Music as an implementation strategy for evidence-based health interventions in Africa: a systematic review using the RE-AIM framework

Abstract

Background

While a growing body of scientific literature suggests that evidence-based interventions may improve health outcomes in diverse settings, little is known about the best strategies for large-scale implementation. In Africa, music—an important positive social determinant of health—leverages existing cultural values, which may effectively enhance the reach, uptake, and long-term sustainability of evidence-based interventions in the region. To understand how music interventions work, why they are effective, and with whom they resonate, this systematic review aims to evaluate the quality and empirical application of music as an implementation strategy for adopting evidence-based interventions in Africa using the RE-AIM framework as a guide.

Methods

A comprehensive librarian-assisted search followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Five major electronic databases, EBSCOhost, PubMed, Web of Science, Embase, and MEDLINE, were searched for empirical studies focused on using music as an implementation strategy to improve health outcomes in Africa. Two independent investigators extracted components of retrieved papers using the RE-AIM framework as a guide.

Results

From 981 citations, eight studies met the inclusion criteria, each reporting a unique music intervention. The interventions were conducted in West Africa (n = 3), South African regions (n = 4), and East Africa (n = 1) and included seven observational studies and one randomized controlled trial (RCT). Using the RE-AIM scoring criteria, we summarize the RE-AIM dimensions reported from selected studies – Adoption (72.5%) being the highest, followed by Reach (62.5%), Implementation (41.7%), and Efficacy/Effectiveness (20.0%). All eight studies (100%) described the intervention location, the expertise of delivery agents, the target population, and the participant characteristics. Moreover, our analysis highlighted the effectiveness of music interventions in enhancing health outcomes, particularly in improving knowledge and awareness (62.5%), facilitating behavioral change (50%), and promoting mental health (25%).

Conclusion

Music interventions adapted to the sociocultural context in Africa have the potential to help prevent diseases, improve well-being, and enhance health outcomes. Our review emphasizes the importance of customizing music-based interventions to fit the cultural context, which can enhance the programs' effectiveness, acceptance, and sustainability. Clinical trials are necessary to confirm the efficacy of music interventions in specific medical conditions and from a public health promotion perspective.

Contributions to the literature.

• Innovative Application of Music in Healthcare:This study highlights music as a novel, non-invasive, and culturally adaptable implementation strategy for promoting health in Africa.

• Use of the RE-AIM Framework:The review systematically evaluates the reach, effectiveness, adoption, implementation, and maintenance of music-based health interventions by applying the RE-AIM framework, offering a replicable model for implementing innovative strategies to prevent high blood pressure and stroke.

• Focus on Health Equity and Cultural Relevance: The findings underscore the potential of music to bridge health equity gaps by leveraging its cultural significance to enhance engagement and intervention uptake.

• Interdisciplinary Integration: The review highlights the integration of health sciences, implementation science, and the arts, promoting interdisciplinary strategies to tackle public health issues.

Background

Music can be used as an evidence-based implementation strategy to promote health and well-being, reduce stress, and alleviate symptoms [1]. We define implementation strategies here as “methods or techniques used to enhance the adoption, implementation, and sustainability of a clinical program or practice.” [2] These implementation strategies involve using music to help achieve specific changes in behavior or feeling [3]. Music has a potentially wide-reaching effect as it can be played to and appreciated by an extensive audience across continents, cultures, and age strata. In Africa, music serves as a crucial positive social determinant of health, drawing on existing cultural values. This approach may enhance the reach, uptake, and long-term sustainability of evidence-based interventions in the region. The various genres of music improve its acceptability and uptake. Listening to music could be a safe, therapeutic, cost-effective, non-invasive, nonpharmacological intervention for addressing multiple medical conditions, including psychological, physical, and social needs [4]. For instance, it has been used to improve conditions like high blood pressure and excessive stress levels [5, 6]. Music also effectively creates public awareness by delivering culturally accepted messages on a large scale and engaging individuals to reflect on health-related topics [7]. Private and public sectors have utilized music to effectively convey health information that promotes disease prevention in a way that resonates with specific demographic groups, such as children, youth, and older adults [8].

In a similar vein, African music not only serves as a health communication and promotion tool but also as a cultural platform for collective experiences and action. African music is a cultural characteristic that defines Africans, binding them together and providing shared experiences [9]. The diverse music genres across Africa, from rhythmic clapping and dancing to popular ones like Afrobeat, Amapiano, Congo rumba, and soukous, demonstrate the unifying effect and potential to overcome barriers in promoting health and creating an impact [10]. Music has a long history of disseminating information and raising awareness, but its role extends to other health-promoting benefits. Studies have shown that music significantly impacts therapy and rehabilitation in various settings, including hospitals, mental health care, senior care, language learning, community and social programs, corporate environments, sports, and other health challenges [7, 11–16].

Despite the promise of music interventions for health, most music interventions for health research have focused on high-income countries, with much less of the LMIC perspective explored. In a systematic review of health communication strategies in sub-Saharan Africa, music was identified as a popular and influential edutainment strategy for creating awareness and communicating preventive measures during several infectious disease prevention campaigns in Africa (e.g., COVID-19, Ebola, and HIV/ AIDS) [17]. Music is critical in traditional healing practices in many African societies [18]. The music approach can stimulate trust in the messaging and provide a reach that is not achievable with other conventional methods. Music has a wider reach through radio and local music groups to even the most remote regions, enabling broader dissemination of health information and awareness [19, 20]. Music interventions may also positively impact other social determinants of health that are important in the African context [7, 21].

Despite its potential, music is largely underutilized for promoting health in Africa. The effect and impact of music-based interventions are still unclear and underreported in this setting. To effectively use music as an evidence-based implementation strategy, we need a comprehensive understanding of how it works, why it is effective, when to use it, and with whom it resonates. This systematic review aimed to assess the quality and real-world application of music as an implementation strategy for facilitating the adoption of evidence-based interventions in Africa, using the RE-AIM framework as a guiding framework.

