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Art Research Paper

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The Sociology of Art

The arts and sociology, as Pierre Bourdieu (1980:207) observed, make uneasy bedfellows. It is an unease that pervades American sociology even more than he imagined. We should bear in mind that barely two decades have elapsed since a handful of American Sociological Association members succeeded in convincing a necessary quorum of colleagues to sign the petition required to set up a new Section. The Culture Section’s growth since then must have come as a surprise even to some of those early supporters.

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Culture and the arts have become increasingly visible in sociological publications (Peterson 1976; Becker 1982; Crane 1987; Balfe 1993), disciplinary recognition (Griswold 2000), and professional organizations, both in the United States and elsewhere (Zolberg 1990). But despite the richly textured potential that the arts afford for social science disciplines, it appears that American sociologists continue to devote relatively little attention to them. The success of culture’s reentry as a domain of considerable significance in American sociological investigation provides an opportune moment to reexamine the standing of the arts in what should be the most hospitable field of the discipline. This research paper provides an account of the persistent hesitancy to recognize the arts as central rather than peripheral in the social scientific field even in the face of the extraordinary promise that artistic transformations in the past century would seem to offer. The theme is that despite the increasing prominence of culture in the profession, the standing of the arts in American sociology appears to have changed less than might have been expected. 232

Staging the Sociology of the Arts in America

Less than a half century ago, a survey of the sociology of art would have begun and ended with contentiously worded assertions concerning the relationships of the arts and society. Certainly, many scholars affirmed that in some ways art mirrors society, but at that point consensus would end. Some insisted that art reflects societal production relationships, serving largely as an ideological tool to maintain dominant groups in favorable situations. Deriving from the materialist orientation of Karl Marx, who actually wrote little about the arts, that perspective provides the foundation of Arnold Hauser’s (1951) massive analysis of artistic creativity through the ages, The Social History of Art. Other scholars, with equal certainty, maintained that great art should be treated as part of an autonomous sphere, surmounting material constraints, but in some way reflecting the spirit of its age. Certain versions of reflection analysis see art reaching for higher values, foretelling cultural and societal tendencies. Of the many anti-Marxist variants on this idea, the one elaborated by Pitirim Sorokin (1937), a work that preceded Hauser’s by more than a decade, was nearly as massive.

As divergent as they are in their foundations, these interpretations of the relations of the arts and society aim to unearth hidden postulates of art in relation to broad social structural processes. Whether from the standpoint of Marxist analysis or anti-Marxist idealism, these are universalizing conceptions of art, representing a Western European, hierarchical scheme of cultural classification (Bourdieu 2000:73, 105). Sorokin embraced 2,500 years of civilization; Hauser starts from the even earlier point— prehistoric cave painting—and both ended their analyses with their own artistic contemporaries. Neither passes muster in the face of modern anthropological perspectives, which see art as part of a cultural system, embedded in its cultural context (Geertz 1973). Regardless of the political or intellectual stance of individual scholars today, their ambitions are far more modest. They rarely undertake to encompass such magisterial breadth entailing so speculative an outlook. This does not necessarily result in a narrowing of vision, however, since the types of art that contemporary researchers consider worthy of analysis are far more varied than what their predecessors documented. Neither Hauser nor Sorokin paid much attention to nonWestern civilizations, barely any at all to primitive and folk forms, and, except disparagingly, to commercial art and entertainment (Hauser 1982). Neither considered the absence of women artists a question worthy of scrutiny. Even within the domain of fine art, both shared a largely unexamined but generally unfavorable opinion of avantgarde art. Finally, like most of their more aesthetically oriented peers, although they dealt with changing genres and stylistic modes, they accepted extant categories of art as unproblematic givens, without considering that other creative forms might be valid for inclusion in the aesthetic field (Zolberg 1997). Yet beyond their ambitious reach, what is remarkable about the Hauser and Sorokin studies is that they were truly exceptional, since on the whole social scientists gave short shrift to the subject of art.

On the Sociological Periphery

Early work in sociology of art.

Even though American sociology had its origins in, and continued to look toward European theoretical formulations, aside from literary and aesthetic scholars who sometimes touched ever so lightly on the social contexts or cultural history surrounding the arts, in the first half of the twentieth century, the sociology of art was largely the concern of a few European scholars. A single major work by Max Weber (1958) dealt directly with a specific art form— music—as a case of his theory of cultural rationalization in the West. When Émile Durkheim founded his important publication, Annales, he situated what he termed “aesthetic sociology” within the sociology that he was trying to establish but only under the residual rubric “ divers ” and beyond considering it as part of the “elementary forms of the religious life” of aboriginal society, he himself did no study of it (Zolberg 1990:38). Only Georg Simmel (1968) wrote frequently about the arts, although less as a social scientist than as a literary and art critic, philosopher, or fashionable essayist (Coser 1965).

By the end of World War II, American sociology, along with American science more generally, became the most dynamic and expansive in the world. This growth was a counterpart to the prominence of the United States on the international scene as the champion of Western humanist values during the war, and defender of freedom during the cold war (Guilbaut 1983; Saunders 1999).

American social scientific scholarship, however, hardly acknowledged the arts as a legitimate object of study. This stance had its nearly symmetrical correlative in the opposing and equally intransigent stance on the part of humanistic scholarship, including literature, aesthetics, art theory, musicology, and history of culture, toward what seemed the threat of the social sciences. The increasing preeminence of the exact sciences during and after the war had drawn many social scientists to adopt the presuppositions, techniques, and methodologies of these disciplines, an orientation that cast a shadow over humanistic subjects such as the arts, and qualitative interpretive methods that art calls for. Still, as higher education was expanded, despite official emphasis on the exact sciences, all university studies were made to grow, including the social sciences and the humanities.

A New Moment in Late-20th Century Sociology

Until the post–World War II period, in the United States, the few scholars who did social studies of the arts were emigré scholars, especially members of the Frankfurt School, such as Theodor Adorno ([1962] 1976), who were escaping persecution by totalitarian states. Straddling the intersection of the humanities and social sciences, these exiles often remained marginal to mainstream intellectual life, were treated as outsiders, and saw themselves in that light (Wilson 1964:v). Their marginality was enhanced by the Marxist orientation to which some adhered, combined more generally with their critical views on American sociology’s “scientistic empiricism,” and, in many cases, contempt for what they took to be its intellectual shallowness (Zolberg 1990:72). Most of them deplored the development of “mass society” and its impact on individual autonomy. Their insistence on taking an evaluative position in their social analysis, rejecting what they regarded as a fictive scientific objectivity, reinforced the exclusion they suffered from the academic mainstream of American sociology. Nevertheless, some of them attracted a following of American scholars, intrigued by and sympathetic to their inquiry in the spheres both of high culture and their critique of culture industries. Although the legacy of earlier misgiving persists, in recent times, it has become considerably muted because of changes in both sets of disciplines that have produced convergences in their orientations (Zolberg 1990).

Foundations for a New Social Study of the Arts

Although in many European countries a considerable body of scholarship was devoted to aesthetics, it was only in the post–World War II period that an autonomous field of sociology of art, distinct from philosophy, history, or criticism materialized. This was the case in France, as the sociologists Pierre Bourdieu ([1979] 1984) and Raymonde Moulin ([1967] 1987, 1992) provided important intellectual leadership and the French state gave institutional support. German philosophical, musicological, and art historical scholarship continued to straddle the social domain as successors to the Frankfurt School tradition for whom the arts, both fine and commercial, were foci of critical study. English literary and historical scholarship infused Raymond Williams’s social analysis of what he saw as the hegemonic role of the arts and served to underpin the development of British culture studies. Williams led the way to open up the social study of the arts by introducing popular forms, such as the movies, radio, jazz, and more popular forms. In the United States, students and faculty who considered the university an agent of government policy, especially through its involvement in the Vietnam War, challenged what they suspected were biases of the social sciences.

Simultaneously, in relation to some of the same developments, the art world itself was undergoing transformation. The trend that had begun much earlier, for the center of the international art market to shift from Paris to New York became a reality in the immediate post–World War II period. As happened during World War I, when the arts were challenged by Marcel Duchamp’s gathering of “found objects”—bathroom plumbing, snow shovels, bicycle wheels—and “assisting” them to the status of art by supplying them with titles and signatures by purported artists, in the 1950s the arts “exploded.” Artists introduced new media, broke the barriers separating genres, and challenged conventional hierarchies, routinely wreaking havoc with artistic traditions, including even the historical avant-garde.

The material conditions that encouraged the entry of large numbers of aspiring artists into the avant-garde art world included growing foundation, corporate, and government support for the arts (Crane 1987). Political ideology played an important role in the form of cold war strategy by American advocates of government support for the arts, who successfully argued for creating a hospitable environment for artistic originality to serve as evidence of the creative freedom that was anathema under authoritarian regimes (Guilbaut 1983; Saunders 1999). Besides providing an opportunity structure for artists, indirectly, it opened the path for social scientists interested in culture, whose forays into studies of the arts gained some legitimacy.

On the basis of what had become “normal sociology” of the 1950s and 1960s, it would have been difficult to predict the efflorescence in the sociology of art that was in the offing. Prior to that time, aside from a few articles, no major sociological works had increased the small, pre-1950s bookshelf. An indication of the new trend appeared in the exploratory work, The Arts in Society a reader edited by Robert Wilson (1964), who wrote a number of its essays and solicited additional ones. Justifying his choices by taking as his point of departure the fairly orthodox idea that artists could “often see what is going on in the society or the psyche a good bit earlier than other men do” (p. vi), he was unabashedly “concerned with the products and producers of high culture.” Only a few years later, another collection of essays heralded an “institutional” approach that examines the functions of the arts in meeting human needs and maintaining social stability (Albrecht, Barnett, and Griff 1970). The editors included studies of the relationship of forms and styles to various social institutions; artists’ careers and their interactions in a variety of artistic milieus; distribution and reward systems; the roles of critics, dealers, and the public in recognizing artists and works.

They were generously open to divergent views that encompassed even Marxian analysts. At the same time, however, these essays demonstrated the infancy of the field of sociology of art: of the authors represented, only onefourth were actually sociologists, while the rest were in anthropology, comparative literature, history, art history, or were practicing artists, painters, dancers, writers. The happy result of this omnium gatherum was that Albrecht and his coauthors contributed to the creation of an American field that integrated European approaches and was strongly cross-disciplinary, ranging over the fine arts, classical and contemporary, as well as folk art, music, dance, and literature, and their corresponding institutional grounding.

A Sociological Space for Art: Current Trends

In light of changes within sociology itself, as well as developments exogenous to the discipline, the sociology of art in the third millennium may be characterized by four trends. First, continuing from already tested frameworks, sociologists examine the roles of the institutions and processes that give rise to or constrain the emergence of artworks. Second, they analyze the artistic practice of creators and patterns of appreciation and acquisition of patrons and collectors. Third, they investigate degrees of access for diverse publics to the arts and the role of the arts in status reproduction. Fourth, in a radical shift, some scholars call into question the very nature of the category “Art,” arguing that “art” needs to be understood not as selfevident but as a social construction. The rapid succession of art styles that has characterized nineteenth- and twentieth-century Europe and the United States is taken by some to be emblematic of the innovativeness of modernity but by others as an indication of over-ripeness, cultural decadence, and anomie. For some observers, the entry of commercial art forms into galleries and museums (Cherbo 1997), the newly found respectability of previously denigrated musical forms such as jazz (Adorno 1976), the growing presence of non-Western music, simultaneously in commercial and serious musical domains, are a sign of the West’s decline. Many question whether these genres— new entrants to “Art”—deserve to be so designated (Zolberg 1990).

For sociologists of culture, generally more dispassionate than cultural critics, developments of this kind provide opportunities for research and theorizing that many analysts hope will help to understand the nature of societal transformations more generally. The use and misuse of aesthetic creation in the interest of particular groups or political ends is one of their recurring concerns (Gans 1974, 1999; Goldfarb 1982; Halle 1993). At the same time, the idea of a domain of art free from material purposes outside of itself remains a seemingly unrealizable ideal, both for artists and for publics more generally.

