Contents

Highlights

Background

Methods
- What we included
- What we didn't include

Overview: culture on referral

Findings
- What do we know for certain?
- Where is there growing evidence?
- Where is further research needed?

Conclusions and implications

Next steps

Studies included in the review

Glossary

Table of studies

Highlights

In recent years, culture on referral programmes have been gaining increased popularity in both cultural and health sectors as a way of addressing health and wellbeing needs. We sought to understand what evidence there is at present to support or challenge the value of culture on referral programmes on physical/mental health and/or wellbeing.

We identified only 13 peer-reviewed studies which examined impacts and outcomes relating to cultural on referral programmes. Across these published studies, the majority of participants were referred due to mild-to-moderate stress, depression or anxiety, and participants were largely female, white and over the age of 50. The most commonly reported programme types were participatory groups using ‘mixed-visual’ or ‘mixed-creative’ participatory arts, with the most commonly reported programme length being 10 weeks, with one session per week of 2 hours.

All 13 studies showed positive outcomes on participants’ wellbeing, with participants reporting feeling more confident, less socially isolated and having better self-esteem. However, these studies predominantly had small sample sizes and did not compare to a control group, meaning it is difficult to determine whether changes in wellbeing were due to the culture on referral programme itself, or whether they were due to factors relating to increased social contact in the group settings within which all of the programmes were delivered.

Overall, while there is promising evidence that there is a positive role for culture on referral programmes in improving wellbeing outcomes, there is a need to understand the specific value of culture on referral programmes compared to other group-based activities. There is also a need to understand the role of specific cultural on referral programmes, such as dance or visual participatory arts, and which of these programmes is most appropriate for differing health and wellbeing needs.

Background

In recent years, culture on referral programmes have been gaining increased popularity in both cultural and health sectors as a way of addressing health and wellbeing needs. We sought to evaluate the evidence surrounding the value of culture on referral programmes and how they might contribute to improved health and wellbeing outcomes and impacts through synthesising and appraising evidence published since 2010. This rapid review of the literature was conducted between October and December 2019 and was updated ahead of publication in September 2020. This review was conducted as part of our synthesis of research relating to our Culture, Health and Wellbeing theme.

Methods

We conducted a rapid review of the academic literature that has been published since 2010 in order to gain a snapshot of the recent evidence relating to culture on referral. We used a systematic approach to identify relevant literature, using academic databases as well as the Repository for Arts and Health Resources.

What we included

We included peer-reviewed, primary research that was published in English between 2010 and 2020. We only included studies that were delivered by cultural organisations, cultural practitioners, or community groups. The focus of the programme had to be centred around cultural activity/participation (e.g. visual arts workshops, choir rehearsals) and had to have primary outcomes relating to physical health, mental health, and/or wellbeing.

What we didn't include

We did not include studies which included creative arts therapies. While we recognise the vital work of creative arts therapists, the focus of this review was on the impacts and outcomes of work produced/supported by the arts, cultural, heritage and screen sectors.

What questions did we ask?

We asked the following questions to guide our analysis of the literature:

1. What evidence is there to support or challenge the impacts/outcomes of culture on referral programmes on physical/mental health and wellbeing?
2. How are the impacts/outcomes of culture on referral programmes researched and evaluated?
3. What are the perceived strengths/limitations of the research?
4. What are the current gaps in understanding and what does future research need to focus on?

Overview: Culture on referral

Culture on referral (also known as arts on prescription) is the process by which a GP or other health/social care professional, local agency (including cultural organisations and community groups) refers a person to an arts or cultural programme. These referrals sit within the broader movement of ‘social prescribing’, which refers to a broad range of non-medical referrals designed to improve health and wellbeing (e.g. physical exercise, financial support, social activity). It is also possible for people to self-refer to programmes, with many cultural organisations advertising these programmes within their local communities and online.

