Culture for health?

At the start of the 21st century, the field of arts and health research did not exist. Now, over two decades later, innumerable research studies worldwide have explored the potential wellbeing and health benefits of engagement with culture, the arts and creative activities.  

Efforts have been made to review this body of research, notably by the All-Party Parliamentary Group on Arts, Health and Wellbeing in the UK and the World Health Organization for Europe. And now, the European Union has embraced the field with its Culture for Health initiative.

The project has many important aspects, not least a repository which maps arts and health initiatives across Europe. Currently, this profiles over 500 projects and programmes throughout Europe including, despite Brexit, 114 in the UK. This resource will undoubtedly help organisations to promote their work and network.

Findings taken at face value

Unfortunately, as a group of researchers active in the field of art, music and health, we have grave concerns over the scope, methodology and quality of the scoping review of arts and health evidence published last month as part of the EU initiative. 

While, for example, the report's authors claim to build on an earlier WHO scoping review, they fail to recognise that this review has been subject to substantial critique or that, when reviewing research for policy development, systematic reviews not scoping reviews are preferred to provide a rigorous assessment of the evidence.

Furthermore, the report simply takes findings from studies at face value and fails to provide the proper academic caveats for studies which are inevitably subject to limitations and biases. No methods for appraising the limitations and biases of these studies nor synthesising the body of evidence are used, despite the existence of widely endorsed best practice methods - GRADE - designed to guide the development of policy recommendations. 

Arts engagement can have negative impact

In addition, there is a failure to acknowledge the biases in the field against recognising the potential harms associated with cultural engagement. This matters because, while the arts have many benefits, the implication that the arts only have positive effects or that all those that take part will experience benefits is simplistic.  

Arts engagement can have negative health impacts, particularly among many professional artists and singers who suffer poor mental health likely related to their arts and musical careers. Further, arts engagement is often found to have no effect on a range of health measures, with the key components of what makes some arts engagement health-promoting still unclear. 

We must be aware of the ways in which oversimplified reporting, such as that of the EU report, can promote healthcare practices in an environment of austerity where over-stretched healthcare services are encouraged to uncritically offer ‘engagement with the arts’ to broadly improve health and treat illness. 

Further reservations

1.    Some sources are presented as research when they are simply opinion pieces commenting on the supposed wellbeing benefits of the arts. A clear example is a report on spontaneous singing by Italians from balconies during lockdown, and how it may have decreased loneliness, improved cohesion and promoted mental well-being.  The paper is purely observational and reports no scientific data.

2.    Many significant research studies published in this period are missing from the report without clear reasons. Considering only the work of the authors of this critique, the EU report excludes a quantification of the arts-mental health relationship, an Australian systematic review on the relationship between arts engagement and health promotion, an umbrella review of the health effects of music and dance participation in healthy adults and studies of singing online during Covid lockdowns.

3.    More seriously, the report is simply inaccurate in its account of some key studies in the field. In discussing a major pragmatic controlled trial on singing for older people, for example, the report states that singing reduced experiences of loneliness, whereas the trial did not explore this issue and the published paper makes no reference to loneliness.

4.    And finally, the report is unduly optimistic about the potential value of singing to improve lung function and breathing among people with COPD. Many relevant studies are missing, and recent evidence outside the scope of the EU report period show that considerable caution is needed in recommending immediate changes to treatment programmes for people with COPD and other lung conditions, based on existing research.

We suggest that readers of this report should approach it with considerable caution, and we would like to see a wider, more rigorous debate on current efforts to promote policy-making and wider implementation of effective and sustainable arts for health programmes across Europe.

Stephen Clift is Professor Emeritus at Canterbury Christ Church University and Visiting Professor at York St John University.
@StephenClift | @CanterburyCCUni

with Helena Daffern, University of York, UK
Christina Davies, University of Western Australia, Australia
Katarzyna Grebosz-Haring, University of Salzburg / Mozarteum University Salzburg, Austria
Mette Kaasgaard, University of Southern Denmark, Denmark
J. Matt McCrary, Hannover University of Music, Drama and Media, Germany
George Musgrave, Goldsmiths, University of London / University of Westminster, UK