Methods

Search strategy

This systematic review was performed and reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Guideline [22]. Five major bibliographic databases—EBSCOhost, PubMed, Web of Science, Embase, and MEDLINE were searched for relevant peer-reviewed studies assessing the application of evidence-based music interventions for health, published between January 2000 and February 2024. We utilized the year 2000 because, within the African landscape, this represents a significant shift in accessibility to music and technology [23]. Moreover, studies were selected during this period to ensure the inclusion of the most recent and relevant studies reflecting current practices and advancements in the field. We used comprehensive search terms containing relevant synonyms, keywords, and MeSH terms related to Africa, music, health, diseases, and awareness utilizing Boolean search operators 'OR' and 'AND.' The articles generated from the search results were stored in a reference management database. This review has been registered on PROSPERO under protocol number CRD42024579088.

Study selection

The searches across the databases included cross-sectional, observational, and quasi-experimental studies that identified music interventions promoting health within the African region. Both quantitative and qualitative studies were included in this study. Studies were screened by two independent investigators—CO and SA—who manually assessed selected articles' titles, abstracts, and full-text content using the eligibility criteria. Discrepancies regarding a study’s inclusion in our study were initially resolved by consensus among the investigators. If this wasn’t possible, a third investigator (OO) made the final decision. In addition to the five major databases examined, the investigators also searched other databases, including Global Health, Family and Society Studies, etc., to find additional studies that could not be found in the five major electronic databases. (See Search Strategy).

Eligibility criteria

We define the eligibility criteria using the PICO framework to i) Population residing in African countries; ii) Intervention that included a music element for disease prevention and promotion, including interventions that focused on prevention using music; iii) Comparison provides knowledge and awareness of disease prevention gained through standard education; iv) Outcome including disease prevention measures including uptake of preventive services. The search was limited to publications written in English. Reviews, letters, and editorials were excluded from the systematic review.

Data extraction and analyses

The two investigators (CO and SA) independently extracted data from selected articles regarding music interventions promoting health in Africa. A coding matrix system was created in Microsoft Excel and used for data extraction and analyses (see Table 1). The following data were extracted: (1) lead author, study title, study location, study purpose and design, study population and sample size, publication years, participants’ age, race/ethnicity, analytical method, predictor and outcome measures, music intervention, limitations, and facilitators.

Table 1.

Characteristics of selected studies

Author and year	Country/city	Study population	Sample size	Partici-pants’ age	Study design	Data collection methods	Focus of the study	Type of music intervention	Facilitators	Outcome measure	Results
Anderson et al., 2022 [24]	South Africa- Limpopo province	Primary school Children/ grade3 learners	Primary school Children/ grade3 learners	Phase 1: n = 12 (Primary Schools) with n = 244 participants in song only intervention. Phase 2: n = 8 Primary schools with n = 124 participants in song only intervention	Mixed method	Pre- and post- intervention questionnaire and interview from 8 primary schools	Health literacy and behavioral education and intervention effectiveness	Culturally and Age-appropriate malaria song using participatory action research		Behavioral change, awareness, and knowledge	The result showed that culturally and age-appropriate songs can play a significant role in developing behavioral changes and spreading awareness against disease in a high-risk malaria region
Manana et al., 2019 [25]	South Africa- Kwazulu-Natal province	Community	Community	Total = 140 Community members = 100 Experts = 40	Mixed method	Self-administered surveys and community dialog sessions	Community participation in health education and implementation effectiveness	Genre song in IsiZulu, on Malaria and Sterile Insect Technique (SIT) for vector control		Knowledge on malaria transmission and SIT technologies	100% of the community (Jozini) and 75% of experts agreed it was culturally appropriate and 92% of all participants agreed on content appropriateness of the song. Malaria signs and symptoms were least remembered (< 10%)
McConnell et al., 2017 [26]	Gambia	The Gambia	The Gambia	N = 46 Performance groups	Qualitative	Ethnographic research of performers and health workers, observation and analysis of Ebola prevention performances	Health message dissemination and promotion	Mandinka language song in call and response form		Health messages on Ebola symptoms, transmission, and prevention	The study explained that positive emotions such as love and happiness facilitate understanding, while negative emotions such as anger and fear present an obstacle for effective communication
Anderson et al., 2018 [27]	South Africa- Limpopo province	Young Children	Young Children	N = 10 Purposively selected experts. Focus group 1: N = 7(Female caregivers and preschool teachers) Focus group 2: N = 5 (Malaria control personnel)	Qualitative	Participatory action research, risk analysis, expert Opinion, expert interview, survey and document search	Health literacy and risk communication	Malaria prevention song with Delphi technique employing repetition		Knowledge and awareness of the link between mosquitoes and malaria	Experts agreed on importance of linking mosquitoes to malaria and recognizing early symptoms. Initially opposed including bed nets but later approved changes post-feedback Focus groups preferred inclusion of bed nets, despite experts' earlier disagreement Rejected indoor residual spraying (IRS) for children due to safety concerns
Stone, 2017 [28]	Liberia—Montserrado County	Community	Community	NA	Qualitative	Ethnographic research	Health message dissemination and promotion	Public Health jingles and Songs, Christian Hymns repurposed for emotional support		Awareness on Ebola	Songs helped convince the public, Ebola was real, dispelling myths. Sounds, particularly sirens, proved to be powerful stimuli of attention and emotion during the Ebola outbreak
Walker, 2022 [29]	South Africa—Cape town	High School Children (15–19 years old)	High School Children (15–19 years old)	N = 200 High School Students	Qualitative	Individual interviews and focus groups		“Sing” music video, Combined pop, gospel, and local South African styles. Focused on emotive imagery, powerful statistics, and musical storytelling to raise awareness about HIV/AIDS		HIV awareness music video. Experiential and firsthand responses to emotive stimuli using Qualitative analysis	Theme 1: Messaging Fatigue Theme 2: Tool for engagement within a saturated aids-related media landscape
Flax et al., 2014 [30]	Nigeria—Bauchi State	Female microcredits clients (15–45 years)	Female microcredits clients (15–45 years)	Total = 461 Intervention arm: N = 40 groups Control Groups: N = 37 groups	Cluster- Randomized controlled trial	Baseline and final survey (Pre and post intervention)	Recommendations to increase adherence to breast feeding through group counselling, health messaging and participant created content	3 component intervention: 1. Group Counselling 2. Cell phone messages 3. Songs and Drama	Enhanced local engagement and discussions, cell phone use	Breast feeding behavior	The main study outcome, exclusive breast feeding to 6 months were increased in the intervention compared to the control arm (P < 0.01). The odds of exclusive breastfeeding to 3 month (P < 0.05), but not to 1 month (P = 0.10), were also elevated in the intervention vs. the control. The intervention also changed breastfeeding behaviors in the first days of life. The odds of initiating breastfeeding within 1 h of delivery (P < 0.001) and giving only colostrum or breast milk in the first 3 d of life (P < 0.01) were increased in the intervention vs. the control arm
Bastien, 2009 [31]	Tanzania	Young people, Kilimanjaro region (majorly between 13–18 age groups)	Young people, Kilimanjaro region (majorly between 13–18 age groups)	N = 65 Young People	Qualitative	Interviews, informal conversations with community members, content analysis of popular songs	Disease prevention messages	Popular Tanzanian songs (Bongo Flava Genre) addressing AIDS metaphors, Stigma, HIV prevention messages	Music cultural relevance and engaging local narratives	Public perceptions and behaviors	Emergent themes from songs are on AIDS Metahors, Stigma, HIV prevention measures. They tried to raise awareness and stimulate awareness offering low cost, wide reach for HIV

