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The potential health benefits of participation in the arts to the person and to the community have received widespread attention in recent years. The arts have been used as a medium for health promotion, as therapeutic interventions, and, in the case of the UK, health action zones and social inclusion partnerships’ arts projects have been specifically used to tackle social exclusion. As with other health care and social interventions, the arts may have the potential to have an impact on health, but these impacts need to be demonstrated, whether the outcomes are improvements in specific health outcomes, or increases in levels of social participation.
FINDING THE EVIDENCE
The evidence that art promotes public health and enhances social inclusion remains elusive. The most comprehensive recent review of arts participation projects in the UK was undertaken between September 1995 and March 1997.1 This was the first large scale attempt to come to grips with the issue of the social impact of the arts, in contrast with previous research that largely focused on the economic benefits.2 The review concluded that participation can have a positive impact on how people feel, can be an effective means of health education, can contribute to a more relaxed atmosphere in health centres, and can help improve the quality of life of people with poor health, but none of the existing studies seemed to include formal outcome evaluations. Similarly, the UK Health Development Agency’s report Art for health found that while there were many examples of good practice, actual evaluation was rare.3
Similarly, we recently carried out a scoping review to identify published examples of formal outcome evaluations of the role of arts in social inclusion and health, and found very few. This does not reflect the number of projects that actually exist, including some projects that are high profile. The UK government has also invested in many area level initiatives that tackle the wider issues of social inclusion, and these may involve arts projects whose health outcomes have not yet been reported; for example, local projects have been funded in response to the needs of specific communities. A further review of unpublished literature relating to arts and health projects is due to be published shortly by the Centre For Arts And Humanities In Health And Medicine at the University of Durham (UK). It shows that, while evaluation is considered important, there is a struggle to find appropriate methods and that the evaluation is, in most cases, inadequate.
THE ARTS AND PUBLIC HEALTH
The arts have a long shared history with health, but claims that the arts actually have a value that goes beyond their intrinsic artistic merit, such as the potential to improve public health, are much more recent. Many formal studies of the relation between art and health have tended to focus on the therapeutic use of the arts, with much of the published work centred on addictions and chronic conditions in particular.4 There has also been exploration of the role that the environment of the hospital can play in healing5: one of the most well known of which suggests that patients exposed to views of trees appeared to recover more quickly than those with a view of a brick wall.6
Box 1 Arts and health: some useful web sites
The National Network for the Arts in Health (NNAH) provides a range of benefits and services for organisations and individuals interested in the field of arts in health. http://www.nnah.org.uk/
Arts as medicine conference held in Glasgow in April 2001. http://www.artsasmedicine.org.uk/
The Centre for Arts and Humanities in Health and Medicine at Durham University (CAHHM) is a research unit building an evidence base for the effectiveness of the arts in healthcare, as well as developing the humanities in the training of medical students and other health professionals. http://www.dur.ac.uk/cahhm/
The NHS Health Development Agency identifies the evidence of what works to improve people’s health and reduce health inequalities. It advises and supports policy makers and practitioners, helping them to get evidence into practice. http://www.hda-online.org.uk
Art in Hospital is a non-profit making arts organisation based at Belvidere hospital in Glasgow’s east end. The project works throughout Greater Glasgow with elderly patients involved in therapeutic art activities. http://userweb.elec.gla.ac.uk/m/mal/aih.htm
Artlink runs a variety of short and long term arts programmes in Edinburgh and the Lothians for people with disability with the objective of increasing accessibility to the arts. http://www.artlinkedinburgh.co.uk/index.html
The Drake Music Project is a national charity that is committed to providing the opportunity for disabled people to explore, compose and perform their own music. http://www.drakemusicproject.com
Project Ability is a Glasgow based arts company specialising in creating opportunities for disabled people to gain access to the visual arts. http://www.project-ability.co.uk
Share Music offers music courses for young people with physical disability or sensory impairment. Courses include music, theatre, drama, art and dance, held in centres with facilities for disabled people. http://www.sharemusic.org.uk
Creating our future... ...minding our past: Scotland’s national cultural strategy, produced by the Scottish Executive in 2000 is online at http://www.scotland.gov.uk/nationalculturalstrategy/docs/cult-00.asp
Preventing social inclusion, a report by the Social Inclusion Unit can be found at http://www.cabinet-office.gov.uk/seu/publications/reports/html/pse/pse_html/
VicHealth is an Australian health promotion body and operates an Arts for Health scheme. http://www.vichealth.vic.gov.au/
Australian Network for Arts and Health (ANAH) focuses on wellbeing via the arts. http://homepage.powerup.com.au/∼anah/
The arts and health have a long shared history
More recently the arts have been seen as a tool for improving public health, reducing health inequalities, and promoting social inclusion, but the evidence remains elusive
Scientific evaluation of the arts may seem inappropriate, but formal evaluation of outcomes is necessary if the debate is to move beyond anecdote and opinion.