Methodological approaches range from an empiricism that relies on quantitative tools to analyze masses of available data, such as the degree of access to cultural resources (Blau 1988), survey data of art world practices, and audience studies (Gans 1974). Equally empirical, but based on microscopic observation and qualitative analysis of cultural practices, is the ethnography of Howard S. Becker’s (1982) Artworlds. Historical and semiotic perspectives have been imported from literary analysis into the social studies. Even more striking is that the range of works and art forms investigated has burgeoned and includes the commercial domain—culture industry—as well as the more traditional fine arts (Peterson 1997). Increasingly, sociologists, following Gans (1974), recognize that the arts may exclude as well as include. The absence of certain classes of aspiring artists such as women and racial minorities from what were defined as the most distinguishing and distinguished art forms is no longer taken for granted (Bourdieu [1979] 1984).

In its most distinctive manifestation, American sociology of culture has synthesized approaches to the social study of science, religion, and work, under the rubric of the “production of culture” (Peterson 1976). Defining culture in a broadly pragmatic sense that allies it to anthropology, it comprises art, popular culture, science, religion, symbols or, more generally, meanings, Richard Peterson and his associates urged that the questions broached by scholars themselves determine the use of synchronic or diachronic modes according to their appropriateness. Proponents of the production of culture approach consider how cultural products were constituted, accentuating the effects of institutional and structural arrangements, both as facilitators of or impediments to creation. Characteristically, they prefer doing middle-range and microscopic analysis that, they believe, more effectively reveals the impact of laws, culture industry practices, and gatekeepers of the form and content of artworks.

Institutions and Processes

Critics and artists have decried, virtually since their establishment, the role of certain institutions, such as official academies and government agencies or ministries that are supposed to provide support for artistic creation. Following the pioneering sociological study by Harrison White and Cynthia White (1965), among the first to analyze systematically the changing structure of opportunity that the French Academy provided for artists of the French painting world in the nineteenth century, more recently, a study of how academies selected for exclusion was carried out by Gladys Engel Lang and Kurt Lang (1990). Focusing on the revival of etching as an art form in the nineteenth century, they show how keeping out or severely limiting women as students and members by most European academies impeded their entry into the highly regarded world of oil painting. Diverted to other, lesser media, such as etching and watercolor, whose professional organizations were newer and less restrictive, aspiring women artists were able to launch careers and gain a measure of status and recognition.

Research on French art institutions has continued to thrive with the work of Raymonde Moulin on the interplay among art museums, the art market, and government policy in providing official recognition for innovative art (1992). In the United States, a system in which the national government’s support for the arts is far more limited, and even declining, the study of how institutions affect the arts has advanced under the leadership of Paul DiMaggio (1986a, 1986b) and Judith Balfe (1993).

Artistic Practices and Worlds of Art

The most significant contribution to understanding how the arts are constituted was Howard S. Becker’s (1982) Artworlds. By adapting a “sociology of work” approach to study what is customarily viewed as unique creations of individual geniuses, Becker’s premise is that making art is not qualitatively different from engagement in other social activities. Becker argues that far from being an individual act, the making of art needs to be understood as a collective process, in which interactions among participants, of whom the named artist is only one, result in the production of “artworks.” The other participants—support personnel— may range from assistants to servants, to managers or agents, critics, buyers, and organizations. Taking into account the size and complexity of modern societies, Becker does not reduce the arts to a single art world. Instead, he argues that art making is constituted in four principal art worlds, each characterized by a particular style of working, based on its own conventions. Thus, the integrated professional artist is trained according to the conventions of an art form such as music, painting, and dance, within the domain either of high culture or commercial. The Maverick is also trained according to those conventions but refuses to abide by them, preferring to risk isolation and failure to innovate on his own terms. The folk artist works within conventions traditional in his community’s lore. Finally, outside of actual constituted art worlds, the least integrated is the naive artist, untrained in art who follows an internal urging to create works that represent idiosyncratic experiences or ideas about religion, representations of personal remembrances, or even aberrations and madness. Whereas the other art worlds have ties to regular art world institutions or practitioners or make it their business to develop ties to them, naive artists must be “discovered” by others or else remain unknown (Becker 1982).

Art and Its Publics: Status Reproduction and Taste

One of the most misleading adages of all time must be there’s no arguing about taste. In reality, taste is always being argued about. Thorstein Veblen (1934) had been one of the first social scientists to interpret the symbolic meanings of taste in his analysis of leisure class behavior during the Gilded Age. Approximately a half century later, Russell Lynes ([1949] 1980) published his classification of high-, middle-, and low-brow taste preferences, in which artworks and fashion are taken as status markers. On the basis of writings by these and other astute analysts, a number of sociologists have noted that taste, in art, design, and fashion may be a person’s social standing. Far from viewing taste as trivial, purely personal, and difficult to fathom because it is nonrational, sociologists such as Bourdieu contend that taste is social in its formation, symbolic in its expression, and has real social consequences for individuals and social institutions. In his more complex level of analysis, Bourdieu goes beyond the idea of taste as a “right” of consumerism. Instead, his observations of social differences in artistic taste enable him to show linkages among taste, symbolic status, and the mechanisms by which they tend to reproduce existing status hierarchies in society at large from generation to generation. Treating taste as an aspect of the individual’s cultural baggage, a durably structured behavioral orientation whose origin stems from early childhood experience in the family, and schooling, Bourdieu employs a variety of methods, quantitative and ethnographic, to show how taste functions as a form of capital to crystallize inequalities based on economic and social advantages or disadvantages. In this way, taste becomes a badge of social honor or, conversely, of scorn, signaling to influential groups that some are more acceptable than others (Bourdieu [1979] 1984, [1992] 1995).

English sociologists of culture have been pursuing cultural reproduction from a parallel perspective. Although they do not, as a rule, use large surveys of taste, many have analyzed the content and uses of aesthetic culture, both high and popular. Raymond Williams (1981), beginning from a Marxian perspective, and moving between literary or film criticism and academic life, was a major influence on what became the field of Culture Studies. Beyond the simple base-superstructure correspondence of Marxism, in which culture is conceived as merely epiphenomenal to existing production relationships, Williams, Stuart Hall (1980), and Janet Wolff (1984), among many others, conceived of culture as a constitutive practice in the construction of social meanings. They have tried to overcome the prevailing, decontextualized, literary-critical mode of analysis by elucidating the relations between, on the one hand, cultural images, objects, and practices, and on the other, social institutions and processes. Scholars associated with the Birmingham Centre for Contemporary Cultural Studies analyzed many aspects of British youth subcultures, and their relationship to new artistic styles.

It would be disingenuous to suggest that there is complete agreement among sociologists about how taste and status are related, and with what consequences. Whereas Bourdieu attributes expertise in manipulating symbolic capital through complex codes available in the lore of dominant class fractions, many others prefer to emphasize observable changes in social stratification patterns, and the conditions of their expression. One of those who question Bourdieu’s analysis is David Halle (1993), who has studied the collection and display of art inside of people’s homes. His interviews with elite collectors of abstract art reveal that, contrary to Bourdieu’s assumption, collectors have little facility or understanding of the works they own. Indeed, such art is nearly as esoteric for them as for nonelites. Halle finds widespread sharing of taste across status lines, especially noting a nearly universal and, it appears, similar mode of appreciation of the landscape genre. Moreover, although educational level is an important enabler of high culture taste, ethnicity and race play important roles in how people select works for the home, in contrast to their responses to questionnaires administered in public spaces (Halle 1993).

Equally unexpected, in their studies of how musical tastes are related to occupational status, Peterson and Simkus suggest that although classical music continues to be a marker for high status occupational groups, more striking is the great breadth of their preference for a variety of music. Thus, whereas less than a third of respondents occupying prestigious occupations say they like classical music best, a somewhat larger proportion say they prefer country and Western music to grand opera. More “distinguishing” is that high-status individuals participate in more cultural activities and enjoy a wider range of music than do those of lesser status. As Peterson and Simkus put it, they are “omnivores” as opposed to less elite groups, whose range of taste in music is much more limited, and whom they characterize as “univores” (Peterson and Simkus 1993:152–86).

For scholars of Renaissance behavior, the omnivore is strongly reminiscent of the character type emergent with the “civilizing process” to which Norbert Elias (1978) devoted his early figurational analysis. In that period of expanded possibilities for travel in Europe as feudalism declined centralized states and monarchical structures began to form, promising young men (and rare women) from more or less isolated localities were being drawn to centers offering new opportunities. They had to learn to behave differently before a new audience and circles of courtly societies than they had in the familiar traditional worlds they inhabited, where their status (for better or for worse), was secure. Cosmopolitanism and the idea of the Renaissance Man came to mark the ideal of behavior, giving rise to a virtual industry of etiquette books, epic poetry, and other literature by authorities such as Erasmus, Castiglione, Chaucer, Shakespeare (Elias 1978). To be considered a country bumpkin was disastrous for seekers after the Renaissance notion of fame. As Bourdieu points out, these qualities became institutionalized in the development of secondary and higher education from the sixteenth through the twentieth centuries, and remnants of this cultural structure persist despite, as Bourdieu noted, the twentieth century’s valorization of science and technology (Bourdieu [1979] 1984).

But What Is Art?

Finally, whereas in the past scholars investigating the place of the arts in society have taken for granted the categories of art conventionally agreed to by art world participants, in recent times certain sociologists have turned their attention to tracing how art classifications are constructed. Like the sociologist of science, Bruno Latour (1987), who questions the processes by which certain frameworks of analysis, categories, and findings come to be incorporated into the scientific canon, some see even more plausible reasons for interrogating how artistic canons are established. Art is a stake in the arena of competition that pervades much of social life, as Bourdieu contends, not only for artists themselves, but for their supporters, patrons, collectors, dealers, and for the writers and scholars who constitute the art worlds in which they exist. In recent times, under pressure from potential publics, market forces, including collectors, and political action, and in light of the openness of the fine arts to new media, existing cultural institutions, such as art museums, are exhibiting works previously excluded from consideration as Art. Previously, for example, African carvings were largely consigned to ethnological collections; now, their entry into art museums has taken the form of an upward spiral in prestige; art of the “insane” has attained high market value (Anne E. Bowler as cited in Zolberg and Cherbo 1997:11–36); and women artists are gaining a level of recognition that had routinely been denied them (Zolberg and Cherbo 1997:1–8). In the worlds of culture industry as well, new musical forms such as “Rock-n-roll” and Rap have emerged from the interplay of business developments, technological innovations, and enacted statutes in such fields as copyright law, which set the parameters for works to come to public attention (Ennis 1992:5–7).

The seemingly impermeable barrier between high art and popular art that took over a century to construct (Levine 1988) has since been breached countless times, not only in America but in Europe as well (Circle 1993:12). In the past three decades, even the massive wall between commercial art forms and the “disinterested” arts has endured a jolting to the point of crumbling. The entry of Latin American, Asian, and African visual and musical forms and motifs into the Western dominated canon has gained increasing legitimacy and audiences (Zolberg 1997:53–72). Moreover, since any kind of art—fine, popular, commercial—may be disseminated through commercial channels of distribution, adding the interplay of official policy with market forces helps to thicken one’s understanding of processes of democratization.

21st Century Prospects for the Arts in American Sociology

By the beginning of the third millennium, the sociological study of culture and the arts is no longer a stepchild of the serious business of sociologists. If not central, then the arts are at least legitimately scholarly, as opposed to a frivolous subject. This flowering came about despite the traditional anti-aesthetic orientation in American social science and the more general unease between social science and the arts. Still, the position of the arts in the social science disciplines continues to remain tenuous and requires repeatedly renewed justification as an intellectual enterprise. In part, this is due to the fact that the crux of the arts since the Renaissance has been the artist as an individual, a tradition of several centuries that emphasizes the uniqueness of the actor and the work he (rarely, she) created. While the notion of such individual agency is relatively compatible with the discipline of psychology, it is less easily reconciled with the collectivist understanding of behavior by sociology. As noted above, this perception underlies the view of art as a collective process (Becker 1982) and sociologists’ emphasis on the production rather than creation of culture. Retaining or reinserting the individual artist as a creative agent has both ethical importance, since it implies respect for the autonomy of the individual, and intellectual validity in a discipline that could easily reduce art to no more than an outcome of general structures and processes. Thus, whereas culture has become a deeply embedded component of sociology dealing with science, theory, macrohistorical questions, education, religion, ethnicity, to name a few, the place of the traditional fine arts has not grown proportionately.