NHS England states that social prescribing has beneficial impacts for a wide range of people, but particularly those who:

• have one or more long-term conditions (e.g. chronic pain)
• have challenges relating to their mental health (e.g. stress, depression, anxiety)
• are experiencing social isolation or feel lonely
• have complex social needs

In order to access a culture on referral programme, a person will typically be referred by a GP or other health/social care professional or local agency to a link worker. Link workers can be employed by a wide range of organisations including those run by the voluntary sector, local authorities or primary care networks. Link workers have strong connections within the community they work in and a vast understanding of programmes that are available to referrals within the local community. Other job titles that fall under the umbrella term of link worker include ‘community navigator’ and ‘social prescriber’.

A link worker will work with the person to co-create a personalised ‘prescription’ which is based on the person’s needs, interests and preferences. In the specific context of culture on referral programmes, the link worker would then introduce the person to a local cultural organisation delivering a dedicated programme with the aim of improving the person’s specific health or wellbeing needs. It must be noted that a link worker’s role is to find the most appropriate programme based on the persons interests and health/wellbeing needs, so this means that a cultural programme will be one of many offerings for a person to choose from.

Once referred, the person will take part in a programme over a set number of weeks. For those who have been referred by a GP or health/social care professional they will be followed-up after the referral with regards to their health and/or wellbeing needs. If a person requires a further referral, they will be re-referred to the link worker by their GP to develop a new ‘prescription’.

Findings

We identified 13 peer-reviewed journal articles which investigated outcomes and impacts relating to culture on referral programmes (see Table of Studies for more information). Eleven studies were conducted in England, with one in Denmark and one in Australia. Across studies there were several characteristics shared by the participants who took part, but it must be noted that many studies did not report participant characteristics beyond gender, age and reason for referral. However, with the data available, most participants were reported as being:

• were referred to the cultural programme due to mild-to-moderate stress, depression or anxiety (9/13)
• self-identified as female (75%)
• were aged 50+ on average, with a range between 25 and 94

The most commonly reported activity type reported was participatory mixed visual/creative arts, which included creating new paintings, photographs and poems. While many of the studies aimed their programme more generally at those with mental health challenges, there were three examples of projects which were specifically aimed at older people (65+). The most commonly reported programme length was 10 weeks, with the shortest being 8 weeks and longest being 6 months.

Researchers used several methods to understand the impacts and outcomes of culture on referral programmes. Five studies were purely qualitative (using interviews and focus groups), four were purely quantitative (using standardised wellbeing measures), and four used mixed-methods (using a combination of questionnaires and interviews/focus groups). In general, there was poor reporting of specific research questions, but the focus of most studies was on understanding short-term changes in wellbeing across the duration of the culture on referral programmes.

What do we know for certain? 

All studies that used a standardised measure of wellbeing (such as the Warwick Edinburgh Mental Wellbeing Scale and Museum Wellbeing Measure for Older Adults) demonstrated positive differences in scores at the beginning of a culture on referral programme compared to the end of the programme. This suggests that there was meaningful positive change in wellbeing as a result of taking part in culture on referral programmes.

For studies that used qualitative methods, a range of benefits were reported by participants. Across studies it was most commonly reported that culture on referral programmes were seen to enable participants to become more confident and improved their self-esteem. Participants also reported that they felt less socially isolated and lonely as a result of taking part. It was noted by participants that they felt supported by others in the group who had similar experiences with mental health challenges, stressing the importance of peer-support and the opportunity to develop new friendships within the context of the programmes.

Participants enjoyed the opportunity to be creative and felt a sense of pride and achievement in being able to meet their creative goals. Taking part also led to participants feeling calmer and more relaxed. Participants reported that taking part in programmes led to improvements in their mood and decreased their feelings of anxiety.

Although we can say with some certainty that culture on referral programmes had a positive impact on wellbeing, it must be noted when interpreting these findings that most of these studies had small sample sizes and did not compare to a control group of participants not enrolled on a culture on referral programme. It was therefore not always clear whether the changes in wellbeing were as a result of the culture on referral programme itself or whether they were due to factors relating to increased social contact in the group settings within which all of the programmes were delivered. For example, in a number of studies participants reported that they developed ‘new friendships’ but it is difficult to determine whether art and culture played an active role in enabling friendships to develop or whether it was the fact that people took part in an activity as part of a group. In other words, would we see similar outcomes in a group setting without art and culture?

