, we propose a way of understanding how art increases synergy in the pursuit of health promotion goals. We argue that art can increase synergy by facilitating deeper engagement with one’s self and with others, as well as by supporting the process of making sense of context. In line with reaching the goals of health promotion delineated in the Ottawa Charter (see Chap. 1, this volume), we also argue that art promotes social justice by amplifying voice, leveraging power, and honoring multiple ways of knowing. We conclude by highlighting implications for the field of health promotion and suggesting lines of further research.

2 Art and Synergy

The Bergen Model of Collaborative Functioning (BMCF) has been employed as an analytical tool for understanding interactions in health promotion programs and initiatives (Corbin et al. 2016). The model depicts inputs, throughputs, and outputs and describes pathways for how collaborative processes interact to produce additive results, synergy, or antagony (see Fig. 21.1). Health promotion initiatives can be mapped according to the BMCF as they all center around a mission (the problem they are trying to solve or the purpose of the initiative); they all involve people (partner resources) including the participants, the health promotion professionals, and ideally other community stakeholders; and very often, they involve financial or other material resources. The processes of leadership, communication, role/procedures, and input interaction vary from arrangement to arrangement but will have an impact whatever those dynamics might be (Corbin et al. 2016). Lastly, all health promotion initiatives have results of some kind, whether people do what they would have done anyway without being impacted by the project (additive); whether there is little, no, or a negative impact from the initiative (antagony); or whether the results of the collaboration are multiplicative—equaling more than the sum of its parts (synergy) (Corbin and Mittelmark 2008). In the best-case scenario, initiatives would only produce synergy , but in real-world scenarios, there are often mixes of these three outputs at different stages of collaborations.

Fig. 21.1
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Bergen Model of Collaborative Functioning. (Reproduced from Corbin et al. (2016). Figure 1. https://doi.org/10.1093/heapro/daw061, licensed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/))

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Using the BMCF as a framework for analyzing the projects and experiences described in this book, we argue that arts-based initiatives may deepen and increase the interaction between the production tasks of the project (the arts-based activity), the partners (participants’ engagement with themselves), communication (participants’ engagement with other participants, their community, existing artwork, and audiences), and the context (both by using art to make better sense of their experiences, and/or using art to have an impact on the context). In the chapters of this volume, participants, practitioners, and researchers often describe these interactions in terms associated with the concept of synergy; yet, there are also some experiences of antagonistic results given the nature of this work.

2.1 Partners: Art and Increased Engagement with the Self

A number of chapters in this volume describe health promotion initiatives integrating art at the level of the individual as processes that enabled participants to deeply engage with their own experiences and beliefs. In many cases, participants and authors note synergy by suggesting that the engagement would not have been possible without the unique dynamics created by introducing art-based elements.

Katisi, Jefferies, and Sebako (Chap. 2) describe the combination of drawings, therapy, and group discussions to uncover the young people’s unprocessed trauma surrounding their parent’s deaths, in synergistic terms:

Drawing, as employed in this context, appears to work well when used in conjunction with written and verbal narratives. It appears to achieve what other types of approaches could miss... such as when the children felt unable or unwilling to bring up issues in group or individual sessions but were able to draw them. (Katisi, Jefferies, and Sebako, Chap. 2, p. 34, emphasis added)

The authors argue that the interaction with drawing encouraged the young people to dig deeper into their experiences and emotions, enabling them to uncover more than would have been possible if they were only provided traditional processing tools.

Another example of this deeper engagement with the self is the CuidarNos project in Puerto Rico (Ramírez et al., Chap. 6), which organized workshops employing a number of diverse artistic and sensory experiences to support the processing of personal and vicarious trauma among intimate partner violence (IPV) service providers in the wake of Hurricane Maria:

Participating in Encuentro CuidarNOS gave a space to breathe and unwind at times when it had been difficult to get it out, and maybe I had not allowed that space. Sometimes, trying to follow the hectic pace of everyday life, it becomes difficult for us to take a space to disconnect, recognize ourselves and allow ourselves to feel and let go. Having this space through CuidarNOS was wonderful with an incredible healing power. (Ramírez et al., Chap. 6, p. 97, emphasis added)

This second example highlights the unique space art activities can create—space to “breathe and unwind”…space to “feel and let go.” This space allowed for deeper engagement with the self, described as “recognizing ourselves,” which the participant experienced as healing.