Two edited books published under the aegis of the ASA Culture Section seem to confirm this observation. Whereas the first, Diana Crane’s (1994) edited collection includes an essay on the arts, the second volume, edited by Elizabeth Long, includes not even one chapter on the fine arts and only one that even approaches this domain (Long 1997). On the other hand, the third and most recent collection of Culture Section sponsored essays suggests that the arts have conquered a new place in the sociological sun (Mark D. Jacobs and Nancy Weiss Hanrahan 2005). The coeditors rehearse the several decades in American social science characterized by “the cultural turn,” the reconceptualization of culture away from the functionalist emphasis on the need for culture to bring about a homogeneous consensus in society. Instead, proponents of the cultural turn sought variations and heterogeneity in the arrival on the public scene of pluralism and tolerance of difference. Rather than require uniformity, the goal is for a more “organic” (as in Durkheim’s formulation) conception to be the basis of social solidarity, not to promote conformity but individual human agency.

The cultural turn had challenged the elite standing of high culture by recognizing the existence of talent and striving among all social groups and the democratization embedded in Pragmatism. For all the attractiveness of openness to different forms, culture was frequently reduced to unending debate on ideology, functionalism, and essentialism versus constructivism. In a break from the past, Jacobs and Hanrahan (2005) put forth a new idea in the field of cultural sociology. They refer to “this newly emerging conception of culture as . . . an aesthetic one, which offers possibilities for intensifying and re-imagining the experience of civic life” (p. 12). From a static or, at the most, slowly changing notion of societal existence, their new approaches emphasize the dynamism of process and human intervention and their impact on existing traditional structures. Beyond these important changes, the new aesthetic conception helps, instead, in the more than two dozen essays by American, Canadian, European, and Asian sociologists, to turn toward normative commitments for the revival of civic discourse in relation to legality and social justice, the politics of recognition, and “the potentialities of ordinary experience” Jacobs and Hanrahan (2005).

Democratization in Diversity

In the context of American idea systems, Peterson’s innovations and the efforts of others associated with the production of culture school are likely to continue to drive research. This approach prepares the way for scholars to enlarge their repertoire of questions and take into account the impact on creation and reception of the arts in light of the enormous changes in the ethnic make up of the American population since the end of World War II. Sources of immigration have been changed decisively by new laws and population movements: Hispanic, Chinese, Indian/Pakistani, Middle Eastern, Russian, peoples of a broad range of educational levels and aspirations. They provide an unprecedented opportunity to investigate the interactions with the varied Anglo-centric cultural choices that have until now been the focus of most studies. Demands for access to elite culture now include not merely “visitors” from modest economic backgrounds, whose entry is far from being attained either in North America or in Europe (Circle 1993:96, 103, 129), but crosscutting socioeconomic distinctions, differences of gender, ethnicity, and race or religion. Each of these may have aesthetic implications that the conflict, as usually expressed— quantity versus quality—does not encompass.

The extraordinary transformation of the international arena in recent years requires that scholarship move more explicitly outside of the American scholarly world and into the wider international realm. This is essential in a world that brings together what had been largely national concerns. As is true of other intellectual fields, the arts are no longer understandable in terms of one society alone since few societies are either homogeneous or sealed off from other geographic, national, or societal units. Thus, whereas it may still be possible to study such issues as arts censorship in the context of a single society, it is more likely that political transformations open the door to new conflicts as global phenomena.

Related to globalization, technological innovations in cyberspace and computer technology militate even more poignantly against retaining the single society as the primary unit of analyses. They not only permit new forms of artistic expression but also enhance attempts to evade control over art content. Providing new avenues for artistic dissemination, they also substitute for direct contact with the storehouses of art, the museum. This suggests that this contextual metamorphosis will set the parameters of the next phase of studies in the sociology of the arts. Cultural sociologists have through theory, example, and practice contributed to the vital and potentially dangerous debates that pervade questions of “identity,” including ethnicity, gender, race, or religion, with strongly political loadings. Pursuing questions of meaning, identity, and value in terms of American society alone is clearly insufficient to understanding social processes and emergent structures. As American sociologists burst the bonds of narrow parochialism and enter the adventurous terrain of global processes, they foster a cosmopolitanism that challenges existing approaches and conceptualizations of the social sciences.

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Article contents

Arts-based research.

• Janinka Greenwood Janinka Greenwood University of Canterbury
• https://doi.org/10.1093/acrefore/9780190264093.013.29
• Published online: 25 February 2019

Arts-based research encompasses a range of research approaches and strategies that utilize one or more of the arts in investigation. Such approaches have evolved from understandings that life and experiences of the world are multifaceted, and that art offers ways of knowing the world that involve sensory perceptions and emotion as well as intellectual responses. Researchers have used arts for various stages of research. It may be to collect or create data, to interpret or analyze it, to present their findings, or some combination of these. Sometimes arts-based research is used to investigate art making or teaching in or through the arts. Sometimes it is used to explore issues in the wider social sciences. The field is a constantly evolving one, and researchers have evolved diverse ways of using the communicative and interpretative tools that processes with the arts allow. These include ways to initially bypass the need for verbal expression, to explore problems in physically embodied as well as discursive ways, to capture and express ambiguities, liminalities, and complexities, to collaborate in the refining of ideas, to transform audience perceptions, and to create surprise and engage audiences emotionally as well as critically. A common feature within the wide range of approaches is that they involve aesthetic responses.

The richness of the opportunities created by the use of arts in conducting and/or reporting research brings accompanying challenges. Among these are the political as well as the epistemological expectations placed on research, the need for audiences of research, and perhaps participants in research, to evolve ways of critically assessing the affect of as well as the information in presentations, the need to develop relevant and useful strategies for peer review of the research as well as the art, and the need to evolve ethical awareness that is consistent with the intentions and power of the arts.

• multisensory
• performance

Introduction

The term arts-based research is an umbrella term that covers an eclectic array of methodological and epistemological approaches. The key elements that unify this diverse body of work are: it is research; and one or more art forms or processes are involved in the doing of the research. How art is involved varies enormously. It has been used as one of several tools to elicit information (Cremin, Mason, & Busher, 2011 ; Gauntlett, 2007 ; Wang & Burns, 1997 ) and for the analysis of data (Boal, 1979 ; Gallagher, 2014 ; Neilson, 2008 ), and so it serves as an enrichment to the palette of tools used in qualitative research. It has been used in the presentation of findings (Bagley & Cancienne, 2002 ; Conrad, 2012 ; Gray & Sinding, 2002 ) and so occupies a space that could be responded to and evaluated as both art and research. It has been used to investigate art and the process of art-making. The emergence of the concept and practice of a/r/tography (Belliveau, 2015 ; Irwin, 2013 ; Springgay, Irwin, & Kind, 2005 ), for example, places art-making and its textual interpretation in a dynamic relationship of inquiry into the purpose, process, and meaning of the making of an artwork.

The field is multifaceted and elusive of definition and encompassing explanation. This article does not attempt such definitions. But it does risk describing some well-trodden pathways through the field and posing some questions. Illustrative examples are offered from the author’s work, as well as citing of works by other researchers who use arts-based approaches.

My own explorations of arts-based research began many years ago, before the term came into usage. I was commissioned to develop a touring play for a New Zealand youth theater, and I chose to write a docudrama, Broadwood: Na wai te reo? (Greenwood, 1995 ). The play reported the case of a remote, rural, and predominantly Maori school that made Maori language a compulsory subject in its curriculum. The parents of one boy argued against the decision, claiming the language held no use for their son. The dispute was aired on national television and was debated in parliament. The minister agreed that the local school board had the right to make the decision after consultation with parents and community. The dispute ended with the boy being given permission to do extra math assignments in the library during Maori language classes. To develop the script, I interviewed all the local participants in the case and sincerely sought to capture the integrity of their views in my dialogue. I accessed the minister of education’s comments through public documents and media and reserved the right to occasionally satirize them. Just a week or two before final production, the family’s lawyer officially asked for a copy of the script. To my relief, it was returned with the comment that the family felt I had captured their views quite accurately. The youth theater was invited to hold its final rehearsal on the local marae (a traditional tribal Maori ground that holds a meeting house and hosts significant community occasions), and a local elder offered the use of an ancestral whalebone weapon in the opening performance, instead of the wooden one made for the production. The opening performance took place in the school itself, and the boy, together with his parents and family friends, sat in the audience together with hundreds of community people. The play had an interactive section where the audience was asked to vote in response to a survey the school had originally sent out to its community. The majority of the audience voted for Maori language to be part of the mandatory curriculum. The boy and his family voted equally emphatically for it not to be. The play then toured in New Zealand and was taken to a festival in Australia.

At the time I saw the work purely in terms of theater—albeit with a strongly critical social function. Looking back, I now see it was a performative case study. I had carefully researched the context and respectfully interviewed participants after gaining their informed consent. The participants had all endorsed my reporting of the data. The findings were disseminated and subject to popular as well as peer review. The performances added an extra dimension to the research: they actively invited audience consideration and debate.

This article discusses the epistemology that underlies arts-based approaches to research, reviews the purposes and value of research that involves the arts, identifies different stages and ways that art may be utilized, and addresses questions that are debated in the field. It does not seek to disentangle all the threads within this approach to research or to review all key theorizations and possibilities in the field. The arena of arts-based research is a diverse and rapidly expanding one, and it is only possible within this discussion to identify some of the common underlying characteristics and potentialities and to offer selected examples. Because this discussion is shaped within an essay format, rather than through a visual or performative collage, there is the risk of marking a limited number of pathways and of making assertions. At the same time, I acknowledge that the discussion might have alternatively been conducted through arts-based media, which might better reflect some of the liminalities and interweaving layers of art-based processes (see further, Greenwood, 2016 ).

The term art itself compasses a wide and diverse spectrum of products and process. This article focuses particularly on dramatic and visual art, while acknowledging that the use of other art forms, such as poetry, fiction, dance, film, and fabric work, have been variously used in processes of investigation. The word art is used to indicate the wider spectrum of art activities and to refer to more specific forms and processes by their disciplines and conventions.

Why Use Art?

One of the main reasons for the growth of arts-based approaches to research is recognition that life experiences are multi-sensory, multifaceted, and related in complex ways to time, space, ideologies, and relationships with others. Traditional approaches to research have been seen by increasing numbers of researchers as predominantly privileging cerebral, verbal, and linearly temporal approaches to knowledge and experience. The use of art in research is one of many shifts in the search for truthful means of investigation and representation. These include, among others, movements toward various forms of narratives (Riessman, 2008 ), recognition of indigenous knowledges, and indigenous ways of sharing and using knowledge (Bharucha, 1993 ; Smith, 2014 ), auto-ethnographies (Ellis, 2004 ), conceptualizations of wicked questions (Rittel & Webber, 1973 ), processes of troubling (Gardiner, 2015 ), and queering (Halperin, 2003 ). Preissle ( 2011 ) writes about the “qualitative tapestry” (p. 689) and identifies historic and contemporary threads of epistemological challenges, methods, and purposes, pointing out the ever-increasing diversity in the field. Denzin and Lincoln ( 2011 ) describe qualitative research as a site of multiple interpretative practices and, citing St. Pierre’s ( 2004 ) argument that we are in a post “post” period, assert that “we are in a new age where messy, uncertain multi-voiced texts, cultural criticism, and new experimental works will become more common, as will more reflexive forms of fieldwork, analysis and intertextual representation” (p. 15). Springgay, Irwin, and Kind ( 2005 ) assert that a/r/tography is not a new branch of qualitative research but a methodology in its own right, and that it conceptualizes inquiry as an embodied encounter through visual and textual experiences. The use of art in research is a succession of approaches to develop methodology that is meaningful and useful.

Art, product, and process allow and even invite art-makers to explore and play with knowing and meaning in ways that are more visceral and interactive than the intellectual and verbal ways that have tended to predominate in Western discourses of knowledge. It invites art viewers to interact with representations in ways that involve their senses, emotions, and ideas. Eisner ( 1998 , 2002 ) makes a number of significant assertions about the relationship between form and knowledge that emphasize the importance of art processes in offering expanded understandings of “what it means to know” (Eisner, 1998 , p. 1). He states: “There are multiple ways in which the world can be known: Artists, writers, and dancers, as well as scientists, have important thongs to tell about the world” (p. 7). Like other constructivists (Bruner, 1990 ; Guba, 1996 ), he further argues that because human knowledge is a constructed form of experience, it is a reflection of mind as well as nature, that knowledge is made, not simply discovered. He then reasons that “the forms through which humans represent their conception of the world have a major influence on what they are able to say about it” (p. 6), and, making particular reference to education, he states that whichever particular forms of representation become acceptable “is as much a political matter as an epistemological one” (p. 7). Eisner’s arguments to extend conceptualizations of knowledge within the field of education have been echoed in the practices of art-based researchers.