Where is there growing evidence? 

There is growing evidence that culture on referral programmes act as stepping-stones to other activities. For example, in some studies it was reported that participants went on to set up their own art groups and engaged more with arts and culture within their daily lives. Furthermore, some participants went on to enrol in further educational opportunities, such as college courses. As many of the studies did not formally follow-up with participants after the end of the programmes it seems important going forwards that the ‘ripple effects’ that may occur as a result of taking part in culture on referral programmes are investigated further. This may give greater insight into the lasting benefits of taking part beyond short-term changes in wellbeing scores.

Where is further research needed? 

Most studies did not describe the culture on referral programme in enough detail. This meant that focus was firmly placed on outcomes over the creative process that participants engaged with as part of their referral. This makes it difficult to disentangle the impacts of the culture on referral programme compared to a group activity that does not involve cultural engagement/participation or compares between different types of cultural activity. More research is therefore necessary to understand the specific value of arts and culture within culture on referral programmes, and this can only be illuminated through an in-depth investigation of the creative process as well as measuring outcomes relating to health and wellbeing.

It was observed that the populations who took part in culture on referral programmes shared many demographic characteristics, with many participants self-identifying as female, white British and aged 50+. We can therefore infer that there may be inequalities relating to both accessing programmes and taking part in research within the culture on referral literature. Although culture on referral programmes had a positive impact on participants’ wellbeing across studies, there are questions that need to be asked relating to the diversity of programmes and how they may be adapted to different communities to ensure better equity in access.

Only a handful of studies investigated the longitudinal impacts of culture on referral, with most studies measuring impacts pre-programme and immediately post-programme. In order to understand whether there are lasting benefits of culture on referral programmes longitudinal perspectives are needed that seek to investigate the longer-term benefits of taking part. Without this knowledge we risk seeing each programme as independent rather than part of a wider culture on referral ethos within different healthcare and community settings both in the UK and internationally.

All the studies identified for this review examined the outcomes of a range of culture on referral programmes, but they did not contextualise the programmes within the specific setting they were operating within. Culture on referral programmes operate within complex systems that bring together primary care services, link workers, community organisations, cultural organisations and creative practitioners. Further research is therefore needed to understand culture on referral programmes within the different contexts in which they operate, rather than as standalone projects. This will enable greater understanding of how to develop sustainable culture on referral programmes that can provide more opportunities for access to a wider group of people.

Conclusions and implications

Although all the studies demonstrated positive outcomes relating to wellbeing for participants taking part in culture on referral programmes, there is still significant progress that needs to be made within this research area to be able to create a stronger evidence base. This is due to the following factors:

• While the wealth of research within England is a positive thing, there is a clear need for a greater geographical spread of research. While there is a lot of activity relating to social prescribing and culture on referral which is happening in England, it is important to understand culture on referral programmes within different policy and healthcare contexts globally.
• There is a lack of exploration into the arts and cultural programmes themselves. This means it is difficult to determine the specific value of arts and culture over other group-based activities (e.g. peer-support groups), and we cannot yet speak to the benefits of specific arts and cultural activities (e.g. dance vs. visual participatory arts) for specific health and wellbeing needs.
• There is an apparent lack of diversity in the participant groups reported within studies. The primary population drawn upon across studies was female, aged over 50 and white British. While it is difficult to determine whether this is due to the processes linked to recruiting research participants or is indicative of wider diversity issues, there is a clear need to explore diversity and inclusion within the research agenda going forwards.
• There is limited exploration of longitudinal impacts of taking part in culture on referral programmes for participants. This means that it is not yet possible to determine whether culture on referral programmes lead to health and wellbeing outcomes in the longer-term. This is important because it will enable an understanding of whether culture on referral programmes lead to, for example, fewer GP visits, participants feeling more connected to their local communities, etc.

