3. Improving HIV/AIDS education and support in KwaZulu-Natal through comics drawing

Submitting Institution

Cardiff University

Unit of Assessment

English Language and Literature

Summary Impact Type


Research Subject Area(s)

Medical and Health Sciences: Public Health and Health Services

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Summary of the impact

[Key: Bold: REF guide text; Bold italic/italic: emphasis; Superscript: refs to section 3 and 5]

Building on research by El Refaie on autobiographical comics, visual metaphor and teenagers' response to cartoons, and on research by Sarangi into communicating HIV risk, comics drawing workshops were designed for use with teenagers who had, or were at risk of, HIV/AIDS. Run at the Whizzkids United Health Academy in South Africa, the workshops helped the teenagers create their own comics stories, enabling them to express their feelings and explore different possible solutions to scenarios from their life experiences. Teenagers who were HIV+ spoke for the first time about their problems, sharing their concerns with each other and with Health Academy counsellors. A booklet of the best comics was distributed to teenagers in Edendale and via the Whizzkids United website.

Underpinning research

Research into visual communication, metaphor and autobiographical comics: The research of Elisabeth El Refaie (Joined as Lecturer '05, SL '11) examines the pedagogical uses of cartoons and comics. Underpinned by a British Academy-funded study3-7 using newspaper cartoons to encourage British teenagers to talk about their identity and perceptions of major geopolitical events, El Refaie3-1,3-2 found that cartoons help young people grasp complex information and engage with different points of view. Cartoons were found to be a valuable way of teaching multimodal literacy skills.3-1,3-4 Her research since 2007 has examined how visual storytelling conveys meanings that are difficult to express in words. Her monograph on autobiographical comics3-3 identifies unique characteristics of the medium, particularly its heavy reliance on visual metaphor and humour, which provide authors with new ways of representing aspects of their life experiences. El Refaie shows how the genre of autobiographical comics has opened up life writing to authors for whom traditional prose writing would not have been a realistic option, including teenagers and underground visual artists.

Research into HIV/AIDS education in high-risk communities: Srikant Sarangi AcSS (Lecturer 93, SL 97, Reader 99, Professor 03-13) has an extensive dossier of health communication projects worldwide. As part of a £1.1m project3-8 held in the Unit's Centre for Language and Communication Research, he examined the role of language in education programmes for the prevention of HIV/AIDS in India.3-5 His work demonstrated that HIV prevention programmes are most successful when the target population is actively involved in their development and implementation, and when they are delivered in a form that all the participants can readily understand.3-6

Specific research for Whizzkids United (WU): Before developing the training materials for WU, El Refaie conducted a literature review of reports on health promotion and literacy campaigns that have used comics, in order to identify the advantages and pitfalls of using drawing classes to promote life skills development and disease prevention. She also examined existing comics for HIV/AIDS education, and also the non-educational comics popular in the primary target group of KwaZulu-Natal teenagers. The analyses reveal a dominant external, paternalistic approach to HIV/ AIDS education, characterised by generic and directive text that might be difficult for teenagers to relate to their own experience. In addition, cultural biases were apparent: in S.African AIDS comic `The Fight', http://bit.ly/TIKnqy, the good white blood cells are represented by white-skinned soldiers; in Brazilian comics, http://bit.ly/XYolVQ, superheroes are used to fight HIV/AIDS. In order to understand the starting point for the workshops, a comics drawing competition was held (cf. section 4). No superheroes were depicted, and the drawings entirely lacked metaphor, being factual and direct. This observation was significant in the development of the materials, because all entrants in the competition had previously participated in WU life skills training, where football is used as a metaphor (described below). WU staff were satisfied that they had understood the football metaphor. Therefore, attention was paid in the workshops to enabling the teenagers to transfer their understanding of metaphor to this new domain.