For our data extraction process, we utilized a validated data extraction tool adapted from the RE-AIM framework, which is a planning and evaluation model consisting of five dimensions used to assess a program's impact and sustainability [32]. The RE-AIM framework comprehensively evaluates the real-world impacts of implementation strategies and assesses five major dimensions: Reach, Effectiveness, Adoption, Implementation, and Maintenance. For this study, these dimensions are defined: (a) Reach—the extent in numbers to which music interventions have been accessible and utilized by different populations across Africa. This includes studies reporting on the number of individuals who received or used the intervention, as well as the total number of young people who participated in the intervention; (b) Effectiveness—the impact of music interventions in addressing specific health conditions prevalent in Africa, such as HIV, Ebola, malaria or other communicable and non-communicable diseases (NCDs). This included studies where interventions are proven effective across different demographic populations; (c) Adoption—the extent to which multiple settings frequented by the target population use or implement music-based interventions as part of their health promotion strategies. This encompasses studies that report on policies implemented to adopt this intervention; (d) Implementation—the extent to which music interventions are delivered with fidelity, exactness, replicability, and consistency across diverse African settings; and (e) Maintenance—long-term sustainability and how the integration of music intervention can be incorporated into routine healthcare practice. This includes studies demonstrating the continued use of interventions and the number of organizations or people using the intervention for future program designs [32].

A narrative synthesis approach was used to analyze the data, encompassing description, summary, and interpretation of the RE-AIM dimensions and other study results. Narrative synthesis is flexible and holistic and can adopt a textual approach and conceptual model to ‘tell the story of the findings from the included study [33].

Risk of bias assessment

We utilized the National Institute of Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies for this study. This tool was used to evaluate 14 different types of bias, including (1) Was the research question or objective in this paper clearly stated? (2) Was the study population clearly specified and defined? (3) Was the participation rate of eligible persons at least 50.0%? Etc. [34] Signaling questions were independently assessed for each domain by two investigators (CO, SA). A third investigator (OO) resolved the differences or disagreements in case of discrepancies.

Results

The process of selecting studies is outlined in Fig. 1. Our initial database search yielded 981 results. After removing duplicate entries, 469 records were identified. After screening their title and abstracts, 455 records were excluded due to their lack of relevance and non-African context. Fourteen articles were identified for a full-text review. Following a comprehensive full-text review, 6 papers were excluded because they focused on topics other than music interventions, were conducted outside of Africa, or emphasized treatment rather than our desired outcomes: prevention, awareness, and associated behavioral changes. Overall, 8 studies were included in this systematic review, having met the eligibility criteria. See Fig. 1.

Fig. 1.

PRISMA flow diagram

Study summary and demographic characteristics

All selected studies included in this systematic review assessed the use of music to promote health, education, and awareness, therefore increasing individuals' ability to make informed decisions. See Table 1. Four out of the eight included articles were based in South Africa [24, 25, 27, 29], three articles were based in West Africa (Nigeria, Liberia, and Gambia) [26, 28, 30], and one article was based in East Africa (Tanzania) [31]. Three studies included children and adolescents aged 10 to 19 [24, 29, 31]. One study focused on females aged 15 to 45 years [30]. The data collection for six studies relied on pre and post-intervention questionnaires, standardized surveys, expert opinions, focus groups, expert and individual interviews, and community dialogue sessions [24, 25, 27, 29–31]. In comparison, two studies relied on ethnographic research [26, 28].

Six articles examined the role of music in raising awareness and increasing knowledge on various health topics of interest among different populations [24, 25, 27, 28, 30, 31]. Three studies concentrated on malaria [24, 25, 27], two on Ebola [26, 28], two on HIV [29, 31], and one on breastfeeding [30]. One study emphasized the importance of developing music interventions adhering to or following scientific methodology to ensure the appropriateness of the intervention for the intended population [24]. Additionally, two studies explored how music interventions can influence behavioral changes to prevent diseases or health conditions [24, 30]. The selected articles aimed to increase awareness, promote preventive measures, and encourage positive behavioral changes and attitudes toward various health issues such as malaria, Ebola, HIV/AIDS, and breastfeeding.