2.2 Communication: Art and Increased Engagement with Others

As art has the potential to deepen connections to one’s experiences and emotions, multiple chapters in this volume demonstrate how arts-based activities can also deepen connections with others by creating a shared experience of new knowledge or by increasing empathy for others’ lived experiences. Again we see the language of synergy used to describe these processes.

Marx and Regan (Chap. 8) describe the connections between participants and the resulting communication tool, a documentary produced during a youth participatory action research (YPAR) project with trans/gender non-conforming (TNGC) youth in the U.S., in the following terms:

In many ways, this project represents a fulfilment of the promise of YPAR and documentary film. It represents a valuable source of data that would otherwise not be available—a rich text that captures TGNC youth’s experiences unmediated, direct from the source. In many respects, this was possibly only because the project was participatory in nature and organized and completed by the youth themselves; their own connection to the material and to the art form enabled the project’s success… The project also afforded students an opportunity to connect more deeply around a shared purpose. (Marx and Regan, Chap. 8, p. 132, emphasis added)

Ruge (Chap. 4), reflecting on a project involving schoolchildren, teachers, and staff in a school-based nutrition initiative in Denmark, describes the complex interactions and collaborations the art projects inspired:

…(T)he combination of teachers’ didactic work with professional art and student creativity supported improved relations and the development of a shared ownership among students. (Ruge, Chap. 4, p. 54, emphasis added)

Art can also deepen connections by providing spaces for people to have fun and create aesthetically pleasing works of art. A participant engaged in creating ceramic tiles for display at a home care center in Scotland explains:

It was SO much fun! Chatting with residents and seeing their creativity! Working with the children, at first everyone was unsure what to do but really everyone put so much in. (Barton, Chap. 5, p. 78)

Arts-based health promotion can create bridges of connection not just among participants within projects but also between groups of people who have marked differences in their understanding and experiences, thus enabling them to gain insight from new perspectives. Leitch (Chap. 17) demonstrates the potential for arts-based initiatives to promote connection and empathy and to provide windows to better understand others, specifically regarding the experience of gender-based violence in Trinidad and Tobago and the importance of preventing such violence:

The task was physically straining. Sawing and lifting heavy pieces of wood, and having my body slowly outlined with chalk, led me to reflect deeply on these Silent Silhouettes. The silence was deafening and emotionally jolting. Constructing these representations of lost lives transcended the physical experience and created a space to contemplate. It felt as though I could feel the pain of my sisters, young and old. I questioned worth and value and love, and what these women and girls must have gone through. Recreating these stories in this way undoubtedly led to a newer and more gravely empathetic outlook on domestic violence. (Leitch, Chap. 17, p. 288, emphasis added).

Similarly, describing the historical use of community theater in Japan, Sandhu, Jimba, Hirose, and Yui (Chap. 7) describe how theater deepens the experience of empathy among people:

…(D)rama is an enduring and powerful intervention for changing people’s mindsets. In particular, drama has unique characteristics whereby the relationship between the audience and the characters creates empathy. Empathy brings us the emotional experiences of the characters on stage as if the action of the play were happening to us. (Sandhu, Jimba, Hirose, and Yui, Chap. 7, p. 116)

2.3 Context: Art for Meaning-Making

The theory of Salutogenesis offers a way of understanding people’s resilience in coping with life’s stressors. One concept that is central to that theory is Sense of Coherence (SoC). SoC refers to an individual’s ability to make sense out of life events and has been associated with increased resilience to stressors (Mittelmark 2017). Art offers a novel medium for contemplating life events, one which leans toward story and sense-making. Some of the initiatives described in this book report on how the process of telling stories through art or using art as a framework for interpreting experiences contributes to participants’ ability to make meaning from their experiences in health-promoting ways.

