3.0 Arts, Culture and Wellbeing – Creative Health

That participation in arts and culture-based pursuits can positively impact health is widely acknowledged,1 acceptance of this interrelationship is reflected at strategic and policy levels (i.e. Cayton, 2007; Cayton & Hewitt, 2007; Gordon-Nesbitt, 2022; Liikanen, 2010; Parkinson, 2021; Musella, 2021; Meadows & McLennan, 2022) where policymakers are increasingly striving to find ways to integrate arts and culture with the more traditional aspects of health and social care. Writing in an advisory capacity intended to assist the Department of Health in understanding ‘its role in relation to arts and health,’ National Director for Patient and Public, Harry Cayton, observed that ‘spending on arts and health is and should be seen as a legitimate, integral part of healthcare and good staff management and support, and entirely appropriate for NHS activity and investment, for instance for health promotion’ (Cayton, 2007). More recently, the Greater Manchester Integrated Care Partnership published their Creative Health Strategy, finding, on the basis of ‘[c]ompelling evidence (…) that engaging with creativity, culture and heritage helps us to lead longer, healthier, happier lives’. The term Creative Health denotes this elision of health and wellbeing which can ‘embrace activities that can enhance health and wellbeing in both direct and indirect ways’ (Gordon-Nesbitt, 2022).2

There is no shortage of literature surveying the myriad of interventions in the broad field of arts and health (i.e. Cayton & Hewitt, 2007; APPG, 2017; Fancourt & Finn, 2019; Staricoff, 2004). In their extensive study reviewing the evidence of the role of arts for improving health and wellbeing, Fancourt and Finn include over 900 publications among which – in turn – ‘over 200 [were] reviews, systematic reviews, meta-analyses and meta-syntheses covering over 3000 studies, and over 700 further individual studies’ (Fancourt & Finn, 2019). The breadth of this undertaking illustrates the wide-ranging character of the field. These authors cover – for example – how the arts affect social determinants of health, supports child development, encourage health promoting behaviours and engage marginalised and hard-to-reach groups as well as how they help to prevent ill health (Fancourt & Finn, 2019). Their findings – alongside those of Cayton and Hewitt, (2007) – show the wide-ranging uses to which the arts (and culture) can be put in the service of an equally broad gamut of potential health and related benefits.

1 The What Works Centre for Wellbeing has produced a number of scoping reviews on the wellbeing impact of a variety of arts and cultural activities. Available at: https://whatworkswellbeing.org/category/culture-arts-and-sport/ 2 Musella (2021) notes that ‘the recent establishment of the National Centre for Creative Health signals a strong commitment to understanding the contribution of arts and creativity to health and social care.’

Equally, any benefits to be gained might accrue to any number of people/ groups within our society. As Cayton and Hewitt summarise ‘many arts and health organisations and initiatives have been established for a number of decades, both in the UK and abroad. They involve individuals, groups and organisations from many different backgrounds including the state, private and not-for-profit sectors, artists, clinicians, art therapists, occupational therapists and managers. They serve a range of different people including those with disabilities, mental health problems, those with terminal illnesses and long-term health conditions, older people, carers, refugees and people from a wide variety of ethic origins’ (Cayton & Hewitt, 2007).

While intriguing, the scope of potential arts and health interventions is considerable, hinting at the possible challenges lying in wait for those attempting to evaluate the efficacy and, if possible, to assign causality to their work.

3.1 What is Wellbeing and How does it Fit Here?

The efficacy of some of the work undertaken in the arts and health space can be assessed in terms of more ‘traditional’/ tangible, metrics. For example, the Greater Manchester based Bronchial Boogie pilot which gave asthmatic school children the opportunity to learn brass and wind instruments3 to improve their lung health had impressive results whereby ‘[b]efore the lessons began, 35% of the pupils who took part had to take time off because of asthma. Now the figure is 5%. Previously, 45% of the pupils had difficulty participating in school sports. Now the figure is 15%’ (Lupton, 2004).4 In her review, Arts in Health: a review of the medical literature, Staricoff is able to identify ways in which arts interventions have brought about clinical effects; including reduction of anxiety and depression of cancer and cardiovascular patients (also see: Renton et al., 2012; Smith et al, 2012), reduction in length of stay on intensive care unit, improved pain management and reduced drug consumption (Staricoff, 2004).

While any of the above examples demonstrate improvements which might be understood to contribute to better health and by extension, improved (mental) wellbeing, it is useful to further define health per se and, to appropriately situate the notion of wellbeing within an understanding of health and the arts and culture space.