Artists themselves understand through their practice that art is way of coming to know the world and of presenting that knowing, emergent and shifting though it may be, to others. Sometimes the process of coming to know takes the form of social analysis. In Guernica , as a well-known example, Picasso scrutinizes and crystallizes the brutal betrayals and waste of war. In Caucasian Chalk Circle , Brecht fractures and strips bare ideas of justice, loyalty, and ownership. Their respective visual and dramatic montages speak in ways that are different from and arguably more potent than discursive descriptions.

In many indigenous cultures, art forms are primary ways of processing and recording communally significant information and signifying relationships. For New Zealand Māori, the meeting house, with its visual images, poetry, song, oratory, and rituals, is the repository library of mythic and genealogical history and of the accumulated legacies of meetings, contested positions, and nuanced consensual decisions. Art within Māori and other indigenous culture is not an illustrative addition to knowledge systems, it is an integral means of meaning making and recording.

One of the characteristics of arts and arts-based research projects is that they engage with aesthetic understandings as well as with discursive explanations. The aesthetic is a contested term (Greenwood, 2011 ; Hamera, 2011 ). However, it is used here to describe the engagement of senses and emotion as well as intellectual processes, and the consequent collation of semiotics and significances that are embedded in cultural awareness and are variously used by art makers and art viewers to respond to works of art. An aesthetic response thus is a visceral as well as rational one. It may be comfortable with ambiguities, and it may elude verbalization.

The processes of art-making demand a commitment to a continuous refinement of skills and awareness. Art-viewers arguably also gain more from an artwork as they acquire the skills and literacies involved with that particular art form and as they gain confidence to engage with the aesthetic. However, viewers may apprehend meaning without mastery of all the relevant literacies. I recall an experience of watching flamenco in El Puerto de Santa Maria, a township outside Cadiz. My senses drank in the white stone of former monastery walls and the darkening sky over an open inner courtyard. My muscles and emotions responded spontaneously to the urgency of the guitar and the beaten rhythms on a packing case drum. My nerves tensed as the singer’s voice cut through the air. The two dancers, both older and dressed in seemingly causal fawn and grey, riveted my attention. I was a stranger to the art form, and I did not know the language of the dance and could not recognize its phases or its allusions. I did feel the visceral tug of emotion across space. My heart and soul responded to something urgent, strangely oppressive, but indefinable that might have an apprehension of what those who understand flamenco call duende . If I was more literate in the art form, I would no doubt have understood a lot more, but the art, performed by those who did know and had mastered its intricacies, communicated an experience of their world to me despite my lack of training. In that evening, I learned more about the experience of life in southern Spain than I had in my earlier pursuit of library books and websites.

Art, thus, is positioned as a powerful tool that calls for ever-refining expertise in its making, but that can communicate, at differing levels, even with those who do not have that expertise. Researchers who use art draw on its rich, and sometimes complex and elusive, epistemological bases to explore and represent aspects of the world. The researchers may themselves be artists; at the least, they need to know enough of an art form to be aware of its potential and how to manipulate it. In some cases intended participants and audiences may also be artists, but often they are not. It is the researcher who creates a framework in which participants join in the art or in which audiences receive it.

Art, Research Purpose, and Research Validity

So far, the argument for the value of art as a way of knowing is multifarious, embodied, and tolerant of ambivalences and ambiguities. Where then are the rigors that are widely held as essential for research? It can be argued that arts-based research, to be considered as research, needs to have explicit research purpose and needs to subject itself to peer critique.

As has been widely noted (Eisner, 1998 ; Leavy, 2017 ; Sullivan, 2010 ), the making of art involves some investigation, both into the process of making and into some aspect of the experiential world. In research, that purpose needs to be overt and explicit. When the purpose is identified, then the choice of methods can be open to critical scrutiny and evaluation. The design of an arts-based research project is shaped, at its core, by similar considerations as other research.

Arts-based research needs to be explicit about what is being investigated. If the objective is not clear, then the result may still be art, but it is hard to call it research. Purpose determines which of the vast array of art strategies and processes will be selected as the research methods. The trustworthiness of any research depends on a number of factors: at the design stage, it depends on a clear alignment between the purpose of the research and the methods selected to carry out the investigation. In arts-based research, as in other research, it is vital that the researcher identifies the relationship between purpose and selected art tools, and offers recipients of the research clear means to evaluate and critique the reliability and usefulness of the answers that come from the research. This is where choices about strategies need to be clearly identified and explained, and both the aims and boundaries of the investigation need to be identified.

This does not imply need for a rigid and static design. Art is an evolving process, and the research design can well be an evolving one, as is the case with participatory action research (Bryndon-Miller, Karl, Maguire, Noffke, & Sabhlok, 2011 ), bricolage (Denzin & Lincoln, 2011 ), and a number of other research approaches. However, the strategic stages and choices of the emergent design donot need to be identified and explained. Nor does it imply that all data or findings need to be fully explicable verbally. One of the reasons for choosing arts-based methods, although not the only one, is to allow the operation of aesthetic and subconscious understandings as well as conscious and verbalized ones. That is part of the epistemological justification for choosing an arts-based approach. The ambivalences and pregnant possibilities that result may be considered valued gains from the choice of research tools, and their presence simply needs to be identified, together with explication of the boundaries of how such ambivalence and possibilities relate to the research question.

Different Kinds of Purpose

The sections of this article examine common and different areas of purpose for which arts-based research is frequently used, arranging them into three clusters and discussing some of the possibilities within each one.

The first, and perhaps largest, cluster of purposes for using arts-based research is to investigate some social (in the broadest sense of the word) issue. Such issues might, for example, include woman’s rights, school absenteeism, gang membership, cross-cultural encounters, classroom relationships, experiences of particular programs, problems in language acquisition. The methodological choices involved in this group of purposes have been repeatedly addressed (e.g., Boal, 1979 ; O’Brien & Donelan, 2008 ; Finley, 2005 ; Leavy, 2017 ; Prosser, 2011 ; Wang & Burns, 1997 ) in discussions of the use of arts-based approaches to the social sciences. The intention for using arts-based tools is to open up different, and hopefully more empowering, options for exploring the specific problem or issue, and for expressing participants’ perspectives in ways that can bypass participants’ discomfort with words or unconscious compliance with dominant discourses, or perhaps to present findings in ways that better reveal their dynamics and complexity than written reports.

Another smaller, but important, cluster of purposes is to research art-making processes or completed art works. For example, a theater director (Smithner, 2010 ) investigates the critical decisions she made in selecting and weaving together separate performance works into a theatrical collage. Or, a researcher (O’Donoghue, 2011 ) investigates how a conceptual artist working with film and video enquires into social, political, and cultural issues and how he shapes his work to provoke viewers to develop specific understandings. These kinds of studies explore the how and why of art-making, focusing on the makers’ intentions, their manipulation of the elements and affordances of their specific art field, and often engage with aesthetic as well as sociocultural dimensions of analysis. Often such studies are presented as narratives or analytic essays, and it is the subject matter of the research that constitutes the arts basis. Sometimes, such studies find expression in new artworks, as is the case in Merita Mita’s film made about the work of painter Ralph Hotere (Mita, 2001 ), which interlays critical analyses, documentation of process, interviews, and pulsating images of the artworks.

The third cluster involves research about teaching, therapy, or community development through one or more of the arts. Here arts are primarily the media of teaching and learning. For example, when drama is the teaching medium, the teacher may facilitate the class by taking a fictional role within the narrative that provokes students to plan, argue, or take action. Students may be prompted to use roles, create improvisations, explore body representations of ideas or conflicts, and explore contentious problems in safely fictitious contexts. Because it examines both work within an art form and changes in learners’ or community members’ understandings of other issues, this cluster overlaps somewhat with the two previous clusters. However, it is also building a body of its own traditions.

One strong tradition is the documentation of process. For example, Burton, Lepp, Morrison, and O’Toole ( 2015 ) report two decades of projects, including Dracon and Cooling Conflict , which have used drama strategies as well as formal theoretical teaching to address conflict and bullying. They have documented the specific strategies used, discussed their theoretical bases, and acknowledged the evidence on which they base their claims about effectiveness of the strategies in building understanding about and reducing bullying. The strategies used involved use of role and improvisation and what the authors call an enhanced form of Boal’s Forum Theatre. Other examples include the Risky Business Project (O’Brien & Donelan, 2008 ), a series of programs involving marginalized youth in dance, drama, music, theater performance, stand-up comedy, circus, puppetry, photography, visual arts, and creative writing; explorations of cross-cultural understandings through drama processes (Greenwood, 2005 ); the teaching of English as a second language in Malaysia through teacher-in-role and other drama processes (Mohd Nawi, 2014 ); working with traditional arts to break down culturally bound ways of seeing the world (Stanley, 2014 ); and the training of a theater-for-development team to use improvisational strategies to address community problems (Okagbue, 2002 ). While the strategies are arts processes and the analysis of their effect addresses aesthetic dimensions of arts as well as cognitive and behavioral ones, the reporting of these projects is primarily within the more traditional verbal and discursive forms of qualitative research.

Sometimes the reporting takes a more dramatic turn. Mullens and Wills ( 2016 ) report and critically analyze Re-storying Disability Through the Arts , an event that sought to create space for dialogue between students, researchers, artists, educators, and practitioners with different involvements or interests in disability arts. They begin their report by re-creating a scene within the workshop that captures some of the tensions evoked, and follow this with a critical commentary on three community-based art practices that engage in a strategy of re-storying disability. They present arts as means to “counter powerful cultural narratives that regulate the lives and bodies of disabled people” (Mullens & Wills, 2016 , p. 5). Barrett ( 2014 ) reports a project, informed by an a/r/tography methodology, which utilized the classroom teaching of the prescribed arts curriculum to allow students to explore evolving understandings of identity and community. Montages of photographs are a central component in the report, as is a series of images that illustrate Barrett’s reflections on her own role within the investigation.

Using Art to Research Social Issues: Collecting Data

Within a social science research project, art processes might be used to collect data, to carry out analysis and interpretation, or to present findings. Perhaps the most common use is to collect data. The process of photovoice (Wang & Burns, 1997 ), for example, gives participants cameras and asks them to capture images that they consider as significant elements of the topic being investigated. Graffiti might be used to prompt absentee students to discuss their perceptions of schooling. Body sculptures, freeze frames, and hot seating are examples of drama strategies that could be used to facilitate reflection and debate about cross-cultural encounters, feelings about hospitalization, experiences of domestic violence, or an array of other topics.

In each case the art produced becomes the basis for further discussion. This process is quite different from historical concepts of art therapy, where the therapist would give expert insight into what a patient’s artwork means; here it is the participants who give the explanation, perhaps independently or perhaps through dialogue with other participants and the researcher. The embodied experience of construction provides a platform and a challenge to talking in ways that are more thoughtful and more honest than through a conventionally structured verbal interview. The talk after making is important, but the art products are not merely precursors to verbal data, they are concrete points of references to which both participants and researchers can refer and can use to prompt further introspection or deconstruction. The process of making, moreover, is one that allows time for reflection and self-editing along the way and so may yield more truthful and complex answers than those that might be given instantly in an interview. Participants who are second language speakers or who lack the vocabulary or theoretical constructs to express complex feelings, reactions, or beliefs can be enabled to use physicalization to create a bridge between what they know or feel wordlessly inside them and an external expression that can be read by others.

The art tools available for such data gathering are as varied as the tools used by artists for making art. They might include drawing, collage, painting, sculpting materials or bodies, singing, orchestration, Lego construction, movement improvisation, creation of texts, photography, graffiti, role creation, and/or spatial positioning.