Mixed methods and randomized control trial study results

See Table 1. Two studies utilized a mixed method study design [24, 25], while one employed a cluster randomized control trial [24]. Anderson et al. reported their music-based intervention was effective in improving knowledge about malaria and its prevention in the target population, showing a statistically significant p-value (p < 0.05) for the group that received the song-only intervention compared to the other four intervention groups studied [24]. Stone et al. reported that musical compositions such as religious songs, jingles, and sounds like sirens effectively captured people’s attention at a crucial time by warning and educating communities about the dangers of Ebola. This was evidenced by the proliferation of these pieces by NGOs, social media reach, and songs becoming anthems [28]. McConnell et al. reported anecdotal evidence suggesting social mobilization through musical lyrics educating communities on Ebola and promoting collaboration, which led to successful Ebola awareness in Gambia. Although the study did not quantify the effectiveness, it mentioned that the National Health Centers received a massive response from the general population regarding the prevention and care of Ebola [26].

Flax et al. assessed infant feeding intentions, beliefs, antenatal care, and breastfeeding advice received at prenatal clinics by mothers during pregnancy. The study found that the initial intentions reported at baseline, i.e., the intention to engage in exclusive breastfeeding and use colostrum or breast milk in the first three days post-delivery, were influenced by intervention practices. These practices included songs and drama developed by participants after learning sessions during follow-up prenatal clinic visits. The intervention notably enhanced the likelihood of exclusive breastfeeding for six months, as evidenced by a significant difference in the intervention group compared to the control group (P < 0.01) [30].

Qualitative results

Five articles used qualitative research design [26–29, 31]. Walker et al. identified two key themes regarding HIV messaging. See Table 1. The first theme highlighted a widespread apathy towards public health messaging about HIV/AIDs. This apathy resulted from various factors, including overexposure to AIDS-related media, the use of unfashionable or older artists in HIV awareness content, which led to poor engagement from the younger demographic, and messages that were judgmental or portrayed black people as poor, sick, potentially and unintentionally reinforcing racial stereotypes. The second theme highlighted the potential of using highly emotive audiovisual content to circumvent AIDS messaging fatigue [29]. Some studies reported their intervention song was well received by the audience and led to a significant improvement in the knowledge of preventing health issues [24, 25, 27]. For instance, Anderson et al. noted that the Zwidade rhythm, developed in the Tshivenda language, received positive feedback from expert surveys and focus groups, including female caregivers, preschool teachers, and male malaria control personnel regarding cultural and age appropriateness [27]. However, the study could not report its effectiveness amongst children due to ethical considerations surrounding including them in the study. In Bastien et al.’s study, music is shown to be a potent tool for HIV/AIDS communication, capable of conveying complex messages through culturally resonant metaphors. Musicians who are influential within the community utilize their songs to challenge stigma, disseminate health information, and promote understanding. This positions them as crucial agents of social change.

Evaluation using the RE-AIM framework

We identified and included eight studies, each reporting on a unique intervention. All included studies were assessed using a previously developed 21-item validated data extraction tool that included both internal and external validity indicators based on the RE-AIM framework [35, 36]. The RE-AIM dimensions were synthesized and summarized, focusing on five key areas: reach, effectiveness, adoption, implementation, and maintenance, as presented in Table 2. Using the RE-AIM data extraction tool, we summarize the RE-AIM dimensions reported from selected studies – Adoption (72.5%) being the highest, followed by Reach (60.7%), Implementation (41.7%), and Efficacy/Effectiveness (20.1%). Maintenance was not reported in any of the studies.

Table 2.

