Contents

Use the links below to navigate to different areas of the report.

Background
Overview of review findings
Reflections on the evidence base

Representation
Reporting
Choice and application of methods
Analysis and reporting of findings
Wider challenges and implications

Recommendations for future work

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Background

Between October 2019 and November 2022, we reviewed extensive literature within our thematic area of culture, health and wellbeing. This theme was seen as being particularly relevant due to the sharp growth in interest in the field by researchers and policymakers.

We explored the literature using a systematic and critical approach to understand the strength of the evidence base, highlight where current gaps in knowledge lie, and outline implications for future research, funding and policy development.

As part of this theme, we explored the following six topics:

1. 1. • Culture on referral or social prescribing through the arts
      • The experiences of cultural practitioners working in healthcare spaces (not yet published due to lack of literature)
      • Training and development of healthcare students
      • Young people’s mental health
      • Older people’s physical health
      • Older people’s wellbeing and social connection

These topic areas were drawn from our scoping and consultation events held over winter 2019-2020 and influenced by our sector survey, as well as reflecting the expertise and research interests of Dr Robyn Dowlen (Postdoctoral Research Associate, 2019-22).

Each individual research review was shaped through our engaged research process, in consultation with practitioners, researchers and policymakers. The research digests outlined the current evidence base for each topic. We have developed complementary materials for each research area, including blogs, podcasts, case studies, conference presentations and reading lists.

In reviewing the literature, we observed a clear growth in interest in the area of culture, health and wellbeing over the past decade. There was a wide range of studies reporting on different cultural programmes and experiences (and their relationship to myriad mental health, physical health and wellbeing outcomes).

The literature within this field is largely concentrated in England, the USA, Canada and Australia. The nature of our rapid review process meant that non-English language journal articles were excluded due to the time and resource needed to translate materials, so this review does not purport to present a truly global perspective.

Despite this caveat, we can assert with confidence that the UK (specifically England) is a research hotspot regarding culture, health and wellbeing research, producing a third of the studies represented across the six reviews.

Numerous research disciplines are represented within this area, with a significant proportion of research bringing together researchers from numerous disciplines to address complex questions. As an example, Figure 1 outlines the spectrum of disciplines represented in the ‘Older people: culture, community, connection’ review.

It is important to note that most research in this area was published by researchers from the sciences and social sciences rather than arts and humanities. There were also very few named cultural practitioners, organisations or those with lived experience of mental or physical health challenges represented in author lists.

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Overview of review findings

The following section provides a summary of the key findings from each topic areas explored as part of our culture, health and wellbeing theme.

Cultural on referral
We identified 13 studies that examined impacts and outcomes relating to culture on referral (or arts on prescription) programmes. All studies demonstrated positive outcomes on participants’ sense of wellbeing, with participants reporting an increased sense of confidence, self-esteem and social connectivity.

Training and development of healthcare students
We identified 20 studies that examined impacts and outcomes relating to the use of culture in the training and development of healthcare students. Programmes incorporating drama and theatre techniques, especially those that used role-play and improvisation, were most commonly associated with improving students’ understanding of patient perspectives and experiences.

There was also emerging evidence of improvements in observational skills as a result of engaging with gallery-based programmes, especially those led by staff members trained in specific viewing techniques (e.g. the Art of Observation).

Young people’s mental health
We identified 20 studies that examined impacts and outcomes relating to young people’s mental health and wellbeing – an increasingly salient area for policy, particularly following the Covid-19 pandemic. Music participation was shown to improve young people’s confidence and self-esteem, which led to increased feelings of wellbeing. Song and lyric writing were shown to be particularly beneficial for helping young people to express their emotions.

Older people’s physical health
We identified 23 studies that examined the role of cultural programmes in supporting older people’s physical health. Dance programmes were shown to have a positive impact on older people’s physical function, balance and posture.

Older people’s wellbeing and social connection
We identified 70 studies that examined the role of cultural participation in supporting feelings of wellbeing and social connection for older people. The strongest evidence was in relation to community-based singing, which was shown to help older people cope with bereavement, develop new friendships and improve overall feelings of wellbeing and social connectedness.