Art Processes as Tools for Analysis

Art processes can also be used to analyze and interpret data. Within qualitative paradigms, the processes of collecting and interpretation of data often overlap. This is also true of arts-based research. For instance, Greenwood ( 2012 ) reported on a group of experienced Bangladeshi educators who came to New Zealand to complete their Masters. While they were proficient in English, they found colloquial language challenging, struggling often to find words with the right social or emotional connotations at the speed of conversation. In previous discussions, they often looked to each other for translation. A teaching workshop, held as an illustration of arts-based research, addressed the research question: what have been your experiences as international students? A small repertoire of drama strategies, particularly freeze frames with techniques for deconstructing and refining initial offers, short animations, and narrative sequencing were used. These prompted participants to recall and show personal experiences, to critically view and interpret one another’s representations, and to further refine their images to clarify their intended meaning. The participants flung themselves into the challenge with alacrity and flamboyance and created images of eagerness, hope, new relationships, frustration, failed communication, anger, dejection, unexpected learning, and achievement. They also actively articulated ideas as we deconstructed the images and, through debate, co-constructed interpretations of what was being shown in the work and what it meant in terms of their experience, individual and shared, of overseas study. The interweaving of making, reflection, discussion, and further refinement is intrinsic to process drama; as a research method, it affords a means of interweaving data collection and collaborative analysis. In this case the participants also debated aspects of the validity of the process as research, raising questions about subjectivity in interpretation, about the nature of crystallization (Richardson, 1994 ), about informed consent, and about co-construction of narratives. Analysis shifted from being the task of an outsider researcher to one carried out, incrementally and experimentally, by insider participants. While the researcher held the initial power to focus the work, participants’ physical entry into the work, and their interrogation of the images that were created constituted a choice of how much they would share and contribute, and so they became active and sometimes playful partners in the research. This approach to analysis shares many features with participatory action research (Brydon-Miller et al., 2011 ), both in eliciting the agency of participants and in evolving a process of analysis that is interwoven with the gathering of data from preceding action and with the planning of further investigative cycles of action.

The work of Boal is perhaps one of the best known examples of the use of an art process, in this case theater, as a means of analysis of data. Boal’s Theatre of the Oppressed ( 1979 ) details a series of strategies for deconstruction and collaborative analysis. For example, in the process he calls image theatre , participants select a local oppressive problem that they seek to resolve. They create and discuss images that exemplify experience of the problem and their idealized solutions (the data); they then analyze their images to find where power resides and how it is supported. Boal’s theater process calls for experimentation with further images that explore scenarios where power could become shared to some extent and could allow further action by those who experience the oppression. The process finishes with consequential explorations of the first step to be taken by participants as a means to work toward an equilibrium of power. Boal, as the title of his book, Theatre of the Oppressed , acknowledges, draws on the work of his Braziailan compatriot, Freire, and particularly on his concept of conscientization (Freire, 1970 , 1972 ). Boal’s process for analyzing experiences of oppression is not so much a direct action plan as a means of analyzing the mechanisms of specific conditions of oppression and the potential, however limited, for agency to resolve the oppression. The sequenced strategies of creating and discussing alternative images of oppression, power relationships, and action enable participants to deconstruct the socio-cultural reality that shapes their lives and to gain awareness of their capacity to transform it.

Art as a Means to Present Findings

There is a large and growing body of research that presents findings in arts forms. A few examples are briefly discussed.

After collecting data, through interviews and official communications from participants in a case where a district school was being threatened with closure, Owen ( 2009 ) commissioned a composer to write a score for sections of his transcripts and create a community opera. He expressed the hope that this would “transform their tiny stories into noisy histories” (p. 3). Part of the data was sung at a conference I attended. I was struck by the shift in power. What I might have regarded as dull data in a PowerPoint presentation now became a compelling articulation of experiences and aspirations and a dynamic debate between personal lives and authoritarian policy.

The AIDS Memorial Quilt project (Morris, 2011 ; Yardlie & Langley, 1995 ) is frequently described as the world’s greatest piece of community folk art. A claim can be made that, while each panel in the quilt is a product of folk art, the collation of the quilt in its enormity is a work of conceptual art that juxtaposes the fragility and isolation of individual loss with the overwhelming global impact of the AIDS epidemic. The quilt can also be seen as research that visually quantifies the death toll through AIDS in Western world communities and that qualitatively investigates the life stories and values of those who died through the perceptions of those who loved them.

A number of museums throughout the world present visual and kinaesthetic accounts of social and historical research. Well-known examples are the Migration Museum in Melbourne, the Apartheid Museum in Johannesburg, and the Documentation Center for the History of National Socialism in Munich. A less securely established exhibition is that of images of the Australian Aboriginal Stolen Generation that was collected by the Dumbartung Aboriginal Corporation to educate community and schoolchildren, “but only had the funding to showcase the exhibit for one night” (Diss, 2017 ). These and many other exhibitions create visual and experiential environments where the data of history can be not only seen and read but also felt.

In a similar way to how these exhibitions use actual archival photographs, theater may use the exact words of interviews to re-tell real stories. In making Verbatim , Brandt and Harcourt ( 1994 ) collated the words from 30 interviews with convicted murderers, their families, and the families of murder victims. “We went into the prisons to find out what the story was that we were going to tell, and that was the story that emerged from the material we collected,” Harcourt explained (White, 2013 ). “Not only the content, but also the form emerged from that context. We didn’t go in having decided we were going to make a solo show. Form emerged from the experience of the prison system.”

A frequently used form is that of ethnodrama (Mienczakowski, 1995 ; Saldaña, 2008 ). Ethnodrama presents data in a theatrical form: using stage, role, and sometimes lighting and music. Saldaña ( 2008 ) explains that ethnodrama maintains “close allegiance to the lived experiences of real people while presenting their voices through an artistic medium” (p. 3) and argues that the goals are not only aesthetic, they also possess emancipatory potential for motivating social change within participants and audiences.

Sometimes the ethnographic material is further manipulated in the presentation process. Conrad ( 2012 ) describes her research into the Native program at the Alberta youth corrections center in play form as “an ethnographic re-presentation of the research—a creative expression of the research findings” (p. xii). Her play jumps through time, creating fragments of action, and is interspersed by video scenes that provide alternative endings that could result from choices made by the characters. Conrad explains her choice of medium: “Performance has the potential to reach audiences in ways beyond intellectual understanding, through engaging other ways of knowing that are empathetic, emotional, experiential, and embodied, with the potential for radically re-envisioning social relations” (p. xiii).

Belliveau ( 2015 ) created a performative research about his work in teaching Shakespeare’s Much Ado About Nothing in an elementary school. He interwove excerpts of students’ performances from the Shakespearean text with excerpts of their discussions about the issues of power, pride, love, and other themes in a new performance work that illustrated as well as explained primary students’ response to Shakespeare. He later presented a keynote at the IDEA (International Drama in Education Association) conference in Paris where he performed his discussion of this and other work with young students. Similarly, Lutton’s ( 2016 ) doctoral research explored the work and challenges of selected international drama educators using imagination and role play. In her final performance of her research, she took the role of an archivist’s assistant at a fictitious Museum of Educational Drama and Applied Theatre to provide “an opportunity for drama practitioners to use their skills and knowledge of drama pedagogy to tell their own stories” (Lutton, p. 36). She states that her choice of research tool embraces theatricality, enabling the embodiment of participants’ stories, the incorporation of critical reflection and of aesthetic knowledge (p. 36).

The Cheviot, the Stag, and the Black Black Oil , developed by John McGrath and the 7:84 Theatre Company, recounts the history of economic exploitation of the Scottish people, from the evictions that followed the clearances for the farming of Cheviot sheep, through the development of Highland stag hunts, to the capitalist domination of resources in the 1970s oil boom. Within a traditional ceilidh form it tells stories, presents arguments, and uses caricature, satire, and parody. The play is the result of research and of critical analysis of movements of power and economic interests. It is also a very effective instrument of political persuasion: McGrath gives the dispossessed crofters a language that tugs at our empathy whereas that of the landlords provokes our antagonism. Is this polemics or simple historic truth? Does the dramatic impact of the play unreasonably capture our intellects? And if the facts that are presented are validated by other accounts of history does it matter if it does? What is, what should be, what can be the relationship between research and the evocation, even manipulation of emotions?

Emotion—and Its Power

In as much as arts offer different ways of knowing the world, their use at various stages of research has the power to influence both what we come to know and how we know it. Art tools, strategically used, allow access to emotions and visceral responses as well as to conscious ideas. That makes them powerful for eliciting information. It also makes them powerful in influencing audiences.

The photos of the brutality of the police and of the steadfastness of the activists in the Apartheid Museum in Johannesburg are examples of powerfully influencing as well as informing data. As well as the events that are recorded, the faces and the bodies speak through the photos. Their exhibition in blown-up size at eye level together with film footage and artifacts create a compellingly powerful response in viewers. Like many others, I came out of the museum emotionally drained and confirmed, even strengthened, in my ideological beliefs. The power of the exhibition had first sharpened and then consolidated my understandings. Was this because of the power of the facts presented in the exhibition, or was it because of the power of their presentation ? Or was it both? When the issue presented is one like apartheid, I am not afraid of having my awareness influenced in multiple ways: I believe I already have an evidence-informed position on the subject. I also applaud the power of the exhibition to inform and convince those who might not yet have reached a position. But what if the issue was a different one? Perhaps one which I was more uncertain about? Might it then seem that the emotional power of the exhibition gave undue weight to the evidence?

The issue here is not a simple one. The presentation is not only the reporting of findings: it is also art. The researcher (in the artist) stays true to the data; the artist (in the researcher) arranges data for effect and affect. Conrad explicitly states her hope that her choice of presentation mode will add impact to her research findings: she wants the presentation of her research about youth in detention centers to engender more empathetic understandings of their experiences and lead, in turn, to more constructive attitudes toward their needs. By putting their words to music, Owen wants his audience to listen more attentively to opinions of the stakeholders in the schools threatened with closure. McGrath wants his audience to side with those dispossessed by the combined power of capital and law. The Dumbartung Aboriginal Corporation plans to emotionally move as well as to inform its community. In writing Broadwood , I meticulously presented both sides of the dispute, I deliberately placed music and metaphor at the service of Maori language, and I deliberately used the spatial suggestiveness of the stage to evoke possibilities in the ending. The boy is alone in the library while his classmates are on the marae listening to an elder explain the history of their meetinghouse. The elder gives them an ancient whalebone weapon to hold, the students pass it among themselves, then hold it out across space to the boy. The boy stands, takes half a cautious step toward them and then stops; the lights go down. I intended the audience to complete the action in their subconscious.

In each of these cases, the art form of the presentation allows the artist/researcher to manipulate affect as well as critical cognition. To my mind, this is not simply another iteration of the argument between subjectivity and objectivity in research. Many contemporary approaches to research openly recognize that knowledge is mediated by context, experience, and social and historical discourses as well as by individuals’ personal interpretation (Denzin & Lincoln, 2011 ; Ellis, 2004 ). It is shaped by what is left out as well as by what is included. The practice of careful and scrupulous reflexivity is a way of acknowledging and bounding the subjectivity of the researcher (Altheide & Johnson, 2011 ; Ellingson, 2011 ). The researcher-who-is-artist draws on a subconscious as well as a conscious sense of how things fit together, and constructs meaning subconsciously as well as consciously, manipulating affect and effect in the process. Perhaps all researchers do so to some extent. For instance, the deliberately invisible authors of much quantitative research, who allow the passive voice to carry much of the reporting, who triangulate and define limitation, create an effect of fair-minded and dependable authority. The affect is not necessarily misleading, and it is something that readers of research have learned to recognize. However, the researcher-who-is-artist can draw on the rich repertoire of an art field that already operates in the domain of the aesthetic as well as of the critically cognitive, in spaces that are liminal as well those that are defined. It is arguable that readers of research still need to recognize and navigate through those spaces. Arguably, the challenge exists not only in the field of research: it is present in all the media that surrounds our daily lives.

A/r/tography and Examination of Places Between

The challenge of exploring liminal spaces of intention, process, explanation, effect, and affect is seriously taken up by the emergent discipline of a/r/tography . The backslashes in the term speak of fracture; they also denote the combined authorial roles of artist, researcher, and teacher. Springgay, Irwin, and Kind ( 2005 ) explain that a/r/tography is deliberately introspective and does not seek conclusions: rather it plays with connections between art and text and seeks to capture the embodied experience of exploring self and the world. Irwin et al. ( 2006 ) state: “Together, the arts and education complement, resist, and echo one another through rhizomatic relations of living inquiry” (p. 70). A/r/tography is explicitly positioned as a practice-based and living inquiry: it explores but resists attempting to define the spaces between artist, teacher, and researcher, and so implicitly rejects boundaries between these roles. It conceptualizes inquiry as a continuing experiential process of encounter between ideas, art media, context, meaning, and evolving representations. At the same time as it blurs distinctions, it teases out interrelationships: it offers art inquiry as something that is purposeful but unfixed, and art knowing as something that is personally and socially useful, but at best only partially and temporarily describable, never definable. This is one reason why its proponents explain it as a substantively different and new methodology outside the existing frameworks of qualitative research.