Assessment of selected studies using the RE-AIM framework

RE-AIM dimensions and components	Frequency Reported	Percentage Reported (%)	Could a culturally and age-appropriate song contribute towards malaria prevention in primary school learners?	“Maskandi experience”: exploring the use of a cultural song for community engagement in preparation for a pilot Sterile Insect Technique release program for malaria vector control in KwaZulu-Natal Province, South Africa 2019	Music and the Ecology of Fear: Kanyeleng Women Performers and Ebola Prevention in the Gambia	Using participatory risk analysis to develop a song about malaria for young children in Limpopo Province, South Africa	Ebola in town: Creating musical connections in Liberian communities during the 2014 crises in West Africa	Emotive media as a counterbalance to Aids messaging Fatigue in South Africa: Response to an HIV/AIDS awareness music video	Integrating group counselling, cell phone messaging, and participant generated songs and dramas into a microcredit program increases Nigerian women's adherence to international breastfeeding recommendations	Reflecting and shaping the discourse: the role of music in AIDS communication in Tanzania
Reach
Method to identify the target population	8	100.0	Reported	Reported	Reported	Reported	Reported	Reported	Reported	Reported
Inclusion criteria	7	87.5	Not Reported	Reported	Reported	Reported	Reported	Reported	Reported	Reported
Exclusion criteria	3	38.0	Not Reported	Not Reported	Not Reported	Reported	Reported	Reported	Reported	Not reported
Sample size	6	75.0	Reported	Reported	Reported	Not reported	Not reported	Reported	Reported	Reported
Participation rate	2	25.0	Not Reported	Not Reported	Not Reported	Not reported	Not reported	Reported	Reported	Not reported
Characteristics of participants	8	100.0	Reported	Reported	Reported	Reported	Reported	Reported	Reported	Reported
Characteristics of non-participants	0	0.0	Not Reported	Not Reported	Not Reported	Not reported	Not reported	Not reported	Not Reported	Not reported
Average of overall reach dimension	4.9	60.7
Efficacy/effectiveness
Measures/results for at least one follow-up	3	38.0	Reported	Reported	Not Reported	Not reported	Not reported	Not reported	Reported	Not reported
Intent to treat utilized	1	12.5	Not Reported	Not Reported	Not Reported	Not reported	Not reported	Not reported	Reported	Not reported
Quality-of-life measures	1	12.5	Not Reported	Not Reported	Not Reported	Not reported	Not reported	Reported	Not Reported	Not reported
Baseline activity measured	2	25.0	Reported	Not Reported	Not Reported	Not reported	Not reported	Not reported	Reported	Not reported
Percent attrition	1	12.5	Not Reported	Not Reported	Not Reported	Not reported	Not reported	Not reported	Reported	Not reported
Average of overall efficacy/effectiveness dimension	1.6	20.1
Adoption
Description of intervention location	8	100.0	Reported	Reported	Reported	Reported	Reported	Reported	Reported	Reported
Description of staff who delivered intervention	6	75.0	Reported	Reported	Reported	Reported	Reported	Not reported	Reported	Not reported
Method to identify target delivery agent	5	62.5	Not Reported	Reported	Reported	Reported	Reported	Not reported	Reported	Not reported
Level of expertise of delivery agent	8	100.0	Reported	Reported	Reported	Reported	Reported	Reported	Reported	Reported
Adoption rate	2	25.0	Not Reported	Not Reported	Not reported	Not reported	Not reported	Reported	Not Reported	Reported
Average of overall adoption dimension	5.8	72.5
Implementation
Intervention duration and frequency	5	62.5	Reported	Not Reported	Reported	Not reported	Reported	Reported	Reported	Not reported
Extent protocol delivered as intended	5	62.5	Reported	Reported	Reported	Reported	Not reported	Reported	Not Reported	Not reported
Measures of cost of implementation	0	0.0	Not Reported	Not Reported	Not Reported	Not reported	Not reported	Not reported	Not reported	not reported
Average of overall implementation dimension	3.3	41.7
Maintenance
Assessed outcomes ≥ 6 months post-intervention	0	0.0	Not Reported	Not Reported	Not Reported	Not reported	Not reported	Not reported	Reported	Not reported
Current status of program	0	0.0	Not Reported	Not Reported	Not Reported	Not reported	Not reported	Not reported	Not Reported	Not reported
Cost of maintenance	0	0.0	Not reported	Not Reported	Not Reported	Not reported	Not reported	Not reported	Not Reported	Not reported
Average of overall maintenance dimension	0	0

All eight studies (100.0%) reported on RE-AIM components such as the method to identify the target population, the description of intervention location, the expertise of delivery agents, and the participant characteristics (see Table 2). However, only 25.0% of the studies reported on participation rates, adoption rates, and baseline activity. Exclusion criteria and follow-up measures were mentioned in 38.0% of the included studies. Intervention duration and protocol adherence were reported in 62.5% of the studies, but none provided data on the cost of implementation.

Reach

All eight studies (100.0%) reported methods for identifying the target population. Various techniques, such as sentinel surveys and epidemiological data on diseases of interest, were used to identify the target population. Six study populations were identified based on their residence in areas with high incidence and prevalence or increased disease risk [24–29]. Several other methods were used to identify target populations in the studies. One study targeted a specific location because it was for a pilot sterile male release intervention program for malaria prevention [25]. Other studies involved recruiting experts and relevant community members to develop culturally and age-appropriate songs [25, 27]. Three studies identified target populations based on school membership or meeting groups [24, 30, 31]. Two retrospective studies reviewed interventions that targeted entire communities [26, 28]. Three studies identified children and young people = 3 aimed to test or understand cultural relevance [24, 29, 31] and n = 2, age appropriateness [29, 31].

Eighty-eight percent of studies reported at least one inclusion criterion. Inclusion criteria included location (n = 2) [26, 28], age (n = 4) [25, 29–31], membership (to school or meeting group (n = 3) [24, 29, 30], subject matter expertise (disease or music n = 2) [25, 27], and others (e.g., marital status, parity, etc., [30]. Exclusion criteria were children [27].

Approximately 75.5% (n = 6) of studies explicitly reported sample size [25, 27, 29–31]; two studies did not report the targeted population studied [26, 28]. Of the six studies reporting sample size, one provided incomplete reports [31]. The participants’ sample sizes ranged from 32 to 461. Only two studies reported participation rates [30]. Twenty-five percent (n = 2) of the studies reported on country-wide interventions and therefore suggested representativeness, although the characteristics of participants were not explicitly stated [26, 28]. All 100.0% (n = 8) reported on participants’ characteristics, including age (n = 4) [25, 29–31], gender (n = 4) [25, 27, 29, 30], expertise and profession (n = 2) [25, 27], role in the family (n = 3) [25, 27, 30], education status (n = 3) [24, 29, 30], and others (n = 1), e.g., parity, marital status, and co-wives. [30].

Efficacy/Effectiveness

All eight articles emphasized the significance of developing and delivering contextually relevant and culturally engaging songs. Six studies utilized local musicians and performers to create the music interventions [25–29, 31]. One study reported collaborating with international musicians [29], while in another study, participants developed and performed music interventions [30]. In all eight studies, those involved in creating the interventions were community members such as teachers, musicians, and cultural groups familiar with the cultural contexts. Additionally, two studies identified individuals with experience in health communication [26, 28]. On the other hand, two articles highlighted the significance of age-appropriate songs [24, 29] in promoting health literacy, health information-seeking behavior, and risk communication to influence behavior change among the intended populations of study. Overall, five articles in the study identified the effectiveness of their music intervention after it reached a mass audience [24, 25, 29–31]. Three of these five articles produced quantifiable results of their effectiveness measurement [29, 32, 33].