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Reflections on the evidence base

The following section brings together our reflections on the evidence base as it stands at the date of publication. It discusses both the strengths and limitations of current evidence and reflects on how it might be strengthened in the future.

These observations reflect some of the key challenges of conveying the value of culture in the context of people’s health and wellbeing.

We have broken these reflections down to highlight the key areas that arose in our analysis of the research:

1. 1. 1. Representation
      2. Reporting
      3. Choice and application of methods
      4. Analysis of findings
      5. Wider challenges and implications

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Representation

We are concerned by a general lack of representation within the research literature, both in the type of cultural experience being explored by researchers and in the people who are recruited as research participants.

Type of cultural experience
There is an evident disparity in the types of cultural experiences represented within culture, health and wellbeing research. Music programmes are the most reported within the literature, especially those involving younger and older people, followed by mixed cultural programmes, including a range of typically visual arts-based activities.

We know through engaging with the cultural sector and examining wider publications (i.e. Creatively Minded: The Directory and the All-Party Parliamentary Group on Arts and Health’s Creative Health report) that in practice there is a much wider range of cultural practices in this field than that yet represented in academic research.

This gap is concerning, as it potentially represents an academic bias towards certain types of cultural activity, leaving the evidence base for heritage-based programmes, digital programmes and cinema and screen programmes comparatively under-investigated.

There was also a lack of consideration of the evolving nature of this field, including discussions around what is considered creative and cultural activity, particularly as it relates to digital and online spaces. The overarching focus on arts and cultural ‘programmes’ or ‘interventions’ in this area also meant the role of everyday cultural participation and its relationship to health and wellbeing was under-explored.

The role of everyday creativity and its connection to wellbeing was identified as a priority area in our research shaping event on everyday creativity and was discussed within our research digest on this topic area.

It is unclear why there is such a clear disparity or bias towards certain cultural experiences within the culture, health and wellbeing literature – is it a question of what is funded? Or is there more research expertise within certain areas than others?

Diversity of research participants
Across our reviews, we observed a lack of diversity in who was represented as research participants. For example, most participants represented in our Culture on referral review were older white women (aged 50+) with mild-to-moderate stress, depression or anxiety.

For research to be robust and representative, participants in culture, health and wellbeing research should reflect the diversity of our society in terms of race, ethnicity, gender, age, socioeconomic status, etc. Having a diverse range of participant voices will not only strengthen the evidence base and make research findings more credible and robust, but it will also make research in this area more ethical and equitable.

Participants in academic research may not offer a direct reflection of who is taking part in these programmes in practice. However, it is important to consider how researchers and the cultural sector might build relationships with different communities to ensure research and practice is as diverse and representative as possible.

Practitioner voices
Cultural practitioners and organisations are working in ever more complicated health settings. This includes supporting people with long-term mental health challenges, as well as working within in-patient settings and care homes. In conversations and meetings with cultural organisations and practitioners over the duration of this theme, we have directly observed the significant knowledge held at ground level. However, the expertise of cultural organisations and practitioners is rarely represented within the academic literature.

In 2020, we conducted a rapid review of the literature which explored the experiences of cultural practitioners working in healthcare contexts. We identified only two peer-reviewed studies which directly explored practitioners’ experiences, and even these studies focussed strongly on patient outcomes.

There is therefore a pressing need to explore the training and development needs of practitioners, as well as supporting their own mental health and wellbeing. By not including cultural organisations and practitioners’ experiences and knowledge gained through their practice, we are failing to obtain holistic perspectives on what it means to plan, deliver and evaluate culture, health and wellbeing programmes in practice. Given the central role of the cultural sector in this area, it would seem we are missing an essential piece of the puzzle by not including the sector’s expertise in drawing together the evidence base.

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Reporting

We have observed commonalities across much of the literature when it comes to what is and is not reported within peer-reviewed journal articles. This section outlines this challenge and discusses how it limits what we know about how culture impacts on health and wellbeing.