A/r/tography emerged out of the field of art education, with the explicit aim to extend the opportunities afforded by education in the arts, and to develop means to record and report the complex facets of learning and teaching in the arts. Consequently its language may be experienced, by readers who are outside the discipline, as highly abstract, deliberately ambiguous, and even esoteric: it seems to speak, as many research disciplines do, primarily to others in its own field. However, its broad principles have been picked up, and perhaps adapted, by practitioners who seek to explore the processes of their students’ learning through the arts and the evolving understandings they develop. For instance, Barrett and Greenwood ( 2013 ) report exploration of the epistemological third space through which place-conscious education and visual arts pedagogy can be interwoven and through which students, many of whom do not aspire to become artists, can use art-making to re-imagine and re-mark their understandings of their physical and social context and of their relationship with community. The value of this kind of research is posed in terms of the insights it affords rather than its capacity for presenting authoritative conclusions.

A Conference Debate, and the Politics of Research

Whether the provision of insights is enough to make art-making into research is a question that is frequently and sometimes fiercely contested. One such debate took place at a European conference I recently attended. It occurred in an arts-based research stream, and it began with the presentation of two films. The films were relatively short, and a discussion followed and became increasingly heated. Personally, I liked the films. The first reported a dance process that became an undergraduate teaching text. The second, in layers of imagery and fragments of dialogue, explored the practice of two artists. However, I was not sure what the added value was in calling either research. I saw art responding to art, and that seemed valuable and interesting enough. Why was the construct of research being privileged? The filmmakers defended the claim to research on the grounds that there was inquiry, on the grounds that art spoke in languages that were best discussed through art, and on the grounds that research was privileged in their institutions. Then a respected professor of fine arts put forward more direct criticism. Research, he argued, needed to make explicit the decisions that were made in identifying and reporting findings so that these would be accessible for peer review. Neither film, he said, did so. Defenses from the audience were heated. Then another senior art educator argued that art itself could not just be self-referential: it had to open a space for others to enter. The debate continued in corridors long after the session ended.

That the criticisms were unrelenting seemed an indication of how much was at stake. The space held by arts-based research within the European academic congregation is still somewhat fragile. The arts-based network was formed because of advocates’ passionate belief in the extended possibilities that arts-based methods offer, and this year again it expressed its eagerness to receive contributions in film and other art media as well as PowerPoint and verbal presentations. However, the network also saw itself as a custodian of rigor.

The participants in the session re-performed an argument that lingers at the edges of arts-based research. At the far ends of the spectrum, art and research are readily recognizable, and when art is borrowed as a tool in research, the epistemological and methodological assumptions are explicable. But the ground is more slippery when art and research intersect more deeply. When is the inquiry embedded within art, and when does it become research? Is it useful to attempt demarcations? What is lost from art or from research if demarcations are not attempted? The questions, as well as possible answers, are, as Eisner suggested, political as well as philosophical and methodological.

The doing of research and its publication have become big academic business. Universities around the world are required to report their academics’ research outputs to gain funding. My university, for example, is subject to a six-yearly round of assessment of research performance, based primarily on published and on funded research outputs. Each academic’s outputs are categorized and ranked, and the university itself is ranked and funded, in comparison with the other universities in the country. There is pressure on each academic to maximize research publications, even at the cost, it often seems, of other important academic activities, such as teaching. The competitive means of ranking also increases contestations about what is real research, serving both as a stimulus for positioning differing forms of inquiry as research and as a guarded gateway that permits some entries and denies others. Politicians and policymakers, in their turn, favor and fund research that can provide them with quotable numbers or clear-cut conclusions. Arts-based research still battles for a place within this politico-academic ground, although there appears to be growing acceptance of the use of art tools as means to elicit data.

Site for Possibilities—and Questions

The politics of research do matter, but for researchers who are committed to doing useful research, there are other factors to consider when choosing research approaches. These include the potentialities of the tools, the matter that is to be investigated, and the skills and practice preferences of the researcher.

The emergence and development of processes of arts-based research are grounded in belief that there are many ways of knowing oneself and the world, and these include emotions and intuitive perceptions as well as intellectual cognition. The epistemology of arts-based research is based on understandings that color, space, sound, movement, facial expression, vocal tone, and metaphor are as important in expressing and understanding knowledge as the lexical meanings of words. It is based on understandings that symbols, signs, and patterns are powerful means of communication, and that they are culturally and contextually shaped and interpreted. Arts-based research processes tolerate, even sometimes celebrate, ambiguity and ambivalence. They may also afford license to manipulate emotions to evoke empathy or direct social action.

The use of arts-based processes for eliciting participants’ responses considerably increases researchers’ repertoire for engaging participants and for providing them with means of expression that allow them to access feelings and perceptions that they might not initially be able to put into words as well as giving them time and strategies for considering their responses. The use of arts-based processes for analysis and representation allow opportunities for multidimensional, sensory, and often communal explorations of the meaning of what has been researched. It also presents new challenges to receivers of research who need to navigate their way not only through the overt ambiguities and subjective expression, but also through the invisible layers of affect that are embedded in art processes.

The challenges signal continuing areas of discussion, and perhaps work, for both arts-based researchers and for the wider research community. Does the use of art in representation of research findings move beyond the scope of critical peer review? Or do we rather need to develop new languages and strategies for such review? Do we need critical and recursive debate about when art becomes research and when it does not? Are the ambiguities and cognitive persuasions that are inherent in arts-based representations simply other, and useful, epistemological stances? Does the concept of research lose its meaning if it is stretched too far? Does art, which already has a useful role in interpreting and even shaping society, need to carve out its position as research? Does the entry of arts-based research into the arena of research call for revisions to the way we consider ethics? How do the procedures of institutional ethics committees need to be adapted to accommodate the engagement of the human body as well as the emergent design and ambiguities of the arts-based research processes? What are the more complex responsibilities of arts-based researchers toward their participants, particularly in terms of cultural protocols, reciprocity of gains, and the manipulation of emotions and cognition through visually or dramatically powerful presentations?

The already existing and expanding contribution of arts-based researchers argues vigorously for the place of arts processes in our congregations of research discussion and production. Quite simply, the arts address aspects of being human that are not sufficiently addressed by other methodologies. They are needed in our repertoire of tools for understanding people and the world. However, like other research approaches, they bring new challenges that need to be recognized and debated.

Further Reading

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This research seeks to understand the contemporary artistic labour of painting in a ‘post-aesthetic’ view, in which artistic knowledge is seen as socially situated, embodied, and emergent; existing in processes rather than artefacts. This has implications for understanding the ‘work’ of painting. Debates on artistic subjectivity and creative work ignore skilled and cognitive processes of labour (Taylor, 2011). An exception is Roberts (2007) who proposes that artistic subjectivity has become ‘decentred’, distributed across people, skills and tools. However, his labour theory does not address painting in any depth. My research explores decentred artistic subjectivity from within painting. Using a practice-led method, it explores how painting can evolve a practice in line with new norms around ‘spectatorship’, and asks how we might understand this labour. Painter-researchers have done much to understand artistic subjectivity as distributed across bodies and materials, but lack focus on ‘social’ conditions of practice. My research brings this social focus, employing a framework of ‘ecological cognition’ to develop a theory and practice of painting as emergent knowledge that unfolds in relationships between bodies, materials, the ‘social’, and the environment. It tests a new practice-led perspective for understanding creative work, exploring cognitive processes of contemporary artistic labour. It brings a ‘social’ perspective to understanding the work of artist and audience in painting as research. It develops a post-Cartesian understanding of ‘making-as-thinking’ that involves body and material interactions, rhythm and gesture. It considers the embodiment of social structures in artefacts and individual habitual practices, examining cognition as a ‘social’ process. It suggests that ‘co-responsibility’ (Bolt, 2007) encompasses artist, audience, and artefacts in meaning-making. It contributes a practical framework for sharing artwork and proposes that ‘creative labour’ (Gulli, 2005) can be a shared art of inquiry that is not just a way of knowing; it reveals social ‘being’.

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• Published: 13 September 2024

A qualitative study on reasons for women’s loss and resumption of Option B plus care in Ethiopia

• Wolde Facha   ORCID: orcid.org/0000-0002-7463-524X 1 ,
• Takele Tadesse 1 ,
• Eskinder Wolka 1 &
• Ayalew Astatkie 2  

Scientific Reports volume  14 , Article number:  21440 ( 2024 ) Cite this article

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Loss to follow-up (LTFU) from Option B plus, a lifelong antiretroviral therapy (ART) for pregnant women living with human immunodeficiency virus (HIV), irrespective of their clinical stage and CD4 count, threatens the elimination of vertical transmission of the virus from mothers to their infants. However, evidence on reasons for LTFU and resumption after LTFU to Option B plus care among women has been limited in Ethiopia. Therefore, this study explored why women were LTFU from the service and what made them resume or refuse resumption after LTFU in Ethiopia. An exploratory, descriptive qualitative study using 46 in-depth interviews was employed among purposely selected women who were lost from Option B plus care or resumed care after LTFU, health care providers, and mother support group (MSG) members working in the prevention of mother-to-child transmission unit. A thematic analysis using an inductive approach was used to analyze the data and build subthemes and themes. Open Code Version 4.03 software assists in data management, from open coding to developing themes and sub-themes. We found that low socioeconomic status, poor relationship with husband and/or family, lack of support from partners, family members, or government, HIV-related stigma, and discrimination, lack of awareness on HIV treatment and perceived drug side effects, religious belief, shortage of drug supply, inadequate service access, and fear of confidentiality breach by healthcare workers were major reasons for LTFU. Healthcare workers' dedication to tracing lost women, partner encouragement, and feeling sick prompted women to resume care after LTFU. This study highlighted financial burdens, partner violence, and societal and health service-related factors discouraged compliance to retention among women in Option B plus care in Ethiopia. Women's empowerment and partner engagement were of vital importance to retain them in care and eliminate vertical transmission of the virus among infants born to HIV-positive women.

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Introduction.

Lost to follow-up is a major challenge in the prevention of mother-to-child transmission (PMTCT) of HIV among HIV-exposed infants (HEI). Globally, about 1.5 million children under 15 years old were living with HIV, and 130,000 acquired the virus in 2022 1 . In the African region, an estimated 1.3 million children aged 0–14 were living with HIV at the end of 2022, and 109,000 children were newly infected 2 . Five out of six paediatric HIV infections occurred in sub-Saharan Africa in 2022 3 . Most of these infections are due to mother-to-child transmission (MTCT), accounting for around 90% of all new infections 4 , 5 . Without any intervention, between 15 and 45 percent of infants born to HIV-positive mothers are likely to acquire the virus from their mothers, with half dying before their second birthday without treatment 3 . Almost 70% of new HIV infections were due to mothers not receiving ART or dropping off during pregnancy or breastfeeding 3 .

In Ethiopia, the burden of MTCT of HIV is high, with a pooled prevalence ranging from 5.6% to 11.4% 6 , 7 , 8 , 9 , 10 . Ethiopia adopted the 2013 World Health Organization’s Option B plus recommendations as the preferred strategy for the PMTCT of HIV in 2013 11 , 12 , 13 , 14 . Accordingly, a combination of triple antiretroviral (ARV) drugs was provided for all HIV-infected pregnant and/or breastfeeding women, irrespective of their CD4 count and World Health Organization (WHO) clinical staging 11 , 13 . Besides, the drug type was switched from an EFV-based to a DTG-based regimen to enhance maternal life quality and decrease LTFU from Option B plus care 11 , 15 . The Efavirenz-based regimen consists of Tenofovir (TDF), Lamivudine (3TC), and Efavirenz (EFV), while the DTG-based regimen consists of TDF, 3TC, and DTG 13 , 15 , 16 . The change in regimen was due to better tolerability and rapid viral suppression, thereby retaining women in care and achieving MTCT of HIV targets 17 , 18 .

The trend of women accessing ART for PMTCT services increases, and new HIV infections decrease over time 3 , 19 , 20 . However, the effectiveness of Option B plus depends not only on service coverage but also on drug adherence and retention in care 4 , 15 , 21 . In this regard, quantitative studies conducted in Ethiopia showed that the prevalence of LTFU from Option B plus ranged from 4.2% to 18.2% 22 , 23 , 24 . Besides, the overall incidence of LTFU ranged from 9 to 9.4 per 1000 person-months of observation 25 , 26 , which is a challenge for the success of the program.

Qualitative studies also revealed that the main reasons for LTFU among women were maternal educational status, drug side effects, lack of partner and family support, lack of HIV status disclosure, poverty, discordant HIV test results, religious belief, stigma, and discrimination, long distance to the health facility, and history of poor adherence to ART 27 , 28 , 29 , 30 , 31 , 32 . Reasons for resumption to care were a decline in health status, a desire to have an uninfected child, and support from others 30 , 33 . Unless the above risk factors for LTFU are managed, the national plan to eliminate the MTCT of HIV by 2025 will not be achieved 34 .

