Discussion

The existing body of nutrition education programmes incorporating puppetry remains limited, with only 25 evaluated interventions over nearly 45 years identified for the purposes of this scoping review. Nonetheless, these studies span 13 countries, multiple age groups, and a range of settings, indicating that puppetry has been applied across diverse educational, nutrition-focused and cultural contexts. Across the studies, puppetry-based interventions most consistently improved nutrition knowledge,^{(Reference Abdelrahman, Hashem and Abo-Seif23,Reference Setiana, Handayani and Suminar33–Reference Darawati, Yunianto and Sulendri36,Reference Wright, Wylie-Rosett and Lukoscheck42–Reference Kumbhar45)} however, several studies did not detect significant knowledge gains.^{(Reference Bertrand and Bertrand22,Reference Martinez, Johannsen and Gertner32,Reference Byrd-Bredbenner, Marecic and Bernstein39)} Pélicand et al. ^{(Reference Pélicand, Gagnayre and Sandrin-Berthon9)} used puppets to facilitate emotional expression among children with diabetes, highlighting how puppetry can support psychosocial skills alongside content learning. The overall heterogeneity in design and measurement means that improvements in knowledge are promising but not yet definitive.

Behavioural, anthropometric, and dietary outcomes were more mixed. Several studies found intervention impacts on anthropometrics,^{(Reference Fitzgibbon, Stolley and Schiffer25,Reference Romo and Abril-Ulloa30)} fruit and vegetable intake,^{(Reference Anggraini, Nisa and Hasina37,Reference Murdani, Nanda and laili38,Reference Nicklas, Lopez and Liu41)} acceptance of functional foods,^{(Reference Alessi, Yassin and Leite27)} and improvements in macronutrient intake,^{(Reference Goodwin, Marsh and Roberts28)} while others did not have comparable findings on similar metrics such as BMI and weight,^{(Reference Fitzgibbon, Stolley and Schiffer25,Reference Bevelander, Engels and Anschütz26)} and dietary intake.^{(Reference Sharma, Chuang and Hedberg24,Reference de Droog, van Nee and Govers29)} While these findings align with broader evidence that multifaceted nutrition education and physical activity interventions can influence weight trajectories,^{(Reference Zhou, Ren and Yin46–Reference Kihm49)} some of the reviewed puppet-based interventions were not powered or designed to detect long-term anthropometric effects.^{(Reference Fitzgibbon, Stolley and Schiffer25,Reference Romo and Abril-Ulloa30,Reference Martinez, Johannsen and Gertner32,Reference Fitzgibbon, Stolley and Schiffer40)}

A key theme across puppetry-based interventions included in this review is the importance of active engagement and the applications of social learning. Interventions that include experiential components such as taste testing, role-play, or interacting with characters appear particularly effective. Both puppetry-based educational videos and live shows improved knowledge or nutrient intake through framing abstract health messages and concepts in ways that the audience found relatable and emotionally resonant.^{(Reference Pélicand, Gagnayre and Sandrin-Berthon9,Reference Abdelrahman, Hashem and Abo-Seif23,Reference Sharma, Chuang and Hedberg24,Reference Alessi, Yassin and Leite27,Reference Glorioso, Narciso and Avilla31,Reference Darawati, Yunianto and Sulendri36,Reference Anggraini, Nisa and Hasina37,Reference Nicklas, Lopez and Liu41,Reference Arora, Kumar and Deep43,Reference Kumbhar45)} However, few studies reported specifically how puppet characters were developed, scripted, or adapted to reflect participants’ culture, identities, languages, or social environments,^{(Reference Sharma, Chuang and Hedberg24,Reference Alessi, Yassin and Leite27,Reference de Droog, van Nee and Govers29,Reference Romo and Abril-Ulloa30–Reference Permanasari, Khoirahman and Utami35,Reference Anggraini, Nisa and Hasina37,Reference Murdani, Nanda and laili38,Reference Kumbhar45)} even though arts-based health literature suggests that culturally grounded characters and narratives can strengthen identification and message relevance.^{(Reference Abu-Ras, Al-Kubaisi and Idris2–Reference Kröger and Nupponen5,Reference Jacono and Jacono11,Reference Skinner, Metcalf and Seager12,Reference Chandler, Leass, Shegog and Aboul-Enein17,Reference Darawati, Yunianto and Sulendri36)} Incorporation of additional methodological information in future interventions on puppet type, character design, and scripting decisions would help further elucidate how these elements influence both audience engagement and intended intervention outcomes.