Outcome over process
Academic journals each have a specific scope, word limit and preferred structure for manuscripts. Researchers will therefore always have to make decisions about what is and is not reported within the context of a journal submission. While we recognise the limitations placed on reporting research findings in the context of peer-reviewed journals, we have consistently seen a lack of detail provided about the cultural experiences held by participants.

Many studies in the research areas we explored provide minimal detail relating to the experiences that participants had, dedicating more time and space to presenting and discussing outcomes. While it is undoubtedly important to showcase the positive impacts and outcomes relating to culture, health and wellbeing programmes, the limited detail provided about the cultural programmes themselves makes it difficult to determine what exactly works, for whom and in which contexts.

Without this detail, it is very challenging to disentangle the role of arts and cultural activity from more generic group-based activities.

Transparency
While we recognise that not everything can be reported within the context of a research article, we observed a large number of studies that did not report even basic information relating to recruitment processes, ethics and participant demographics.

The omission of such information makes it challenging to assess the quality of the research when using critical appraisal tools and limits the critical synthesis of studies within reviews. With regards to participant demographics, for example, many studies did not report any demographic information beyond age and gender. Not reporting this information limits our understanding of the value of cultural programmes with a focus on health and wellbeing for those from minoritized communities who may require tailored, co-created programmes.

This transparency issue links to the previous section on the representativeness of participants in this field and raises concerns about the rigour and translatability of findings.

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Choice and application of methods

One of the key strengths of this research area is the multidisciplinary approaches taken to understand the value of culture for health and wellbeing. A number of studies took multidisciplinary approaches with large teams, bringing together researchers from the too often separate worlds of culture and health. This means that a broad range of methods and methodologies were engaged with to understand the impacts of cultural programmes on people’s health and wellbeing.

The following section outlines some of the challenges involved in selecting methods in this area to demonstrate value in the context of health and wellbeing.

Justification of methods
Across the board, there was a lack of justification for why particular research methodologies and methods were selected. This was particularly the case in the Culture on referral review, where the Warwick Edinburgh Mental Wellbeing Scale was chosen across a significant number of studies as a core outcome measure, with no explicit discussion of why this scale was used as a measure of wellbeing in preference to other approaches.

While the scale is a validated measure of wellbeing, the lack of criticality in choosing to adopt the scale in the context of complex research questions raises concern.

This absence of justification was also evident in some qualitative and mixed methods studies, with a lack of consideration given to the different populations taking part (i.e. older people, younger people, people experiencing mental health challenges) and how methods should be adapted to support participation.

This lack of critical lens when applying different methodological approaches is perhaps tied to the formulation of overly broad research questions and study aims, which led to several studies presenting generic, superficial findings that are not necessarily transferable outside the narrow scope of the study.

The lack of justification impacted negatively on the quality of mixed-methods studies in particular. When appraising mixed-methods literature, most studies using this approach did not justify the use of mixed-methods approaches, which led to poor integration of qualitative and quantitative findings.

Bringing together quantitative and qualitative data should theoretically strengthen the findings as this approach incorporates statistical data and trends with the lived experiences of participants. This is particularly important given that the impacts and outcomes relating to cultural programmes are numerous and complex.

In addition to this, only a handful of studies followed participants beyond the duration of programmes; the majority of studies were short-term with limited follow-up. This was particularly evident within our Culture on referral review, where there were few examples of follow-up to identify the longer-term impacts of social prescriptions – i.e. the number of GP visits, feelings of social inclusion and connectivity, etc.

This lack of follow-up also means there has been little consideration to date of how programmes with limited duration impact on people in the longer term – i.e. are there any negative impacts after programmes come to an end? Are people re-referred to programmes?

Lack of participatory methods
Given the increasing use of co-production within cultural practitioners and organisations to create culture-based programmes with people experiencing mental or physical health challenges, there was a real absence of participatory and co-produced approaches to research in this field.