Results for at least one measure of effectiveness were reported in 38.0% (n = 3) of interventions [24, 25, 30]. Only one (12.5%) of the study interventions utilized intent-to-treat analysis [29]. Baseline activity was reported by two articles [24, 30], with two studies comparing baseline assessments and intention to treat using post-intervention evaluations and surveys, respectively [24, 30]. One study provided anecdotal evidence of follow-up results, which mentioned increased calls and inquiries to the Directorate of Health Promotion and Education following the performances [26]. Some participants noted ‘they were more likely to remember the images presented in the “Sing” music video due to the feelings of shock and empathy associated with them. Only one paper [30] reported attrition rates.

In a study by Anderson et al., music was identified as a significant, practical, and effective learning intervention to promote awareness about malaria prevention in primary schools [24]. The study revealed a 77.0% increase in knowledge about malaria prevention among children in the music intervention group, with 87.0% demonstrating that they had learned all the correct prevention methods. A study by Manana et al. investigated using Maskandi music to raise awareness about the Sterile Insect Technique (SIT) for malaria vector control. According to their findings, 92.0% of participants found the health education song content adequate, practical, and effective [25]. Additionally, Flax et al. found that the intervention group had a 70% higher rate of initiating breastfeeding within one hour of delivery compared to the control group. Moreover, the intervention group demonstrated an 86.0% higher rate of exclusively feeding colostrum or breast milk to their newborns during the first three days after birth. Furthermore, the control group had higher rates of exclusive breastfeeding at three months (71.0%) and six months (64.0%) [30]. Some studies did not provide measurable outcomes demonstrating the effectiveness of the music shared with participants in promoting health [26, 28, 31]. For instance, Walker et al. did not directly measure study effectiveness, but they reported that images seen by participants from the SING video on HIV/AIDS awareness would likely have a lasting impact [26]. Some studies using participatory risk analysis recommended further research to measure interventions’ effectiveness [27].

Adoption

Most studies did not report on adoption measures other than one, which reported a 100.0% adoption rate among microfinance meeting groups eligible for the integrated breastfeeding interventions [31].

Implementation

Half of the studies reported short intervention durations of one week, six weeks, two months, and seven months [24, 26, 29, 30]. Almost two-thirds (62.5%) reported the extent to which the protocol was delivered as intended [24–27, 29]. Interventions were delivered as intended in all 5 of the reported studies; however, 2 of the interventions allowed for adaptation and creativity in developing and providing musical interventions following structured and uniform training of delivery agents [26, 30]. None of the studies reported on the cost of implementation; however, two studies provided information on the cost measures. They included transportation payment and contract fees for community outreach performances and donations and support received for live performances [26, 28].

Maintenance

None of the interventions reported outcomes assessed six months after the intervention or provided details on the program's plans for continuity and sustainability. However, the studies inferred sustainability. One study reported that participants remembered the song because it was composed to be remembered by setting information to rhythm and repetition to help memory retention, inferring sustainability [24]. The study also reported the ripple effect of increased knowledge in parents and students in other grades who weren’t participants in the study. Three studies (37.5%) included educating the music delivery agents [24, 26, 30]. This knowledge can be transferred, thereby enabling sustainability. Six (75.0%) utilized local delivery agents [24, 26, 28–31]. Although their popularity varied, the use of famous locals was associated with increased community ownership [25]. Three studies (37.5%) utilized existing songs and a video recorded years before [28, 29, 31]. Two studies that used a participatory approach to developing appropriate music [25, 27] reported that the updated and final versions of the songs created will be rerecorded and made into a video as part of efforts to engage communities.

Findings on the risk of bias assessment

To assess the quality of evidence in this study, we utilized the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies and reported in Table 3. This quality assessment tool enabled us to evaluate selected articles on the following indicators to establish selected studies' validity and reliability (I) Research question, (II) Study Population, (III) Groups recruited from the same population and uniform eligibility criteria, (IV) Sample size justification, (V) Exposure assessed prior to outcome measurement, (VI) Sufficient timeframe to see an effect, (VII) Different levels of the exposure of interest (IX) Exposure measures and assessment (X) Repeated exposure assessment (XI) Outcome measures and blinding of outcome assessors (XII) Follow-up rate and statistical analyses. After two investigators ' independent reviews, each selected study's overall methodological quality rating was reported as good, fair, or poor (CO, SA). Discrepancies and differences were resolved by a third investigator (OO) (Table 3). These findings are highlighted below:

Table 3.

Risk bias assessment of selected studies using the NIH quality assessment tool for observational cohort and cross-sectional studies

Author and year	Was the research question or objective in this paper clearly stated?	Was the study population clearly specified and defined?	Was the participation rate of eligible persons at least 50%?	Were all the subjects selected or recruited from the same or similar populations (including the same time period)? Were inclusion and exclusion criteria for being in the study prespecified and applied uniformly to all participants?	Was a sample size justification, power description, or variance and effect estimates provided?	For the analyses in this paper, were the exposure(s) of interest measured prior to the outcome(s) being measured?	Was the timeframe sufficient so that one could reasonably expect to see an association between exposure and outcome if it existed?	For exposures that can vary in amount or level, did the study examine different levels of the exposure as related to the outcome (e.g., categories of exposure, or exposure measured as continuous variable)?	Were the exposure measures (independent variables) clearly defined, valid, reliable, and implemented consistently across all study participants?	Was the exposure(s) assessed more than once over time?	Were the outcome measures (dependent variables) clearly defined, valid, reliable, and implemented consistently across all study participants?	Were the outcome assessors blinded to the exposure status of participants?	Was loss to follow-up after baseline 20% or less?	Were key potential confounding variables measured and adjusted statistically for their impact on the relationship between exposure(s) and outcome(s)?
Anderson et al., 2022 [24]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes	No	Yes	No
Manana et al., 2019 [25]	Yes	Yes	NR*	Yes	No	CD*	CD*	NA*	Yes	No	Yes	NA*	NR*	No
McConnell et al., 2017 [26]	Yes	Yes	NR*	Yes	No	NA*	NA*	NA*	Yes	No	No	NA*	NR*	NR*
Anderson et al., 2018 [27]	Yes	Yes	NR*	Yes	No	NA*	NA*	NA*	NA*	NA*	NA*	NA*	NA*	NA*
Stone, 2017 [28]	Yes	Yes	NR*	No	No	Yes	Yes	No	Yes	No	Yes	No	NA*	No
Walker, 2022 [29]	Yes	Yes	Yes	Yes	No	NA*	NA*	No	Yes	No	Yes	No	NA*	NA*
Flax et al., 2014 [30]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Bastien, 2009 [31]	Yes	Yes	NR*	Yes	No	NA*	NA*	NA*	NA*	NA*	Yes	NA*	NA*	NA*