Another educational approach across the studies reviewed is the frequent use of puppetry to introduce or reinforce nutrition information or nutrition related behaviour combined with other multi-component aspects in support of the intervention (such as teacher- or parent-led activities, take-home materials, or environmental modifications) intended to support behaviour change.^{(Reference Abdelrahman, Hashem and Abo-Seif23–Reference Fitzgibbon, Stolley and Schiffer25,Reference Alessi, Yassin and Leite27,Reference Romo and Abril-Ulloa30,Reference Martinez, Johannsen and Gertner32,Reference Usfar, Budiman and Lan34,Reference Darawati, Yunianto and Sulendri36–Reference Murdani, Nanda and laili38,Reference Nicklas, Lopez and Liu41,Reference Perez-Rodrigo and Aranceta44)} This aligns with broader behaviour-change models that emphasise layering information, skills practice, social support, and structural changes to influence diet-related behaviours.^{(Reference Rinderknecht and Smith50–Reference Browne, Minozzi and Bellisario54)} Within this framework, puppetry-based interventions may be particularly well suited for capturing attention and engaging the audience, modelling dialogue about complex topics and concepts, and lowering barriers to participation across diverse audiences and participant age groups; however, additional intervention components are needed to sustain and translate outcomes from puppetry-based interventions into everyday food choices.

The review highlights important gaps in the current evidence base. First, there is limited use of standardised, validated measures of dietary intake, psychosocial constructs, and anthropometric outcomes, which complicates cross-study comparison. Second, most interventions in this review assessed outcomes immediately or shortly after the puppetry-based intervention, with relatively few studies incorporating longer-term follow-up. Therefore, it remains uncertain whether observed gains in knowledge or short-term changes in diet-related behaviour are sustained over time. Third, almost none of the included interventions utilised a control group or explicitly compared different puppet formats, story styles, or degrees of audience participation, even though emerging applied-puppetry and arts-based health research suggests that these design choices may influence engagement and effectiveness

Future research should therefore prioritise more rigorous study designs, including randomised or well-controlled quasi-experimental trials; transparent methodological designs describing puppet design, script development, and intervention implementation processes; and incorporation of longer follow-up timeframes to capture maintenance of behaviour change. Studies that explicitly test puppetry as a standalone component as compared to puppetry-based interventions that are developed in combination with other educational strategies would help to determine whether puppets primarily act as a tool to capture the interest of and engage the audience, or whether puppetry can be utilised in nutrition education intervention settings to facilitate positive impacts on nutrition- and health-related knowledge, attitude, and behaviour outcomes.

Finally, this review underscores the potential for puppetry-based nutrition education to be integrated into broader health promotion and disease prevention programmes. Existing evidence from related fields, including oral health, sexual health, general health behaviours, and mental health promotion, suggests that puppets can facilitate dialogue, enhance recall of key messages, and support emotional processing among children and adults.^{(Reference Abu-Ras, Al-Kubaisi and Idris2,Reference Ladera-Castañeda, Córdova-Limaylla and Briceño-Vergel8,Reference Chandler, Leass, Shegog and Aboul-Enein17,Reference Alosail, Alwadi and Alroweilly55,Reference Synovitz56)} Leveraging these constructs within well-designed, theoretically-based, and culturally tailored nutrition interventions may contribute to creatively addressing challenges in engaging diverse populations and translating nutrition knowledge into sustainable dietary change.