References to the research

(All items are available from the HEI)

1. El Refaie, E. 2009. Multiliteracies: How readers interpret political cartoons. Visual Communication 8,2: 181-205. DOI: 10.1177/1470357209102113


2. El Refaie, E. 2011. The pragmatics of humor reception: Young people's responses to a newspaper cartoon. HUMOR 24,1: 87-108. DOI: 10.1515/HUMR.2011.005


3. El Refaie, E. 2012. Autobiographical Comics: Life Writing in Pictures. Jackson: University Press of Mississippi. Shortlisted for 2013 Eisner awards (Best Academic Book) http://bit.ly/17EB454. ISBN: 9781617036132


4. El Refaie, E. & Hörschelmann, K. 2010. Young people's readings of a political cartoon and the concept of multimodal literacy. Discourse: Studies in Cultural Politics of Education 31,2: 195-207.
DOI: 10.1080/01596301003679719


5. Mooney, A. & Sarangi, S. 2005. An ecological framing of HIV preventive intervention: a case study of non-government organizational work in the developing world. Health 9,3: 275-96. DOI: 10.1177/1363459305052901


6. Sarangi, S. 2008. The micropolitics of disclosure, stigma and (dis)trust surrounding HIV/AIDS in India. In I. Markova and A. Gillespie (eds.) Trust and Distrust: Sociocultural Perspectives. Charlotte, NC: Information Age Publishing, 153-177. ISBN: 9781593118426.

Research grants

7. British Academy, 2005-7, £6973, Editorial cartoons and geopolitical perceptions, SG-39469, PI: E.El Refaie [partly held at University of Durham]

8. Leverhulme Trust, 2001-6, £1.1m Language and Global Communication, F/00/407D, PI: T.van Leeuwen; Co-Is: S.Sarangi, N.Coupland, P.Garrett, A.Jaworski

Details of the impact

Context: Whizzkids United (http://www.whizzkidsunited.org/) is the youth outreach programme of the UK charity Africaid. Using football as a metaphor for life, its six week course On the Ball (OtB) harnesses explicit analogy (e.g. strategy, focus, hard work, teamwork, self-determination) to teach life skills and HIV prevention to teenagers. OtB graduates are encouraged to attend the WU Health Academy (HA) in the Edendale district of Pietermariztburg, KwaZulu-Natal, a clinic and drop-in centre offering testing, counselling and treatment for HIV/AIDS. Over 5.6m people in South Africa have HIV/AIDS, with the highest prevalence recorded in KwaZulu-Natal (39.5% of the adult population, according to UNAIDS in 2009). Most teenagers with HIV in the target group were born with it. Due to taboos that prevent open discussion, children are deprived of clear information about both risks and prevention, even though they are sexually active from a young age.

The OtB programme is highly successful (25,000 graduates), but the WU founder Marcus McGilvray contacted the Cardiff team in Autumn 2011 for assistance with communicating the health messages. Only 14% of Edendale OtB graduates had gone on to visit the HA, located some 5km from their schools and villages. At the HA, teenagers can access the full range of information and support they need. An estimated 70% of children taking an HIV test at the HA were first reached through the OtB scheme. The Cardiff researchers began, at his request, by examining the football-coaching materials to suggest improvements, particularly in communicating the importance of attending the HA. El Refaie's research on metaphor was central to this evaluation. As part of their scoping study, the Cardiff team asked the OtB coaches for their views on the teaching materials, and it became clear that the images (photographs) were not well-targeted to the teenagers. This raised the question of how comics (El Refaie's research specialism) might be used instead.

Process: El Refaie proposed to McGilvray that the teenagers might draw their own illustrations for OtB. To assess the feasibility of the idea, a comics drawing competition was organised, judged by GP Dr Ian Williams, whose website (http://graphicmedicine.org) promotes the use of comics for healthcare professionals, patients and carers. The idea of developing comics drawing as an activity in its own right was partly inspired by written comments on some of the comics in the competition, welcoming this alternative to football. Comics drawing was developed as an alternative mainstream educational approach for WU, with dedicated workshops teaching participants to create original stories in the comics format. The first aim was to empower the young people to use this creative narrative medium to express their feelings and concerns. The second aim was to produce comics for distribution, reflecting the teenagers' own perspectives on HIV/AIDS and thus appealing to other local youngsters, as well as providing a way to promote the services of the HA. El Refaie created the materials with reference to Sarangi's research into HIV education. Stephen Silverwood of `Upside Comics', a charity that runs comics drawing classes in UK schools and social clubs, assisted with teaching ideas; Steve Marchant, a comics artist and educator who runs comics drawing workshops with groups of underprivileged children and adults and authored the `The Cartoonist's Workshop', inked and coloured the comic strips produced by the teenagers.