^*CD cannot determine, NA not applicable, NR not reported

Quality rating (Good, Fair, Poor):

Rater 1 # initials: Good (OC)

Rater 2 # initials Fair (SA)

Research questions

This review included 8 studies [24–31]. All studies (100.0%) clearly stated their research questions or objectives and provided well-defined study populations. Study Population and Sample size justification.

Five studies (62.5%) selected participants from the same population, enhancing internal validity [25–27, 30, 31]. However, only two studies (25%) provided sample size justifications or power analyses [29, 32].

Exposure and outcome measures

Six studies (75.0%) reported clear and consistent exposure measures [24–26, 28–30]. Similarly, six studies (75%) demonstrated clear and consistent outcome measures [24, 25, 28–31]. Only one study (12.5%) assessed exposures more than once over time [30].

Blinding of outcome assessors

Only one study (12.5%) (33) reported blinding of outcome assessors. Most studies (87.5%) either did not employ blinding or did not report on this aspect [24–29, 31].

Follow-up and confounding

Follow-up rates were often not reported or not applicable, with only two studies (25.0%) reporting them [24, 30]. Only one study explicitly reported adjusting for confounding variables (12.5%) [30]. Three studies (37.5%) did not address this issue [24, 25, 28], and four (50.0%) either did not report or deemed it not applicable [26, 27, 29, 31].

Discussion

According to the WHO, Africa faces a significant burden of infectious diseases [37]. The prevention of communicable and non-communicable diseases in Africa remains a dual priority due to the current and expected increase in disease burden. By 2030, there is projected to be a surge of non-communicable diseases like hypertension, stroke, diabetes, cancer, and respiratory diseases [38]. Music has been increasingly recognized as a tool for healthcare, with its therapeutic potential being employed in various clinical settings [38]. Several systematic reviews have shown that music has been used to reduce symptoms and complications of non-communicable diseases such as stroke [39], neurological diseases [39], hypertension [40], cancer [41], mental health [42], and create awareness about infectious diseases such as COVID-19, Ebola, HIV/AIDS, tuberculosis, and malaria [8]. Music as an intervention to promote health is not new in Nigeria. Two songs, titled "Choices" and "Wait for Me," were created in 1989 by Nigerian musical icons King Sunny Ade and Onyeka Onwenu to promote sexual health and sexual responsibility among youths [43]. Some studies have gone beyond raising awareness to assess the impact of music-based interventions on disseminating health information. In our systematic review, the selected studies utilized music as an intervention strategy, leveraging Africa’s diverse musical culture to engage communities. While music interventions are universal, we focus on Africa for its unique sociocultural, historical, and health contexts affecting music's role in health. Overall, our review emphasizes the importance of music in increasing knowledge and awareness and improving behavioral changes. It also highlights the need for socio-culturally appropriate, sensitive, and participatory interventions to ensure sustainability. Moreover, our systematic review is critical because it is one of the few studies to methodically examine the effectiveness of evidence-based music intervention to reduce and prevent diseases in Africa.

Cultural music can convey essential health messages and engage and mobilize communities. Using music to raise awareness and promote healthy behavior is compelling because emotions play a crucial role in transforming knowledge into meaningful action and behavior [30]. The "ripple effect" of music on broader community members (e.g., parents) can further facilitate and enable behavior change [24]. The Maskandi experience, which engaged local artists, teachers, and parents, demonstrated that music-based intervention can be tailored to fit the cultural context, enhancing program effectiveness, acceptance, and sustainability [25]. The importance of positive emotions like love and happiness and negative emotions like fear and anger could facilitate more profound insight and acceptance of health information [30]. Music intervention is an easy and multidimensional intervention without significant adverse side effects that can be widely used and has a promising impact on preventing and reducing the rise and spread of diseases.

Increasing knowledge and awareness and improving behavioral changes

The systematic review highlights how interventions can increase knowledge and awareness and improve behavioral changes. Across the studies, interventions employing culturally and contextually relevant strategies, such as community-designed music interventions, demonstrated notable effectiveness in disseminating health-related information. Anderson et al. (2022) [24] and Manana et al. (2021) [25] used music-based interventions to target specific age groups and communities. These approaches not only increased knowledge about malaria transmission but also actively engaged participants, leading to measurable behavioral changes. These findings are consistent with literature highlighting the importance of participatory research and community engagement using culturally appropriate educational strategies [44, 45]. Music, deeply embedded in local traditions, has proved to be a powerful tool for promoting health literacy and making information more accessible and memorable. Moreover, assessments conducted before and after interventions demonstrated increased knowledge levels, indicating these methods effectively shift behaviors towards healthier practices [24].

Socioculturally appropriate, sensitive, and participatory interventions

The review highlights the importance of customizing interventions to fit the cultural and social contexts of the target populations. The success of these interventions greatly depends on their cultural appropriateness and sensitivity. The studies by McConnell (2017) [26] and Anderson et al. (2017) [27] showed how interventions that resonate with the local culture, such as using traditional music and involving the community in risk analysis, can improve community engagement and the effectiveness of health messages. These studies highlight that culturally appropriate and participatory interventions are more likely to achieve positive outcomes, as they are viewed as legitimate and respectful by the communities they serve. Moreover, the participatory nature of these interventions created a feeling of ownership among community members, further fostering the effectiveness and long-term viability of the initiatives. By engaging local stakeholders in the planning and implementation phases, these programs profoundly impacted the target populations.