Zarei (Chap. 3) describes the use of the ancient poetry of Rumi to support Iranian women following divorce. One participant reflected how Rumi’s poetry enabled her to see that there are lessons to be learned and positive actions to take, even in the face of difficult experiences:

Honestly, I was never sure I could stand on my feet again after I got divorced. I had a lot of problems (after the divorce). Now I found that divorce has taught me a lesson. So I would rather accept all outcomes from divorce—loneliness, stigma, and even rejection—because in Rumi’s poems I realized that even a misery is the basis for self-development and growth. (Zarei, Chap. 3, p. 48)

2.4 Antagony: Deep Engagement Can Also Go Awry

Of course, health promotion initiatives that incorporate art do not always have synergistic impacts. Indeed, especially when dealing with sensitive topics and populations, this deeper engagement can trigger negative memories or emotions and might result in antagony. As a result, those using art in this work must attend to preparing for ways to manage these potential negative processes or outcomes. The home care initiative in Scotland discussed how the project resulted in some distressing feelings:

While there was much joy and laughter throughout the project, one resident found that taking part triggered memories that were upsetting. The female resident initially spent a happy, creative two hours during the first workshop; however, when she returned on the second day, she was despondent, lamenting about her lack of inspiration. (Barton, Chap. 5, p. 78)

However, in this case, as family members joined the process, there was an opportunity to repair the distress and build connections:

When a family member arrived later, she was able to put this reaction into context as the resident had, in the past, baked beautiful wedding cakes, and this experience brought back memories as she grieved for her younger self. The resident did, however, return to a later workshop to paint her two tiles—a butterfly for the tree and a bird for her bedroom door. (Barton, Chap. 5, p. 78)

In addition, if participants in arts-based initiatives are encouraged to share their personal experiences and have high hopes of improved conditions, but those in leadership are not willing/able to make substantial changes, the project can produce antagony for both groups in conflict. Thus, leaders of these initiatives and their partners must be realistic about what outcomes can be expected from these projects.

Another consideration, as conveyed in the chapter on art-based conference sessions (Ayele et al., Chap. 20), is that planning, organizing, setting up, and taking down art works and supplies may require more time and flexibility than more traditional health promotion approaches.

Figure 21.2 depicts the relationships described above. The “partners”—which may be the participants, researchers, community members, or other stakeholders—engage in art activities (the production tasks of these initiatives) and connect more deeply with themselves and one another, as indicated by the circular arrow from partners to partners and by the arrow to communication. Art also impacts the context in a bi-directional way by helping participants to make sense of their contextualized experiences and by impacting context through sharing, activism, and wider dissemination. The arrow to synergy indicates the potential for arts-based practices, by increasing these interactions, to contribute more than what the initiative could have achieved without their inclusion. Finally, the dotted line to antagony reminds health promoters of the possibility that such deep engagement or time-consuming processes could produce unintended or negative consequences, especially with unrealistic expectations or unwilling partners.

Fig. 21.2
figure 2

The Bergen Model of Collaborative Functioning (BMCF) depicting dynamic relationships in art initiatives. (Adapted from Corbin et al. (2016). Figure 1. Some modifications were made. https://doi.org/10.1093/heapro/daw061, licensed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/))

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3 Art, Health Promotion, and Social Justice

Above, we described how the chapters in this volume led us to understand art as a way of deepening engagement and increasing synergy in health promotion work. Our second conclusion relates to art’s ability to work toward the health promotion goal of social justice. As referenced in Chap. 1, Bell and Desai (2011) argue that art has a critical role to play in the move towards achieving social justice. Based on the many contributions in this volume, we also propose that art can work to address social injustices when included in health promotion initiatives. There are at least three ways art promotes justice in health promotion initiatives: by amplifying marginalized or silenced voices, by leveraging power, and by honoring multiple ways of knowing in the knowledge production process.

3.1 Art Amplifies Voices for Social Justice

The social processes of oppression work to routinely silence the voices of marginalized people and communities (Spivak 1988) by rendering them nonexistent. Ways of thinking that do not fit into the dominant discourse of Western ways of knowing or colonial narratives are discounted, silenced, and suppressed (Chandanabhumma and Narasimhan 2019; de Sousa Santos 2016; Chilisa 2005). We argue, however, that art has the ability to speak directly to—and can even be used in the fight against—those social processes of oppression.