Currently, because of its fewer side effects and better tolerability, a Dolutegravir (DTG)-based regimen is given as a preferred first-line regimen to pregnant and/or breastfeeding women to reduce the risk of LTFU 13 , 16 . The goal is to reduce new HIV transmissions and achieve Sustainable Development Goal (SDG) 3.3 of ending Acquired Immunodeficiency Syndrome (AIDS) as a public health threat by 2030 35 , 36 , 37 . As mentioned above, there is rich information on the prevalence and risk factors of LTFU among women on Option B plus care before the DTG-based regimen was implemented. Besides, the previous qualitative studies addressed the reasons for LTFU from providers’ and/or women’s perspectives rather than including mother support group (MSG) members. However, there was a lack of evidence that explored the reasons for LTFU and resumption of care after LTFU from the perspectives of MSG members, lost women, and healthcare workers (HCWs) providing care to women. Therefore, this study aimed to explore the reasons why women LTFU and resumed Option B plus care after the implementation of a DTG-based regimen in Ethiopia.

Materials and methods

Study design and setting.

An exploratory, descriptive qualitative study 38 was conducted between June and October 2023. This study was conducted in two regions of Ethiopia: Central Ethiopia and South Ethiopia. These neighbouring regions were formed on August 19, 2023, after the disintegration of the Southern Nations, Nationalities, and Peoples' Region after a successful referendum 39 . The authors included these nearby regions to get an adequate sample size and cover a wider geographic area. In these regions, 140 health facilities (49 hospitals and 91 health centers) provided PMTCT and ART services to 28,885 patients at the time of the study, of whom 1,236 were pregnant or breastfeeding women (675 in South Ethiopia and 561 in Central Ethiopia).

Participants and data collection

Study participants were women who were lost from PMTCT care or resumed PMTCT care after LTFU, MSG members, and HCWs provided PMTCT care. Mother support group members were HIV-positive women working in the PMTCT unit to share experiences and provide counselling services on breastfeeding, retention, and adherence, and to trace women when they lost Option B plus care 11 , 40 . Healthcare workers were nurses or midwives working in the PMTCT unit to deliver services to women enrolled in Option B plus care.

Purposive criterion sampling was employed to select study participants from twenty-one facilities (nine health centers and twelve hospitals) providing PMTCT service. A total of 46 participants were included in the study. The interview included 15 women (eleven lost and four resumed care after LTFU), 14 providers, and 17 MSG members. Healthcare workers and MSG members were chosen based on the length of time they spent engaging with women on Option B plus care; the higher the work experience, the more they were selected to get adequate information about the study participants. Including the study participants in each group continued until data saturation.

The principal investigator, with the help of HCWs and MSG members, identified lost women from the PMTCT registration books and appointment cards. A woman's status was recorded as LTFU if she missed the last clinic appointment for at least 28 days without documented death or transfer out to another facility 15 . Providers contacted women based on their addresses recorded during enrolment in Option B plus care, either via phone (if functional) or by conducting home visits for those unable to be reached. Informed written consent was obtained, and the research assistants conducted in-depth interviews at women’s homes or health facilities based on their preferences. After an interview, eleven women who lost care were counselled to resume PMTCT care, but nine returned to care and two refused to resume care. Besides, the principal investigator, HCWs, and MSG members identified women who resumed care after LTFU, called them via phone to visit the health facility at their convenience, and conducted the interview after obtaining consent. The research team covered transportation costs and provided adherence counselling to women post-interview. A woman resumed care if she came back to PMTCT care on her own or healthcare workers’ efforts after LTFU.

One-on-one, in-depth interviews were conducted with eligible MSG members and HCWs at respective health facilities. A semi-structured interview guide translated into the local language (Amharic) was used to collect data. The guide comprises the following constructs: why women are lost to follow-up from PMTCT care, what made them resume caring after LTFU, and why they did not resume Option B plus care after LTFU with probing questions (Supplementary File 1 ). The interview was conducted for 18 to 37 min with each participant, and the duration was communicated to study participants before the interview. The interview was audio-taped, and field notes were taken during the interviews.

Data management and analysis

Thematic analysis was used to analyze the data. The research assistants transcribed the interviews verbatim within 48 h of data collection and translated them from the local language (Amharic) to English for analysis. The principal investigator read the translated document several times to get a general sense of the content. An inductive approach was applied to allow the conceptual clustering of ideas and patterns to emerge. The authors preferred an inductive approach to analyze data since there were no pre-determined categories. The core meaning of the phrases and sentences relevant to the research aim was searched. Codes were assigned to the phrases and sentences in the transcript, which were later used to develop themes and subthemes. The subthemes were substantiated by quotes from the interviews. The interviews developed two themes: reasons for LTFU and the reasons for resumption after LTFU. The findings were triangulated from healthcare workers, MSG members, and client responses. Open code software version 4.03 was used to assist in data management, from open coding to the development themes and sub-themes.

Background characteristics of the study participants

We successfully interviewed 46 participants (14 providers, 15 women, and 17 MSG members) until data saturation. The mean (± standard deviation [SD]) of age was 25.53 (± 0.99) years for women, 32.5 (± 1.05) years for MSG members, and 32.2 (± 1.05) years for care providers. Three out of fifteen women did not disclose their HIV status to their partner, and 5/15 women’s partners were discordant. The mean (± SD) service years in the PMTCT unit were 10.3 (± 1.3) for MSG members and 3.29 (± 0.42) for care providers (Supplementary File 2 ).

Reasons for LTFU

Women who started ART to prevent MTCT of HIV were lost from care due to different reasons. Societal and individual-related factors and health facility-related factors were the two main dimensions that made women LTFU. The societal and individual-related factors were socioeconomic status, relations with husbands or families, lack of support, HIV-related stigma and discrimination, lack of awareness and perceived antiretroviral (ARV) side effects, and religious belief. Health facility-related factors such as lack of confidentiality, drug supply shortages, and inadequate service access led to women's loss from Option B plus care (Supplementary File 3 ).

Societal and individual-related factors

Socioeconomic status.

Lack of money to buy food was a major identified problem for women’s LTFU. Women who did not have adequate food to eat became undernourished, which significantly increased the risk of LTFU. Besides, they did not want to swallow ARV drugs with an empty stomach and thus did not visit health facilities to collect their drugs.

“My life is miserable. I have nothing to eat at my home. How would I take the drug on an empty stomach? Let the disease kill me rather than die due to hunger. This is why I stopped to take the medicine and LTFU.” (W-02, 30-year-old woman, divorced, daily labourer)

Women also disappeared from PMTCT care due to a lack of money to cover transportation costs to reach health facilities.

I need a lot of money to pay for transportation that I can’t afford. Sometimes I came to the hospital borrowing money for transportation. It is challenging to attend a follow-up schedule regularly to collect ART medications.” (W-11, 26-year-old woman, married, housewife)

Relationships with husbands and/or families

Fear of violence and divorce by sexual partners were identified as major reasons for the LTFU of women from PMTCT care. Due to fear of partner violence and divorce, women did not want to be seen by their partners while visiting health facilities for Option B plus care and swallowing ARV drugs. As a result, they missed clinic appointments, did not swallow the drugs, and consequently lost care.

“Due to discordant test results, my husband divorced me. Then I went to my mother's home with my child. I haven’t returned to take the drug since then and have lost PMTCT care.” (W-03, 25-year-old woman, divorced, commercial sex worker)

Women did not disclose their HIV status to their discordant sexual partners and family members due to fear of stigma and discrimination. As a result, they did not swallow drugs in front of others and were unable to collect the drugs from health facilities.

“I know a mother who picked up her drugs on market day as if she came to the market to buy goods. No one knows her status. She hides the drug and swallows it when her husband sleeps.” (P-05, 29-year-old provider, female, 3 years of experience in the PMTCT unit) “I don't want to be seen at the ART unit. I have no reason to convince the discordant husband to visit a health facility after delivery. My husband kills me if he knows that I am living with HIV. This is why I discontinued the care.” (W-12, 18-year-old woman, married, housewife)

Women who lack partner support in caring for children at home during visits to health facilities find it difficult to adhere to clinic visits. Besides, women who did not get financial and psychological support from their partners faced difficulties in retaining care.

“Taking care of children is not business for my husband. How could I leave my two children alone at home? Or can I bring them biting with my teeth?” (W-05, 24-year-old woman, divorced, daily labourer) “ I didn't get any financial or psychological support from my husband. This made me drop PMTCT care.” (W-15, 34-year-old woman, married, daily labourer) Lack of support

Women living with HIV also had complaints of lack of support from the government, non-governmental organizations (NGOs), and HIV-related associations in cash and in kind. As a result, they were disappointed to remain in care.

"Previously, we got financial and material support from NGOs. Besides, the government arranged places for material production and goods sale to improve our economic status. However, now we didn't get any support from anywhere. This made our lives hectic to retain PMTCT care.” (W-06, 29-year-old woman, married, daily labourer)

HIV-related stigma and discrimination

Fear of stigma and discrimination by sexual partners, family members, and the community were mentioned as reasons for LTFU. Gossip, isolation, and rejection from societal activities were the dominant stigma experiences the women encountered. As a result, they did not want to be seen by others who knew them while collecting ARV drugs from health facilities, and consequently, they were lost from care and treatment.

“Despite getting PMTCT service at the nearby facility, some women come to our hospital traveling long distances. They don't want to be seen by others while taking ARV drugs there due to fear of stigma and discrimination by the community.” (P-10, 34-year-old provider, female, 2 years of experience in the PMTCT unit) “I am a daily labourer and bake ‘injera’ (a favourite food in Ethiopia) at someone's house to run my life. If the owner knew my status, I am sure she would not allow me to continue the job. In that case, what would I give my child to eat?” (W-12, 18-year-old woman, married, housewife) “My family did not know that I was living with the virus. If they knew it, I am sure they would not allow me to contact them during any events. Thus, I am afraid of telling them that I had the virus in my blood.” (W-05, 24-year-old woman, divorced, daily labourer)

Lack of awareness and perceived ARV side effects

Sometimes women went to another area for different reasons without taking ARV drugs with them. As per the Ethiopian national treatment guidelines 13 , they could get the drugs temporarily from any nearby facility that delivers PMTCT service. However, those who did not know that they could get the drugs from other nearby PMTCT facilities lost their care until their return. Others were lost, considering that ARV drugs harm the health status of their babies.

“One mother refused to retain in care after the delivery of a congenitally malformed baby (no hands at birth). She said, 'This abnormal child was born due to the drug I was taking for HIV. I delivered two healthy children before taking this medication. I don't want to re-use the drug that made me give birth to a malformed baby." (P-14, 32-year-old provider, female, 4 years of experience in the PMTCT unit)

When they did not encounter any health problems, women were lost from care, considering that they had become healthy and not in need of ART. Some of them also believe that having HIV is a result of sin, not a disease. Besides, some women believed that it was not possible to have a discordant test result with their partner.

“I didn't commit any sexual practice other than with my husband. His test result is negative. So, from where did I get the virus? I don't want to take the drug again.” (W-02, 30-year-old woman, divorced, daily labourer)

Religious belief

Some study participants mentioned religious belief as a reason for LTFU and a barrier to resumption after LTFU. Women discontinued Option B plus care due to their religious faith and refused to resume care as they were cured by the Holy Water and prayer by religious leaders.

“I went to Holy Water and was there for two months. My health status resumed due to prayer by monks and priests there. Despite not taking the drugs during my stay, God cured me of this evil disease with Holy Water. Now I am healthy, and there is no need to take the medicine again.” (W-09, 25-year-old woman, married, daily labourer)

Some women believed that God cured them and made their children free of the virus despite not taking ART for themselves and not giving ARV prophylaxis for their infants.

“Don't raise this issue again (when MSG asked to resume PMTCT care). I don't want to use the medicine. I am cured of the disease by the word of God, and my child is too. My God did not lie in His word.” (MSG-16, 32-year-old MSG, married, 16 years of service experience “Don't come to my home again. I don't have the virus now. I have been praying for it, and God cured me.” (W-03, 25-year-old woman, divorced, commercial sex worker)

Health facility-related factors

Shortage of drug supply.