Cost-effective, community-based approach for broad reach, sustainability, and scalability

This review underscored that interventions utilizing local resources such as music and community gatherings can be cost-effective and scalable. Studies by Anderson and McConnell emphasized that these community-designed interventions reduce costs and facilitate broader reach and scalability [24, 26, 27]. The design of music interventions using local and existing structures and resources within the community facilitates easy replicability and adaptability in different settings, allowing for scalability and expansion to larger populations without significant additional expense. Integrating these interventions into existing community structures and practices could ensure sustainability. These programs can maintain relevance and effectiveness over time by aligning with cultural norms and leveraging traditional communication channels. The low-cost nature of these interventions, combined with their participatory approach, ensures that they are effective in the short term and sustainable in the long run, providing a model for other communities to adopt.

Given the cultural relevance of music in African communities, clinicians might consider utilizing culturally relevant, age-appropriate, contextual music to raise awareness of important health issues and educate on healthy behaviors in hospital waiting rooms. Similarly, the integration of music interventions could be valuable in providing complementary mental health support in the management of psychosocial conditions such as stress, pain, fear, and anxiety. This could especially be beneficial in settings with limited human resources to provide conventional health education and clinical management of psychosocial health challenges. Music can potentially be an accessible and cost-effective approach to health service delivery.

On a broader scale, music-based interventions could be effectively incorporated into public health campaigns. By leveraging its broad appeal, ability to engage diverse populations, and influence emotions, music could serve multiple purposes, such as in campaigns to promote disease prevention, health education, behavioral change, service uptake, build trust in health systems, and inspire hope during health crises. Music interventions are adaptable and can be delivered at scale, reaching the last-mile target audience. By leveraging technology, music interventions can provide vital public health messages to large populations at a time. In contrast, in rural and underserved areas, such interventions might be particularly impactful in reaching populations with limited access to technology-driven communication strategies.

From a policy perspective, policymakers could consider supporting these interventions as part of a broader effort to enhance the effectiveness of health promotion activities. Based on our review of music-based interventions in Africa, we identify several best practices, including co-creation and community engagement, and the use of socio-culturally appropriate local musical traditions, instruments, and genres. Music is a low-cost and culturally relevant tool in African settings. It could be a great addition to existing health promotion efforts, particularly in resource-limited settings and hard-to-reach areas where other interventions might be less feasible or have less penetration.

More research is needed that is focused on the emotional and social aspects of learning to foster deeper engagement and memory retention through music. Further research is necessary to strengthen the evidence base for music interventions in health. Research should prioritize using RCTs to better establish these interventions' efficacy across various health conditions, health service types, and populations within Africa. Identifying scientific methods for developing culturally and age-appropriate songs will be beneficial; research focused on the emotional and social aspects of learning fosters deeper engagement and memory retention through music [24]. Furthermore, there is a need to explore the long-term effects of music interventions, especially in relation to sustained behavior change and health outcomes. Lastly, future research should investigate the cost-effectiveness of music interventions. This will be critical for determining their scalability and integration into existing health systems without imposing significant financial burdens, especially in resource-limited settings.

While our systematic review provided valuable insight, there are limitations related to potential biases in study selection or data extraction. For example, the interventions in six studies are situated in areas with high disease incidence and prevalence with the risk of exposure to other interventions. Moreover, we may have excluded relevant studies from different regions by focusing solely on the African context. It's important to note that none of the included studies addressed complete disease prevention, reduction, and eradication. This suggests a need for further research to explore how music interventions can contribute to effectively reducing and preventing the burden of diseases in Africa on a broader scale over a long-term period. Also, many of the included studies had relatively small sample sizes, which may limit the generalizability of the findings. The methodology employed in some of the studies could result in research gaps and potential bias in the results that weaken the overall strength of the evidence. Methodological weaknesses in some studies included the absence of control groups, reliance on self-reported data, short follow-up periods, and the need for more information on cost-effectiveness and sustainability. Furthermore, considerable heterogeneity among the studies regarding design, populations, and interventions made it challenging to draw definitive conclusions or categorically compare results across studies. This underscores the need for more standardized research approaches in future studies.

Conclusion

A comprehensive literature review revealed the need for more research examining music interventions' efficacy in reducing and preventing diseases in Africa. This identified an opportunity for broadening the application of music-based interventions. Moreover, our systematic review suggests that evidence-based music interventions have more applications than creating awareness and disseminating information. Our review explores implementation strategies to eradicate diseases and improve African health outcomes. Further, high-end clinical trials are needed to verify the effects of music-based interventions on disease prevention, reduction, and eradication.

Authors’ contributions

JI, JDT, OW, and OE conceptualized the study. CO, SA, UN, AE, and OO curated the data. CO, SA, and OO were responsible for the methods, formal analysis, and visualization. CO, SA, UN, and AE wrote the original draft. Authors (OO, UN, IO, CA, NO, RV, TO, DO, JDT, JI) reviewed and substantially edited the manuscript.

Funding

This work was supported by the National Institutes of Health [grant number NIH-R01HL-168766–02].

Data availability

Not applicable. This study is a systematic review, and all data analyzed were obtained from previously published studies, which are publicly available or can be accessed through the respective journals.

Declarations

Ethics approval and consent to participate

Not applicable. This study is a systematic review of previously published literature and does not involve human participants or require the collection of new primary data. Therefore, ethics approval and consent to participate are not required.

Consent for publication

Not applicable. This study is a systematic review of previously published literature and does not involve new individual data or require consent for publication.

Competing interests

The authors declare that they have no competing interests.