The past three years have contributed to an unprecedented climate of instability and uncertainty. This has had a profound impact on the mental health of the global population, with young people being especially hard hit.
Even before the pandemic, more than 45% of young people aged 15 to 19 (Vigo et al., 2016) showed signs of distress and suffering. And adolescents bear the brunt of difficulties and hardship in the context where they live, as confirmed by the ‘Headway, Mental Health Index 2.0’ study conducted by The European House in June 2023. This often leads to anxiety (28%), depression (23%), loneliness (5%), stress (5%), or fear (5%), undermining the ability of these young people to fulfil their potential. Their physical health, social skills, behaviour and financial situation also suffer as a result. Moreover, their performance at school is affected, resulting in some leaving school early or attempting to self-harm or even end their lives.
Developing accessible and scalable interventions to tackle depression and anxiety has become a public health priority (Collins et al., 2011). Despite being a global problem, the issue is even more pressing in the low- and middle-income countries of Sub-Saharan Africa, such as Kenya, where the risk of mental health problems in young people is exacerbated by social and environmental stressors. A 2020 study (Osborn, Venturo-Conerly, Wasil, Schleider, et al., 2020) showed that 46% of Kenyan adolescents attending secondary school suffer from depression, while 38% have anxiety disorders[1].
However, the social and economic context leaves no scope for change: traditional treatments are often out of reach due to systemic and structural barriers, such as limited access to many of the evidence-based therapies (EBTs). These therapies are long, and their roll-out requires dedicated investment. What is more, they need to be delivered by experienced mental health professionals, but there are only 116 psychiatrists and fewer than 500 psychiatric nurses across the whole of Kenya (Marangu, E. et al., 2021). There is a dearth of mental health policies and investments (Mutiso V. et al., 2020; WHO Mental Health Atlas 2020). And mental health problems are highly stigmatised in society, which prevents young people from seeking help. Many of the interventions are adapted from approaches developed in the West, and fail to adequately take into account the socio-cultural context where they are implemented. There is a need for easily scalable, stigma-free tools that do not require the intervention of expert personnel based in the area of implementation (Osborn T. et al., 2022).
The need for scalable, accessible and stigma-free non-drug mental health interventions — that show the potential to significantly reduce depression symptoms — is therefore urgent.
The Pre-Texts protocol: a possible scalable and low-cost solution to address the mental health of young adolescents?
Art and literature can contribute significantly to psychological change, by boosting self-esteem, resilience and self-confidence. Doris Sommer — Professor of Romance Languages and African American Studies at Harvard University — and her team are developing a multicentre protocol across several continents, focusing on creative artistic literacy and aimed at developing critical thinking, with the well-being of adolescents in mind. The program is based on previous research on the effectiveness of cultural interventions in preventing or reducing emotional and behavioural issues among children and adolescents.
The intervention, named Pre-Texts, has been applied to Kibera, a slum with a population of around 300,000 in Nairobi, Kenya. Kibera is one of Africa’s largest slums, where violence and crime are rife, along with severe financial hardship and drug use (Onyango & Tostensen, 2015). This slum is also a hotbed of serious mental health problems. It therefore immediately became a case study. The findings were published recently in The Lancet and ClinicalMedicine 2023.
The Pre-Texts Protocol for learning new skills and developing critical thinking
The protocol invites participants to use simple texts, such as an extract from a novel, a physics lesson or a technical manual, as the raw material — or, in other words, as a pre-text — for making art, experimenting and improvising. This is followed by collective reflection on the interpretation process. The protocol has been adopted by schools at all levels and by a number of cultural centres around the world. It is having a positive impact on the well-being of young people. Make-believe play provides a safe space where literacy, innovation and citizenship education come together, creating a low-cost, high-impact holistic educational program.
In Kibera, the study was funded by the Mind Brain Behavior Initiative (MBB) and by Harvard University's Center for African Studies. The Shamiri Institute and the University of Nairobi were involved in its implementation. After a preliminary workshop held in January 2020, attended by many teachers and a team of recently graduated facilitators aged 18 to 22, the resources were given adequate training on the protocol. This was a randomised controlled trial (RCT) in which the 235 students (53.19% females) involved were randomly divided into groups of around eight people. One arm of the study followed the protocol, while the other performed after-school activities on study skills, as the control group.
What is the Pre-Text protocol?
How does it work? It consists of five simple steps. After an initial icebreaker, the facilitator calls on one person to read a text of any kind (a technical manual, scientific article, poem, or extract from a novel) out loud. While that person reads, the group listens and draws. During the session, the participants ask questions about the text in writing. This is done anonymously. In this phase, each participant acts as an interrogator of the text. This helps them develop critical thinking skills and learn about the role of interpretive reading, discovering that different ideas can be an added value rather than a stumbling block. Each person then selects a question that they would like to answer. A member of the group suggests a creative activity to do together, based on the text (a fashion show, song, recipe, etc.). Following a discussion, the participants have the chance to give free rein to their creativity, both individually and as a group.
They then sit in a circle to reflect for a moment on what they have created, with the opportunity to say one or two sentences about it. Last but not least, the participants search for extracts or texts related to the original text. This encourages meta-cognitive and emotional reflection. Everyone is invited to take part, contributing in this way to the process of interpreting educational materials through creative arts.
The activities for individual groups continued for one week. Questionnaires were provided at the start and end of the program, and a follow-up questionnaire was distributed after one month.
The findings are consistent with recent research on the effectiveness of short interventions delivered by lay providers (Osborn T. et al., 2020; Osborn, Venturo-Conerly, et al., 2021; Venturo-Conerly et al., 2022): the adolescents following the Pre-Texts protocol showed a greater reduction in depression and anxiety symptoms at the last follow-up than the control group.
For more information, additional data relating to this article can be found at the following link: https://doi. org/10.1016/j.eclinm.2023.102288.
Art and culture to reduce anxiety and depression in adolescents
The findings suggest that a short arts-literacy intervention with educational materials in a group setting, implemented as an after-school program, may reduce depression and anxiety symptoms in adolescents in Sub-Saharan Africa.
Pre-Texts is currently being trialled in Pescara, an Italian city that is emerging as a culture-based laboratory for social innovation, thanks to a convergence of intentions and an awareness shared by many stakeholders in the local area, including the university. The training course, which focused on the application of the protocol, was mainly aimed at teachers from higher education institutions and cultural and social workers. Multiple interpretations of the initial text — an extract from The Ignorant Schoolmaster by Jacques Rancière — emerged during the training week. The text was the starting point for countless artistic expressions, including miming, the pairing of pieces of music and works of art with passages from the text, and a fashion show. The participants are now certified facilitators of the protocol and have already started using it in their places of work, gathering positive feedback on the teaching method’s effectiveness and engagement, the mutual discovery between classmates, and group dynamics.
There is a need for interventions that can complement existing EBTs while expanding the help-seeking avenues for young people. Such interventions should rely on simple therapeutic protocols, should be evidence-based, designed to be easily scalable, and delivered in community settings like schools.
Several aspects of the international study still require finalisation (such as the sample size, follow-up period, and cross-cultural integration of tools), and its effectiveness over time needs to be verified with future studies. However, the initial findings have helped pave the way for a new method that unleashes the potential of creative expression to improve well-being and can also be used in less privileged settings with limited resources.