The use of the arts in promoting social goals is not new. Since the late 1960s artists and arts organisations have engaged in what was termed “community arts”: delivering projects to excluded individuals and groups. These have ranged from projects in schools, to those in hospitals, prisons, housing schemes, workplaces, and in the streets—all outside the conventional settings of the theatre, gallery, concert hall, or museum. The intention was not simply to create greater access to the arts, but to reflect a community of interest. With an emphasis on participation, community arts projects dealt with issues such as class, race, or gender, or were linked to campaigns on health, housing, or the environment, described as “arts plus social concern”.7,8
More recently a role has been outlined for the arts in helping achieve wider public health objectives, such as developing social capital, promoting social inclusion among disadvantaged groups, and ultimately promoting public health. This approach is exemplified by the Art for health report, which reviews good practice and initiatives in this area.9 It suggests that the arts may be one of the intersectoral interventions that the Acheson report viewed as being important in redressing social and health inequalities.10
COLLECTING THE EVIDENCE
Though some commentators have suggested that scientific evaluation of the impact of the arts is inappropriate,11 such studies in clinical settings are not uncommon, and evaluations point to a possible therapeutic value of the arts in symptom relief, in rehabilitation, and in contributing to quality of life in specific patient groups. Recent Cochrane reviews have examined the effectiveness of specific arts related interventions as part of reminiscence therapy for dementia,12 as part of life skills programmes for chronic mental illness,13 and possible psychophysiological causal pathways linking music therapy with clinical outcomes have been described.14 Evaluation of the impact of the arts in clinical settings may however be easier than assessing the impact on communities and neighbourhoods, where it may be difficult to link specific aspects of the intervention to specific health outcomes.
None the less, while the need to evaluate arts in such a scientific fashion has been derided, the growing policy commitment to arts and social inclusion projects has led to a demand for more and better evaluation. Although some specific arts evaluation tools do exist15,16 the search by the arts world for the Holy Grail continues—that is, an evaluation of the impact of arts projects that will provide the definitive argument to government and others for additional support for the arts. However, one commentator suggests that those involved in searching for evidence of the impact of arts and health are making two false assumptions: firstly that there is a piece of evidence/research that will once and for all “prove” the arts are good for your health, and secondly that this evidence will bring about some kind of Damascene conversion on politicians who will immediately pour millions into the arts. Neither assumption is likely to be true.17
ARTS AND HEALTH: IS EVALUATION NECESSARY?
Is evaluation really needed? To some, the answer is clearly no: like many interventions, arts will seem harm free and the potential benefits obvious. It may seem at best churlish (and positivism gone mad) to expect the arts to justify their existence on scientific grounds, and of course the arts have value irrespective of any presumed health effects. However, there is a need to answer the question of what evidence exists to support the introduction of these services, and to help explore the basis on which organisations justify setting up arts initiatives. In the health field proper recognition of the health effects of interventions, and resources, are likely only to follow from good evidence that they achieve their intended health and wellbeing outcomes. In the absence of evaluation there always will be much uncertainty over benefits, harms, and value for money. A scientific approach to evaluating the arts may help move the debate about the arts and health beyond anecdote and opinion.
We would like to thank Hilary Thomson for comments on an earlier draft of this paper.
Funding: Christine Hamilton is Director of the CCPR and is funded by SHEFC. Mark Petticrew is a member of the ESRC Evidence Network and is funded by the Chief Scientist Office of the Scottish Executive Department of Health.
Conflicts of interest: none.