1. Feb-Jul 2012: Bespoke research (see above), including an analysis of the comics drawn by OtB participants for a competition (105 entries, two prizes awarded). At a consultation meeting with McGilvray, it was agreed to develop the materials in a manner that did not rely on the teachers having previous experience of comics drawing.

2. Aug-Nov 2012: El Refaie constructed the Workshop 1 content, focusing on the core themes that her research showed best enabled teenagers to understand visual forms of storytelling and use them effectively to express their own thoughts and experiences, including different ways of depicting character traits and emotions. Workshop 1 consists of basic drawing skills classes (3 x 60-90 minute sessions). From Nov 2012 it was delivered both at the HA (>100 teenagers) and in local schools (>75) by Mar 2013.

3. Nov-Dec 2012: El Refaie assembled a library of c.30 graphic novels for the HA, to raise the teenagers' awareness of different styles and narrative techniques. She developed materials for Workshop 2, an intensive two-day comics drawing course for selected graduates of the introductory workshops, focussed on visual metaphor and comics story structure. The Powerpoint slides for both Workshops were colour-printed and laminated for use in venues without computers/electricity. `I love drawing comics' T-shirts with the Cardiff University and WU logos were designed, printed and donated by the Unit for Workshop 2 participants.

4. Jan-Apr 2013: Workshop 1 artwork and feedback from participants and the local trainers was received and analysed. On 23-24th Feb, McGilvray and 9 colleagues including counsellors ran Workshop 2 for the first time, with 29 15-20 yr olds (HIV+ ♀9/♂7; HIV- ♀7/♂6), travelling up to 40km each day (3 buses) to attend. A full report of the weekend was written by a researcher at WU.5-1 The input included a `tree of life' metaphor to help the teenagers develop a visual image of their identity in the context of family and friends, culminating in discussing the power of a `forest' of such trees.5-1 In line with El Refaie's research the workshop helped the participants use metaphor to talk about HIV. Evidence of the success of this includes: "HIV is like an octopus" (♂); "I think the virus is the soldiers that killed the soldiers of the body" (♂); "It's like a snake, maybe cobra if I may say because it's a dangerous animal" (♂).5-1 Within four teams, role play was used to construct story episodes for six-frame comics. The artwork was scanned in Cardiff, and selected originals were sent to Steve Marchant for collation into a colourful booklet of the comics stories which can be viewed and downloaded at http://bit.ly/19HSuyD. Between its launch on 05/06/13 and 31/07/13, visitors from at least 26 countries had viewed the booklet, including 111 in the UK and 65 in the US.5-8 The booklet was distributed in the UK at the `Making Sense of HIV' conference, Cumberland Lodge, 12-14.06.13 and in KwaZulu-Natal through the OtB program and the WU Health Academy.

Evidence of impact: Workshop 1s were initially held at the Health Academy (HA), but they were so popular that schools asked to run them in their Life Orientations classes,5-3 increasing the reach by 75%.5-4 The commitment to Workshop 2 attendance surprised McGilvray. There was a full turn out, and "All the kids were there at 8 am on the dot both mornings, which is not usual, in a place that works on `African time'. We'd expected not being ready to start until 9.30."5-5

Impact of Workshop 2 on the teenagers: Two of the teams were composed only of HIV+ participants. McGilvray said, "One of the most amazing things ... was when they opened up and realised they all had the same problem. There was a surge of emotion and relief when they found out they were all HIV positive".5-5 They spoke of how they feared disclosing their status, in case the others found out and ostracised them.5-1,5-5 Both HIV+ teams developed this theme in their comics (while the HIV-negative teams focussed on the importance of being tested).