3 In combination with asthma education.

4 Evaluation of Sing and Breath – a singing for lung health intervention based in Salisbury that sought to ‘support and educate people with lung conditions in Salisbury to better manage their breath through singing’- set out to gauge success across a number of social vectors (i.e. peer support, reduction of social isolation, etc), clear that ‘the evaluation is not seeking to demonstrate measurable changes in clinical outcomes for participants and, evaluation methods are based on participants’ perceptions and self-reporting. Data collection intentionally did not seek information about clinical indicators such as reduced use of medication or increased peak flow’. However, where this kind of information has been offered by participants, it has been considered as qualitative data in the evaluation process (Farrally, 2020). Even where clinical improvement might be an expected outcome, depending on aims and objectives, it may not be a ‘useful’ metric for evaluative purposes.

Health can be understood from physical and mental perspectives (Fancourt & Finn, 2019). In its foundational constitution, the World Health Organization (WHO) defined health as ‘a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity’ (cited in: APPG, 2017). As the preceding discussion implies these realms can easily overlap. For example, a person struggling with poor physical health may find that their mental health suffers as a result. Furthermore, while modern medical science is now more adept at coping with disease and infirmity than was the case in 1946 (when the WHO began its activities), the challenges of aging populations, chronic and social (i.e. alcohol, drugs, violence, poor mental health) disease are now foremost issues. This is recognised in WHO’s expanded definition of health which proposes that ‘health and wellbeing include physical, cognitive, emotional and social dimensions’ (APPG, 2017).

Though it is clear that health and wellbeing are linked concepts, it is nevertheless difficult to pin down the notion of wellbeing. Writing in their Inquiry Report for creative health, the All-Party Parliamentary Group (APPG) wrestle with this task (also see: Oman, 2021 on interchangeability of terms). Outlining some of the attempts to define wellbeing, these authors note the lack of consensus in the area. They argue the utility of confining the focus of wellbeing to mental wellbeing (rather than including the physical as the WHO does) and also, of distinguishing wellbeing from mental health per se; i.e. low levels of wellbeing do not necessarily denote the presence of a mental disorder. Despite these difficulties, they foreground a useful construct developed through a Delphi consensus process5 and, identifying three aspects of wellbeing. These comprise the personal which ‘includes confidence and self-esteem, meaning and purpose, reduced anxiety and increased optimism; the cultural dimension [which] includes coping and resilience, capability and achievement, personal identity creative skills and expression and life skills such as employability;6 the social dimension [which] includes belonging and identity, sociability and new connections, bonding and social capital, reducing social inequalities and reciprocity’ (APPG, 2017).

As definitions go, this one is wide ranging. Recognising its scope allows for the acknowledgement of the ways that wellbeing can be substituted/ conflated with notions such as self-esteem and resilience. This is important as it allows for the inclusion of (particularly grey) literature where wellbeing is not directly mentioned but proxies, or related concepts, are. These factors contribute to wellbeing, and it is worth examining the measurement approaches taken.7

5 Here, the overarching approach is based on a series of ‘rounds’, where … experts are asked their opinions on a particular issue. The questions for each round are based in part of the findings of the previous one, allowing the study to evolve over time in response to earlier findings… [P]articipants are able to see the results of previous rounds—including their own responses—allowing them to reflect on the views of others and reposition their own opinions accordingly (Barrett & Heale, 2020).

6 Interestingly, in their interim evaluation of an arts for wellbeing social prescribing scheme, White and Salamon suggest that part of their evaluation went unanswered by all respondents as they did not necessarily ‘draw the link between arts participation and employment’ (White & Salamon, 2010).

7 There is a significant criminal justice literature pertaining to arts and culture-based interventions relating to desistance, wellbeing per se is not always a foremost metric but it is nevertheless clear that the outcomes of the intervention (and the changes in metrics) will contribute to improved wellbeing overall (i.e.: Caulfield et al., 2018; Massie et al., 2019; Froggatt & Breton, 2020).

3.2 How We Know Wellbeing through Data8

As the foregoing suggests, wellbeing is something of a contested area. This has consequences for the ways in which wellbeing might be captured in a measurable way, which – perhaps unsurprisingly – is attempted using a variety of methods.9 For the purposes of the discussion here, it is important to know that wellbeing data can be objective (i.e. mortality rates, higher educational attainment, economic sufficiency and stability) or subjective (i.e. life satisfaction, joy, contentment, hope). Subjective data can be viewed through the lens of the hedonic (i.e. transient happiness or contentment derived from doing what we like or, avoiding doing what we do not like) or the eudaimonic (i.e. more durable contentment deriving from meaning and purpose; a sense that the things one does in life are worthwhile). While there may be a tendency (especially prevalent in academic and policy settings) to prioritise numbery quantitative data over their wordy qualitative counterpart (Oman & Taylor, 2018), Oman is forthright in resisting ‘this assumption that any data is better than another because we read them as text or count them as numbers or collect them differently.’ Rather, she argues that ‘[a]ll well-being10 data might be valuable to understanding well-being. Whether they are qualitative or quantitative is not the issue at hand. Instead, context is the issue: where the data came from, are they used appropriately and how are they applied?’ (Oman, 2021).