Finally, it is important to note that the 2019/20 coronavirus pandemic will impact on the ability for many culture on referral programmes to be engaged with face-to-face. While we have not identified any published literature that focuses on the digital delivery of culture on referral programmes, it will be necessary to learn how programmes have been adapted during this time and what the implications are for the facilitation of programmes going forwards.

Next steps

Our research and evidence base for cultural value needs to respond to what works now and what needs to change in the future, so that we support practitioners and policymakers to develop models and practices that are more robust, equitable and sustainable.

If you are aware of new publications or feel we have missed a vital piece of research please get in touch at: ccv@leeds.ac.uk

Studies included in the review

1. Baker, D., Ley, A., Alexander, J. and Beer, A. 2012. Eco art on prescription. Mental Health and Social Inclusion. 16(2), pp. 84-89.
2. Crone, D., Sumner, R., Baker, C., Loughren, E., Hughes, S. and James, D. 2018. ‘Artlift’ arts-on-referral intervention in UK primary care: updated findings from an ongoing observational study. The European Journal of Public Health, 28(3), pp.404-409. DOI: 10.1093/eurpub/cky021
3. Holt, N. 2020. Tracking momentary experience in the evaluation of arts-on-prescription services: using mood changes during art workshops to predict global wellbeing change. Perspectives in Public Health. Advanced Online Publication, DOI: 10.1177/1757913920913060
4. Jensen, A. 2019. Culture vitamins–An arts on prescription project in Denmark. Perspectives in Public Health. 139(3), pp.131-136. DOI: 10.1177/1757913919836145
5. Makin, S. and Gask, L. 2012. ‘Getting back to normal’: the added value of an art-based programme in promoting ‘recovery’ for common but chronic mental health problems. Chronic Illness. 8(1), pp.64-75. DOI: 10.1177/1742395311422613
6. Poulos, R.G., Marwood, S., Harkin, D., Opher, S., Clift, S., Cole, A.M., Rhee, J., Beilharz, K. and Poulos, C.J. 2019. Arts on prescription for community‐dwelling older people with a range of health and wellness needs. Health & social care in the community, 27(2), pp.483-492. DOI: 10.1111/hsc.12669
7. Stickley, T. 2010. The arts, identity and belonging: A longitudinal study. Arts & Health. 2(1), pp.23-32. DOI: 10.1080/17533010903031614
8. Stickley, T. and Eades, M. 2013. Arts on prescription: a qualitative outcomes study. Public Health, 127(8), pp. 727-734. DOI: 10.1016/j.puhe.2013.05.001
9. Stickley, T. and Hui, A. 2012. Social prescribing through arts on prescription in a UK city: participants’ perspectives (part 1). Public Health, 126(7), pp.574-579. DOI: 10.1016/j.puhe.2012.04.002
10. Thomson, L.J., Lockyer, B., Camic, P. and Chatterjee, H. 2018. Effects of a museum-based social prescription intervention on quantitative measures of psychological wellbeing in older adults. Perspectives in Public Health, 138(1), pp.28-38. DOI: 10.1177/1757913917737563
11. Thomson, L., Morse, N., Elsden, E. and Chatterjee, H. 2020. Art, nature and mental health: assessing the biopsychosocial effects of a ‘creative green prescription’ museum programme involving horticulture, artmaking and collections. Perspectives in Public Health. Advanced Online Publication. DOI: 10.1177/1757913920910443
12. van de Venter, E. and Buller, A. 2015. Arts on referral interventions: a mixed-methods study investigating factors associated with differential changes in mental well-being. Journal of Public Health, 37(1), pp.143-150. DOI: 10.1093/pubmed/fdu028
13. Vogelpoel, N. and Jarrold, K. 2014. Social prescription and the role of participatory arts programmes for older people with sensory impairments. Journal of Integrated Care, 22(2), pp. 39-50. DOI: 10.1108/JICA01-2014-0002

Glossary

The following definitions are intended to provide a workable guide to readers who are not specialist in this area rather than being conclusive definitions of terms.

Table of studies