The Western Australian Indigenous Storybooks project (Stoneham, Davies, and Christopher, Chap. 16) is an art-based activity that provided a medium for Indigenous communities in Western Australia (and elsewhere) to connect, reclaim, and revitalize what had become a negative narrative about Indigenous peoples. The Storybooks project enabled community members themselves to write about positive stories of Aboriginal Australian individual and community life:

The Storybooks provide a forum and opportunity to share these ideas/projects/events that may otherwise go untold or unrecognized... As suggested via evaluation feedback, the Storybooks not only provide an outlet for people’s voices, they also contribute to a sense of pride, ownership, and mental and social well-being. The Storybooks provide authors with the opportunity to tell their stories in their own words and in a manner that is compatible with the traditional yarning process. (Stoneham, Davies, and Christopher, Chap. 16, p. 275)

This project worked to amplify community voice for the greater community. When voices are amplified and directed toward powerful stakeholders, we see it as leveraging.

3.2 Art Leverages Power for Social Justice

Arts-based activities can leverage and/or create an exchange of power in both practice and in research. In the LOMA project in Denmark, schoolchildren had the ability to contribute to organizational thinking about nutrition within their school (Ruge, Chap. 4). Likewise, Marx and Regan (Chap. 8) describe how the participatory methods of arts-based research also can transfer power:

This participatory video may also open space for societal transformation as it offers a way of allowing research subjects to direct the audience’s gaze and control the audience’s understanding of the subjects’ experiences (Kindon 2003). This radical restructuring of the research process not only transfers power to those who may otherwise be powerless within a traditional research paradigm, but it also enables the types of discussions that may give rise to material changes in the lives of TGNC youth. (Marx and Regan, Chap. 8, p. 137)

Photovoice exhibitions can leverage power in a way that language oftentimes cannot. By presenting unflinching visuals, which have been provided by individuals within their own context, photovoice products transcend layers of social stratification. In Chap. 10, Caman describes how photos provided a direct conduit that served to elevate and amplify the stories of displaced Syrian youth in Turkey to policy makers:

Photovoice was often a language bridge for young people, who experienced forced migration from a neighboring country with a different language and a different alphabet… photovoice might also have helped to create a channel for young people to talk about their migration-related traumas or challenges… Photovoice also acted as a bridge to policy makers and other stakeholders, who had the power to create system-level changes. By seeing the photos and reading the quotations, they might have felt something viscerally that moved them, through empathy, to change certain policies and/or practices. (Caman, Chap. 10, p. 175)

While arts-based practice and research methods can amplify and leverage voices, these efforts also provide an important perspective for building our understanding of health promotion when they provide the basis for knowledge production.

3.3 Art Honors Multiple Ways of Knowing to Promote Social Justice in Knowledge Production

A key issue in health promotion work is that interventionsFootnote 1 are often developed outside the communities where they are implemented. This can lead to disconnections between what health promotion professionals think communities need and what they actually need (Chandanabhumma and Narasimhan 2019). Chilisa (2005) argues for the importance of honoring Indigenous worldviews of disease processes as vital to ethical health promotion and painstakingly documents the ways in which HIV-prevention efforts in Botswana failed because of a lack of connection between Northern conceptions of disease and local ways of knowing. An important feature of arts-based interventions is that they often allow for participant expression and multi-way communication of understanding health issues that are usually lacking in “traditional” health education approaches.