Thus, while it is possible to measure (or attempt to measure) wellbeing as a numbery value (i.e. return on investment - ROI or social return on investment – SROI)11 this is not necessarily the most appropriate approach for capturing information pertaining to wellbeing (i.e. Oman, 2021).

8 Oman, 2021.

9 Oman (2021) provides an excellent precis of the ‘knowing’ of wellbeing through the lens of a history of data. The author’s premise – that data are, of course, coloured by the biases, interests and policy proposals of those who interpret them or commission their collection and collation – informs her enlightening overview of the types of data that can – and have – been used to evidence wellbeing.

10 Oman (2021) notes that the contestation around wellbeing extends to failure to agree on a single spelling. In her work, she prefers ‘well-being,’ and the original spelling is retained here.

11 Interestingly, Transported Art do include a ROI value in their evaluations of the arts and cultural projects that they undertake. It is notable, however, that they caveat the values assigned to activities as follows ‘these are monetised values but we avoid the £ sign which undermines the message that these [are] social and cultural, not financial values’. See: https://www.transportedart. com/about/evaluation/ . In their reports examining the social and wellbeing benefits of engaging with culture and sport, Fujiwara et al. employ methods and analyses which priorities ‘cashable or financial benefits and savings’ (2014) and subjective wellbeing using wellbeing valuation which draws on large data sets of individuals’ subjective wellbeing data ‘to assess the extent to which engagement in arts and sports impacts on people’s subjective wellbeing and then place[s] monetary values on these impacts’ (2014a). Musella discusses wellbeing valuation approaches and the use of wellbeing in policy appraisal noting that a ‘wellbeing valuation approach has helped build consensus of monetisation and value of subjective wellbeing impacts […] The HM Green Book Supplementary Guidance emphasises wellbeing as a key component in the assessment of costs and benefits to society. It introduces a simple but effective measure of wellbeing: the ‘Wellbeing-adjusted Life Year’ (WELLBY). This is defined as a one-point change in life satisfaction on a Likert scale between 0 to 10 for an individual for one year. The use of the WELLBY approach as a metric allows evaluators to capture the full social and economic benefits of cultural policy actions’ (Musella, 2021). MacLennan et al. (2021) and MacLennan & Stead (2021) examine the pros and cons of quantifying and monetising wellbeing effects using Social Cost Benefit Analysis (SCBA) approaches. It is not clear that any of the methodologies outlined are particularly appropriate for use with smaller scale interventions.

Further, where mental health is a particular focus, ‘outcomes have to be subjectively validated by the participants and […] intended outcomes may not translate straightforwardly into measurable health improvements on clinical scales.’ 12 Instead, ‘good observational data’ can play an important role here and the current move away from the traditional view of the evidence hierarchy increasingly favours ‘a combination of methods’ (APPG, 2017).13 Such an argument strongly implies that both validated survey measures and free text approaches14 to data gathering are the most appropriate answer to the question of How We (Might) Know Wellbeing through Data for evaluation of arts and cultural interventions aimed at supporting mental wellbeing.15 An approach comprising these elements provides the possibility to meaningfully capture data pertaining to the subjective wellbeing benefits of an intervention, is most appropriate for gaining insight into mental wellbeing and, if well administered, any change experienced by participants over time.

12 In this case the authors are arguing that clinical approaches including Randomised Control Trials (RCTs) are of limited utility (and often infeasible).

13 In their review of the interaction of arts, culture, health and wellbeing in the criminal justice sector, ACE note that a minority of studies captured in their literature search used biomarkers to detect changes in stress hormones such as cortisol or ‘to see whether and how far cultural engagement might affect the many mental health conditions that are characterised by underlying inflammatory immune responses’ (ACE, 2018). In this way, clinical/traditionally medicalised approach to measuring psychological/ mental wellbeing is utilised. It is also possible to track markers such as reduction in medication use or number of primary care visits. In their interim evaluation of a social prescribing programme, White and Salamon did not collect this data, ‘possibly due to […] [the] emphasis on being an non-medical intervention’. The same researchers question whether tracking medication and service use is particularly meaningful for the context they are investigating (White & Salamon, 2010).

14 Oman (2020) argues for free text approaches to the appraisal of wellbeing findings in her extensive work with the Office of National Statistics ‘Measuring National Well-being’ data set suggests that ‘people often preferred describing well-being in their own words to only sticking to the categories offered by the ONS’. Also, Ander et al. (2011) observe that scales seeking to standardise ‘what psychological wellbeing is’ can leave little space for individual voices which may ‘have a very different perspective on what makes them happy or well.’

15 In her review of literature contributing to her exploration of the measurement of the impact of arts and culture on wellbeing, Musella finds that the studies reviewed were multidisciplinary, ‘using both quantitative and mixed-method design to look at how and why wellbeing improves.’ Also, it is noteworthy that ‘quantitative studies that did not use a pre-post design were excluded from the review’ (Musella, 2021). MacLennan et al. (2021) also note that a mixed methods approach to identifying wellbeing benefits may be most appropriate.