Impact of workshop on Health Academy staff: The staff had not anticipated the power of the experience, nor the extent to which they would for the first time gain access to such deep levels of disclosure: "when the children come to the clinic we focus on the services...but for this weekend we try to sit down with them and they were expressing themselves. How do they feel about them-selves. Now we can understand each other. How this person feels."5-1 Staff learnt that the most significant concern for HIV+ teenagers is isolation and fear of rejection, and not knowing who they can trust.5-2 This extends to fear of breaking up the family by implicating their parents as HIV+ and worry about siblings' status.5-5 Directly resulting from Workshop 2, the HA will develop new programmes that create opportunities for HIV+ teenagers to talk to each other and work together.5-5 Staff also came to understand better why teenagers sometimes fail to take their antiretroviral (ARV) medication: not only does it stigmatise them, but many, taking it from childhood, had never been told what it was for (and did not know they were HIV+).5-5

Impact on individuals: Comments from participants recorded during the workshop (translated from Zulu) 5-1 exemplify their first disclosures of intensely private information: "I don't know how I got HIV and I never did find out. I do find it hard to let other people know my status. I feel bad when other people talk about HIV/AIDS." (♂). "I was so scared. I was not drinking my medicine. So, I was so angry, why me! Only me! Why was HIV in my body?" (♀). "When I found out I was HIV positive, I didn't want to tell my parents and my friends, because I was afraid. I felt that if they knew my HIV status they would chase me away" (♀). "It's very challenging to see your friends coming from hospital, they have a negative status, and you are the only one who is positive." (♂). They also commented on the impact of the workshop: "I used to be confused. But now I'm not confused because there are other people who have the same problem" (♂). "I feel happy... because they shared my problem" (♀). One 19-yr-old who impressed staff as a listener and supporter in his (HIV+) group has been offered a part-time job at the HA (with training) to set up a youth-led support group. This could not have happened without the workshop.5-5,5-6,5-7

Nature of the impact: The workshops have made an impact on the health and quality of life of teenagers with, or at grave risk of, HIV.5-5,5-7 The activities have affected their attitude, awareness and behaviour, and make a major contribution to WU's work in creating new opportunities for empowerment and a positive future.5-5 The main claim made here is for significance, in creating life-changing experiences, new peer support networks, reduction of isolation, improved use of medication for the participants, and, for one participant, a career opportunity. Also significant is the new information for staff, that has enhanced the HA's services for the entire community. 5-1,5-5 Reach is inevitably more modest, because of the need for qualified counsellors to work with small groups and individuals and the associated high costs, which require fund-raising.5-7 Nevertheless, Workshop 1 was delivered to 175 teenagers between Nov 2012 and Mar 2013, and funding for the next round of Workshop 2 was secured in Sep 2013. Although limited, the reach is effective: "I would confidently say that as a result of Comic Strip more youth have accessed HIV testing and counselling."(McGilvray)5-4 Additional reach occurred when, in Mar 2013, McGilvray ran Workshops 1 & 2 at the WU Health Academy in the Sahel region of North Ghana, with 20 participants aged 12-14.5-3,5-5 The materials remain at the clinic, so repeat workshops can run.

Sources to corroborate the impact

  1. Report by the Whizzkids United Health Academy research officer (Feb 2013). This 18 page report is the primary source of impact evidence. It chronicles the events, summarises observation notes and presents extensive interview data from the teenagers and staff. As the report contains the teenagers' names, HIV status and many photographs, it is confidential.
  2. The WU February 2013 newsletter http://bit.ly/VdoR3f has a feature about the Comics workshop 2.
  3. The WU April 2013 newsletter http://bit.ly/108xTys reports that the Comics workshops in South Africa are so popular that they have been adopted by a local school (one of several doing so) (see last item of newsletter), and that the workshops were also piloted in Ghana (see CEO message).
  4. E-mails from the CEO of Africaid, founder of WU, about the plans for running future workshops and the increased take up of HA services due to the workshops (2013).
  5. Testimony from CEO of Africaid, founder of WU (Jul 2013). This 8 page account of the workshops in RSA and Ghana verifies the positive impact on teenagers and HA staff, including new insights into how to offer effective and relevant support.
  6. The WU July 2013 newsletter http://bit.ly/15RLJZq features an extract from one of the comics, and reports the important finding that "the youth feared being ostracised rather than death."
  7. Blog from volunteer in charge of the comics workshops. http://bit.ly/18y8k19 (22/07/13), confirming the success of the project so far, and the plans for the next few months.
  8. Bit.ly statistics on the visits to the comic booklet on line, confirming the claim about the number of countries and the numbers from the UK and US.

1, 4, 5, 8 available from HEI as are copies of 2, 3, 6, 7 saved as pdf on 5.7.13 and 25.7.13