Amieva et al. (Chap. 12), reflecting on their work using literary and other arts-based methods, describe how art enables diverse stakeholders to engage in thinking about and contributing to a more robust understanding of Chagas disease:

We are sure that both arts and education, in a broad and inclusive sense, are key elements to shorten the distance between formal and non-formal knowledge and build alternatives that impact and transform reality. For this reason, we promote joint work among researchers, teachers, students, and the community in general at all educational levels (school as well as technical and professional training levels) and in all possible contexts (rural/urban, formal/informal, where there are/are not vector insects, etc.) with the purpose of engaging a greater number and diversity of voices talking about Chagas (Carrillo et al. 2018). (Amieva et al., Chap. 12, p. 213)

Arts-based research methods provide a clear pathway for translating marginalized and/or Indigenous or local knowledge into published scholarship. In the case presented by Madsen et al. (Chap. 11), poetic analysis was used to highlight the absence of stories of recovery from mental health concerns in the Aboriginal communities. This case is an example of using this form of art to work around “culturally toxic stories”:

This term describes the way settler or colonizing stories do harm to Indigenous storytelling practices, culture, and community stories in an ongoing way. A key quote from one of the storytellers and co-researchers that shaped the direction for the research project captures it well: “It’s about the way they tell their stories about us. It’s about the way we then have to tell our stories within their stories. No wonder you go womba (mad/crazy)” (Saunders 2016, p. 16). (Madsen et al., Chap. 11, p. 190)

4 Final Reflections

This volume has provided numerous examples of how arts-based activities have been incorporated into a variety of health promotion initiatives. In Chap. 1 these initiatives are presented in the frame of the five action areas outlined in the Ottawa Charter for Health Promotion. Further, the projects, experiences, and reflections have demonstrated how art supports the key values of health promotion: art is inherently interactive and thus encourages deep engagement and participation; art inspires connection, collaboration, and synergy; art empowers by serving as a conduit and lever to power; and art promotes social justice by honoring multiple ways of knowing and amplifying marginalized and historically silenced voices to counteract hegemony.

In this chapter, using the Bergen Model of Collaborative Functioning (Corbin et al. 2016), we put forward a way – among others – of theorizing how arts-based initiatives might contribute added value to health promotion research and practice. We argue that by increasing engagement within and among participants and with context, these initiatives are able to achieve more. We begin to trace these pathways by aligning the experiences described in this book’s chapters to an existing health promotion model in the hope that other researchers might pick up this line of thinking and use a process model framework to assess and evaluate arts-based initiatives. Much more research is needed to build our understanding of not just if arts-based initiatives produce synergy but how and why. Ultimately, we hope these efforts will build our understanding and knowledge base in a way that both connects with existing theory and also encourages co-creation of knowledge in partnership with communities and their members.

In addition to thinking of art as a way to increase synergy, we also argue that it can contribute to the promotion of social justice and reduce inequities in health. As described in the introductory chapter of this book (Chap. 1), the field of health promotion is fundamentally concerned with social justice. The Declaration of Alma-Ata for universal primary health care was a response to the recognition that good health is not experienced equitably (Corbin 2005). The prerequisites of health (WHO 1986) and later the social determinants of health (CSDH 2008) support our understanding of health inequities and how health is experienced by different communities across a social gradient. What is less often discussed are the historical processes that have led to the experience of this inequity and how we might, as scholars and practitioners, begin to redress these inequities (Spencer et al. 2019).

By incorporating the arts, we do not limit ideas to Northern/Western and other traditional hierarchies of power. Of course, it is essential to be attentive to the inherent risk of falling into a naive position that assumes that just because an initiative has art, then surely it is “healthy,” democratic, and respectful of a diversity of ways of knowing. Indeed, art is difficult to decouple from its colonial significance, which like other knowledge traditions insists on a hegemonic view that the more “Western” an art form, the more legitimate it is— reflexivity, questioning and critical thinking are crucial in any initiative that seeks to incorporate art as a liberatory practice (Chalmers, 2019). In actuality, what imparts these characteristics to an initiative is the theoretical foundation and ideologies upon which it is based, as well as engaged and reflective practitioners/researchers/activists. In other words, the use of art itself does not guarantee social justice; however, if the use of art is taken up with the intention of social justice, a spirit of collaboration, with the leadership of diverse communities and a decolonial perspective (Chandanabhumma and Narasimhan 2019) – much is possible.

Finally, our goal with this book was to produce a collection of arts-based projects that enable other health promoters, artists, researchers, practitioners, and communities around the world to have access to tangible ideas for how to incorporate art into their own work, projects, and everyday life. We hope that you, dear reader, may go forth and put these ideas into action.