There is growing recognition of the importance of integrating lived experiences into our understanding of the value of culture for health and wellbeing, including The Lived Experience Network (LENs) and UK Research and Innovation’s (UKRI) Mobilising Community Assets to Tackle Health Inequalities investment fund. While lived experience is central in policy and practice discussions, the absence within this research area should be noted.

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Analysis and reporting of findings

Through our appraisal of the published research, we observed a number of key weaknesses in the analysis and reporting of research findings, which limit the strength of the evidence available. In some cases, this has led to an overstatement of findings that are not reflective of the data presented. The following section will outline the key aspects of analysis and reporting that may have introduced bias into studies.

Underdeveloped qualitative analyses
The major problem we observed in relation to qualitative studies was the often surface-level analysis that did not necessarily get to the core of participants’ lived experiences. This is, in part, a result of poorly designed approaches to gathering qualitative data – including short interviews (10-20 minutes in length) and open ended questions in written evaluation forms.

In the most extreme examples, this led to the presentation of vague, under-developed findings that did not explore key concepts or findings arising from the data. For example, in the Young people’s mental health review, the concept of ‘safe spaces’ occurred frequently but was not explored in any real detail – i.e. what makes a space ‘safe’? How do arts and cultural experiences contribute to the feelings of ‘safety’ in different spaces?

Significance chasing?
Although a large majority of quantitative studies we examined used appropriate approaches to analysis, a handful of studies used a large range of outcome measures and chased for significance that was not there. For example, some studies reported overarching impacts to participant wellbeing when only a given subscale of a single outcome measure reached the significance threshold. This led in the most extreme cases to an inappropriate overstatement of findings. While this was rare within the broad literature we examined, it is essential to examine findings using a critical lens to evaluate whether reported findings are reflective of the data provided.

Acknowledging failure
There was a very limited acknowledgement of failure within the literature, with most studies reporting only positive findings. Studies with no significant findings, or mixed findings, tended to point to undermining the choice of methods rather than considering why a given programme may not have led to anticipated changes in health and wellbeing outcomes.

This reluctance to discuss failure reflects the wider need in this area to remain independent and unbiased and to be able to showcase what works (and what doesn’t) for whom, in which circumstances, and why.

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Wider challenges and implications

Sustainability
We observed a lot of pilot programmes within the literature, with many studies funded by short-term research grants. This reflects the wider challenge of creating sustainable programmes that can support and evaluate the health and wellbeing of the population over the long term. Although there are growing examples of programmes that are using research to scale-up culture, health and wellbeing programmes (i.e., Kings College London’s SHAPER programme), these kind of programmes require significant investment and complex stakeholder engagement and therefore remain exceptional.

Lack of open access literature
Most of the research we examined was published behind journal paywalls, so it is positive to see funders such as UK Research & Innovation (UKRI) now requiring immediate open access for peer-reviewed research articles.

We need cultural organisations and practitioners to be able to use research to support their practice, and although more institutions are supporting open access publishing, this is happening slowly and is less frequent in literature published by international researchers. We would encourage the publication of pre-prints or accepted manuscripts of articles so that research is more accessible and readily available.

This openness is also required from the cultural sector. It is very rare that evaluation reports are published openly for scrutiny and inclusion within literature reviews. There are a number of sector resources such as the Repository for Arts and Health Resources and the newly launched database from the Social Prescribing Network, which have begun to collate grey literature. However, these databases require upkeep and engagement from the sector to ensure they are as relevant and useful as possible. This is an area we are keen to address ourselves at the Centre for Cultural Value.

Keeping up
We know that practice on the ground is often evolving much quicker than the evidence base can. For example, culture on referral programmes are evolving rapidly while associated research takes longer to be published. The digital cultural programmes we saw springing up during the Covid-19 pandemic - which seem to have had considerable impacts on personal and collecting mental and physical health and wellbeing - evolved at a lightning pace. It is therefore quite likely that this literature review does not yet reflect all the evidence being gathered in this policy area.

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Recommendations for future work

The following section outlines recommendations we have formulated in response to the thematic areas outlined in this paper.