Women were not provided with all HIV-related services free of charge and were required to pay for therapeutic and prophylactic drugs for themselves and their infants. Most facilities face a shortage of prophylactic drugs, primarily cotrimoxazole and nevirapine syrups, for infants and women, and other drugs used to treat opportunistic infections. As a result, women lost their PMTCT care when told to buy prophylactic syrups for infants and therapeutic drugs to treat opportunistic infections for themselves.

“Lack of cotrimoxazole syrup is one of the major reasons for women to miss PMTCT clinic visits. In our facility, it was out of stock for the last three months. Women can't afford its cost due to their economic problems.” (MSG-03, 34-year-old provider, married, 12 years of service experience)

Inadequate service access

Most women travelled long distances to reach health facilities to get PMTCT service due to the absence of a PMTCT site in their area. Due to a lack of transportation access and/or cost, they were forced to miss clinic visits for PMTCT care.

“In this district, there were only two PMTCT sites. Women travelled long distances to get the service. To reach our facility, they must travel half a day or pay more than three hundred Ethiopian birr for a motorbike that some cannot afford. Thus, women lost the service due to inadequate service access.” (P-06, 30-year-old provider, male, 2 years of experience in the PMTCT unit)

In almost all facilities, PMTCT service was not given on weekends and holidays, despite women's interest in being served at these times. When ARV drugs were stocked out at their homes, they did not get the drugs if facilities were not providing services on weekends and holidays. When appointment date was passed, they lost care due to fear of health workers’ reactions.

Lack of confidentiality

Despite maintaining ethical principles to retain women in care, breaches of confidentiality by HCWs were one of the reasons for LTFU by women. Women were afraid of meeting someone they knew or that their privacy would not be respected. As a result, they lost from PMTCT care.

“I don’t want to visit the facility. All my information was distributed to the community by a HCW who counselled me at the antenatal clinic.” (W-09, 25-year-old woman, married, daily labourer)

Reasons for resumption after LTFU

Healthcare workers' commitment to searching for lost women, partners’ encouragement, and women’s health status were key reasons for resuming women's Option B plus services after LTFU.

Healthcare workers’ commitment

The majority of lost women resumed Option B plus care after LTFU when healthcare workers called them via phone or conducted home visits for those who could not be reached by phone call.

“We went to a woman’s home, who started ART during delivery and lost for four months, travelling about 90 kilometers. She just cried when she saw us. She said, 'As long as you sacrificed your time traveling such a long distance to return me and save my life, I will never disappear from care today onward.' Then, she returned immediately and was linked to the ART unit after completing her PMTCT program.” (P-13, 32-year-old provider, male, 5 years of experience in the PMTCT unit) “We have an appointment date registry for every woman. We waited for them for seven days after they failed to arrive on the scheduled appointment date. From the 8th day onward, we called them via phone if it was available and functional. If we didn't find them via phone, we conducted home visits and returned them to care.” (P-02, 24-year-old provider, female, 3 years of experience in the PMTCT unit)

Partner encouragement

Women who got their partners' encouragement did not drop out of PMTCT care. Besides, most women returned to care and restarted their ARV drugs due to partner encouragement.

“I did not disclose my HIV status to my husband, which was diagnosed during the antenatal period. I lost my care after the delivery of a male baby. When my husband knew my status, rather than disagreeing, he encouraged me to resume the care to live healthily and to prevent the transmission of HIV to our baby. This was why I resumed care after LTFU.” (W-14, 28-year-old woman, divorced, daily labourer)

Women’s health status

Some women returned to Option B plus care on their own when they felt sick and wanted to stay healthy.

“When I felt healthy, I was away from care for about eight months. Later on, when I sought medical care for the illness, doctors gave me medicine and linked me to this unit (the PMTCT unit). I returned because of sickness.” (W-06, 29-year-old woman, married, daily labourer)

This qualitative study assessed the reasons why women left the service and why they resumed care after LTFU. The study aimed to enhance program implementation by providing insights into reasons for LTFU and facilitators for resumption from women's, health professionals', and MSG members' perspectives. We found that financial problems, partner violence, lack of support, HIV-related stigma and discrimination, lack of awareness, religious belief, shortage of drug supply, poor access to health services, and fear of confidentiality breaches by healthcare providers were major reasons for LTFU from PMTCT care. Healthcare workers’ commitment, partner encouragement, and feeling sick made women resume PMTCT care after LTFU.

In this study, fear of partner violence and divorce were identified as major reasons that made women discontinue the PMTCT service. Men are the primary decision-makers regarding healthcare service utilization, and the lack of male involvement in the continuity of PMTCT care decreases maternal health service utilization, including PMTCT services 41 , 42 . In addition, economic dependence on men threatened women not to adhere to clinic appointments without their partner’s willingness due to fear of violence and divorce 28 . Thus, strengthening couple counselling and testing 13 , male involvement in maternal health services, and women empowerment strategies like promoting education, property ownership, and authority sharing to reach decisions on health service utilization were crucial to retaining women in PMTCT care. Besides, legal authorities and community and religious leaders should be involved in preventing domestic violence and raising awareness about the negative effects of divorce on child health.

Financial constraints to cover daily expenses were major reasons expressed by women for LTFU from PMTCT care. Consistent with other studies, this study revealed that a lack of money to cover transportation costs resulted in poor adherence to ART and subsequent loss of PMTCT care 27 , 29 , 43 . As evidenced by other studies, lack of food resulting from financial problems was a major reason for LTFU in the study area 30 . As a result, women prefer death to living with hunger due to food scarcity, which led them to LTFU. Besides, women of poor economic status spent more time on jobs to get money to cover day-to-day expenses than thinking of appointment dates. Thus, governments and organizations working on HIV prevention programs should strengthen economic empowerment programs like arranging loans to start businesses and creating job opportunities for women living with HIV.

Despite continuous information dissemination via different media, fear of stigma and discrimination was a frequently reported reason for LTFU among women in PMTCT care. Consistent with other studies conducted in Ethiopia and other African countries, our study identified that fear of stigma and discrimination by partners, family, and community members are significant risk factors for LTFU 27 , 28 , 29 , 31 . As a result, women did not usually disclose their HIV status to their partners 28 , 32 so that they could not get financial and psychological support. This highlights the need to intensify interventions by different stakeholders to reduce HIV-related stigma and discrimination in the study area. Women's associations, community-based organizations, and religious, community, and political leaders should continuously work on advocacy and awareness creation to combat HIV-related stigma and discrimination.

Our study revealed that a lack of support for women made them discontinue life-saving ARV drugs. In developing countries like Ethiopia, most women living with HIV have low socio-economic status to run their lives, and thus they need support. However, as claimed by the majority of study participants, the government and organizations working on HIV programs were decreasing support from time to time. This was in line with qualitative studies such that lack of support by family members or partners 27 was identified as a barrier to adherence to and retention in PMTCT care 27 , 28 , 29 , 30 , 32 . Organizations working on HIV programs need to design strategies so that poor women get support from partners, family members, the community, religious leaders, and the government to stay in PMTCT care. Moreover, some women thought incentives and support must be given to retain them in Option B plus care. Thus, HCWs should inform women during counselling sessions that they should not link getting PMTCT care to incentives or support.

Women infected with HIV want to be healthy and have HIV-free infants, which could be achieved by proper utilization of recommended therapy as per the protocol 27 , 43 . However, women’s religious beliefs were found to interfere with adherence to the recommended treatment protocol, made them LTFU, and refused resumption after LTFU. Although religious belief did not oppose the use of ARV drugs at any time, women did not take the medicine when they went to Holy Water and prayer. As evidenced by previous studies, lost women perceived that they were cured of the disease with the help of God and refused to resume PMTCT care 27 , 30 . This finding suggests the need for sustained community sensitization about HIV and its treatment, engaging religious leaders. They need to inform women on ART that taking ARV drugs does not contradict religious preaching, and they should not discontinue the drug at any religious engagement.

Once on ART, women should not regress from care and treatment due to problems related to the facility. Unlike the study conducted in Malawi, which reported a shortage of drugs as not a cause of LTFU 29 , in the study area there was a shortage of drugs and supplies to give appropriate care to women and their infants and to retain them in care. They did not get all services related to HIV free of charge and were requested to pay for them, including the cotrimoxazole syrup given to their infants. The finding was consistent with the study conducted in Malawi, where the irregular availability of cotrimoxazole syrup was mentioned as a risk factor for LTFU 32 .

On some occasions, there may also be a shortage of ARV prophylaxis (Nevirapine and Zidovudine syrups) at some facilities for their infants that they couldn’t get from private pharmacies. Services related to PMTCT care were expected to be free of charge for mothers and their infants throughout the care. Ensuring an adequate supply of prophylactic and therapeutic drugs should be considered to prevent the MTCT of HIV and control the spread of the disease among communities via appropriate resource allocation. Facilities should have an adequate supply of ARV prophylaxis and should not request that women pay for diagnostic services. Besides, they always need to provide cotrimoxazole syrup free of charge for HIV-exposed infants.

Lack of awareness of a continuum of PMTCT care among women is a major challenge to retaining them in care. Women who experienced malpractice against standard care practice and had misconceptions about the disease were at higher risk for LTFU. Those women who forgot to take ARV drugs due to different reasons (maybe due to poor counselling) did not get the benefits of ART. Improved counselling and appropriate patient-provider interaction increase women’s engagement in care and reduce the risk of LTFU 28 , 44 . Thus, proper counselling on adherence, malpractice, and misconceptions should be strengthened by healthcare providers in PMTCT units to create optimal awareness for retention.

Maintaining clients’ confidentiality is the backbone of achieving HIV-related treatment goals. However, some women disappear from PMTCT care due to a lack of confidentiality by HCWs delivering the service. Although not large, women claimed a lack of privacy during counselling, and disclosing their HIV status in the community was practiced by some healthcare professionals. The finding was consistent with the study conducted in developing countries, including Ethiopia, where lack of privacy and fear regarding breaches of confidentiality by healthcare workers were identified as risk factors for LTFU 31 , 32 , 44 . Thus, HCWs should deliver appropriate counselling services and maintain clients’ confidentiality to develop trust among women.

The validity of the findings of this study was strengthened by the triangulating data collected from women, MSG members, and HCWs delivering PMTCT service. Besides, the study included women from the community who had already been lost from care during the study, which minimized the risk of recall bias. However, we recognized the following limitations. First, the study did not explore the husband’s perspective to validate the findings from women and HCWs. Second, the study may have different reasons for LTFU for women who were unreached or unwilling to participate compared to those who agreed to be interviewed. Thus, further studies are advised to include the husband’s perception to validate their concern and to address all women who have lost care.

Conclusions

Financial constraints to cover transportation costs, fear of partner divorce and violence, HIV-related stigma and discrimination, lack of psychological support, religious belief, shortage of drug supply, inadequate service access, and breach of confidentiality by HCWs were major reasons for women’s lost. Healthcare workers’ commitment to searching for lost women, partners’ encouragement to resume care, and women’s desire to live healthily were explored as reasons for resumption after LTFU. Women empowerment, partner engagement, involving community and religious leaders, awareness creation on the effect of HIV-related stigma and discrimination for the community, and service delivery as per the protocol were of vital importance to retain women on care and resume care after LTFU. Besides, HCWs should address false beliefs related to the disease during counseling sessions to retain women in care.

Data availability

All data generated or analysed during this study are included in this article and its Supplementary Information files.

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Acknowledgements

The authors acknowledge the staff of the South Ethiopia and Central Ethiopia Regional Health Bureaus for their technical and logistic support. Moreover, the authors sincerely thank the research assistants who translated and transcribed the interview. The authors would also like to thank the study participants who were involved in the study.

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W.F. was involved in the study's conception, design, execution, data acquisition, analysis, interpretation, and manuscript drafting. T.T., E.W., and A.A. were involved in the project concept, guidance, and critical review of the article. All the authors have reviewed and approved the final manuscript and agreed to publish it in scientific reports.

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The study protocol was reviewed and approved by the Institutional Review Board (IRB) of Wolaita Sodo University (ethical approval number WSU41/32/223). The study was carried out following relevant legislation and ethics guidelines. Written informed consent was obtained from all participants before an interview, and interviewee anonymity was guaranteed.

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Facha, W., Tadesse, T., Wolka, E. et al. A qualitative study on reasons for women’s loss and resumption of Option B plus care in Ethiopia. Sci Rep 14 , 21440 (2024). https://doi.org/10.1038/s41598-024-71252-2

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DOI : https://doi.org/10.1038/s41598-024-71252-2

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