For the research community

1. 1. 1. We should aim, as researchers, to take a broader approach to this area – enabling wide-ranging cultural and creative activities to be represented in the research literature. This includes areas of heritage, everyday creativity, mixed-arts and digital and online programmes. This will ensure research is capturing the broad value of culture for health and wellbeing within an increasingly hybrid creative and cultural landscape.
      2. It is clear that researchers are already fostering multidisciplinary approaches within academia. Still, voices from the creative and cultural sectors and people with lived experiences of health and wellbeing challenges should now be better integrated into the design, implementation, dissemination and evaluation of research from the outset to ensure their experiences are reflected in research outcomes.
      3. There should be a greater impetus for research that draws on the experiences of wider demographic groups – recognising and acting on the systemic barriers that exclude people from minoritized backgrounds from participating in research. There should be greater transparency as to who is represented in research and acknowledgement of the health inequalities that are observable for different communities. Participatory and co-created research programmes are essential to highlight the voices of under-represented and minoritized groups and ensure work in this area is relevant and meaningful to them.
      4. Rigorous mixed methods research that centres on participants’ lived experiences, balances process with outcomes and captures follow-up (or ripple effects) are an essential next step. This will allow for the capturing of evidence that both shows what works but also how programmes can be embedded within new and evolving structures and systems within culture and health (i.e. Integrated Care Systems).
      5. We should not be afraid to apply critical framings to research in this area. There is active discussion and debate in this area, but there is also a lack of critique within the literature both when it comes to the choice and application of methods, as well as in the overstating of research findings. There are growing numbers of higher education training courses available in the field of culture, health and wellbeing, and we would advocate for critical skills training to be embedded alongside teaching in research methods, for example.

For funders

1. 1. 1. There are still significant gaps in the evidence surrounding the value of culture for health and wellbeing, which need to be addressed through direct funding. Funders should explore ways to strategically coordinate grant making to encourage more sustainable research and practice methodologies. This approach should include more longitudinal research programmes that support the ‘scaling’ of learning. This funding may be possible from consortium-based funding models and structures that can combine resources to fund at scale over longer periods of time (see for example, Born in Bradford).
      2. Sustainable research practices in this field should also consider the role of early career researchers (who are often on project-by-project contracts). While there appear to be many PhD opportunities in this area, there are fewer examples of next-step funding to support the development of new and emerging researchers who could address some of the gaps identified in this paper (i.e. broadening the cultural experiences represented).
      3. Alongside funding primary research in this area, funders should also ensure that programmes and platforms are available for the collation of grey literature (including evaluation reports) that make it accessible to the academic, creative and cultural sectors and beyond. There should also be investment in the upkeep and development of repositories that bring this grey literature together.
      4. More global approaches to investment should be explored to balance the skewed (i.e., UK-centric) representation of research in this area.

For the Centre for Cultural Value

1. 1. 1. We will continue to facilitate engagement between researchers, funders, policymakers and the creative and cultural sectors, including through our ongoing relationships with UKRI, Arts Council England and the Department for Culture Media and Sport (DCMS). In this role as conduit, we will aim to ensure that timely and rigorous research and evidence that promotes the value of culture in supporting health and wellbeing is shared as widely as possible.
      2. We will continue to work with our policy partners at Culture Commons and national bodies such as the National Centre for Creative Health, the Culture Health & Wellbeing Alliance, UCL WHO Centre, National Centre for Culture and Academic Exchange to better understand what types of research are having the most impact with decision-makers, and how this might map onto the strengths and weaknesses of the existing research and evidence base.
      3. We will work with funders and partners to explore the possibility of a global review of culture, health and wellbeing research, building on the reviews that have been done in this area to date, to ensure that important findings and best practice can be considered by policymakers.

Report prepared by Dr Robyn Dowlen for the Centre for Cultural Value. If you want to cite this work, please use: Dowlen, R. (2023) Vision paper: culture, health and wellbeing. January 2023. Leeds: Centre for Cultural Value.

We would love to hear from you if you have thoughts about the report and the recommendations. Please contact us by emailing: ccv@leeds.ac.uk