AHSW's Director and Trustees reflect on various aspects of arts, health and wellbeing.
Is the Evidence for Arts and Health Good Enough?
AHSW Director Alex Coulter’s latest musings on the evidence base follow a meeting she attended with the Chief Medical Officer (CMO), Professor Dame Sally Davies, in her role for the All Party Parliamentary Group on Arts, Health and Wellbeing.
Many of you will remember that her annual report: ‘sets out the evidence that frames our understanding of public mental health and concludes that this subject should no longer be framed in terms of ‘well-being’. This does not refer here to the concept of ‘well-being’ more generally as it applies more broadly across the business of Government or ‘health’ more generally. I welcome the consideration of the wider determinants of health in policy making. It refers here to the concept of well-being as relates only to mental health.’
The report, and the subsequent debate that it has provoked, has shone a spotlight on how we define wellbeing, the evidence base for wellbeing, and how we measure interventions aimed to increase it. I had a few light bulb moments myself during the meeting. One issue the CMO confronts is an underlying assumption inherent in the discourse on mental wellbeing that positive wellbeing is at the opposite end of the same continuum as mental ill-health. She and her team tracked this back to the Foresight Report in 2008, ‘Mental Capital and Wellbeing: Making the most of ourselves in the 21st century’. This report then led to NEF developing the Five Ways to Wellbeing ‘Connect…Be active…Take notice…Keep learning…Give’, while acknowledging the lack of robust evidence for interventions that could improve wellbeing. The subsequent blossoming of wellbeing as a concept across a range of policy areas perhaps indicates that wellbeing is an idea whose time has come.
The CMO is an independent voice scrutinizing health policy. She challenges us to really question whether we have a sound definition of wellbeing and whether we are measuring it effectively and appropriately. She questions the use of the Warwick Edinburgh Mental Wellbeing Scale (WEMWBS) and as many arts and health projects use the WEMWBS it is important that we know she has raised this question over its appropriateness. There are many who have defended it in response. My understanding is that she says it draws together measures for mental ill-health with measures for mental wellbeing thereby assuming they are on the same continuum, but that there is no evidence to justify this.
Sally Davies also expressed the view that we should interrogate wellbeing, identify its constituent parts and focus on interventions aimed at specific, identifiable and measurable benefits, for example a reduction in loneliness or an improvement in manual dexterity. For those working in arts and health, as for everyone, wellbeing is a relatively new concept, but one that we have embraced with enthusiasm. Our work with people with Parkinson’s Disease may be a useful area of practice to consider in relation to this. At a recent All Party Parliamentary Group roundtable on Music and Health, the neuroscientist Professor Michael Trimble spoke about his extraordinary research into the effect of music on the brain, how specific music selected for its rhythm and beat can function as a brain stimulation and appear to have an immediate effect on people with Parkinson’s ability to walk. This work is a medical approach both in terms of the intervention itself and the methodologies used to research it. As a social model, Dance for Parkinson’s is an international movement, developed in the USA and now spreading rapidly in several countries, with a strong network of practitioners in this country. There is a growing body of evidence on the benefits, led by academics at Roehampton University. The focus is on dance to improve balance and gait. However, researchers have also observed and measured improvements in communication between couples and a reduction in loneliness generated through the social networks of a regular group activity, even a re-found sense of feeling ‘beautiful’. As an aside, Dance for Parkinson’s sessions regularly have at least as many men as women attending and drop out rates are low – because it is fun! These benefits might well be grouped under a ‘wellbeing’ umbrella.
When it comes to definitions for wellbeing and how it relates to other terms I am intrigued by the fact that, to quote the CMO’s report again: ‘Well-being is a field in its infancy related to mental health but subjective well-being has a much longer, scientifically robust tradition within ‘quality of life’ research. In the health psychology literature, well-being is generally regarded as a pillar of quality of life. Measures of quality of life have accrued a much more robust body of knowledge on their multi-dimensional properties and psychometrics.’ I start to get a bit lost here. What is the difference between subjective wellbeing as a pillar of quality of life and wellbeing in relation to mental health? Then, in recent conversations with public health colleagues, I have become aware of the concept of salutogenesis, a term coined by the medical sociologist, Aaron Antonovsky, in 1979. The salutogenic model is concerned with health, stress and coping. His theory rejects the medical-model dichotomy separating health and illness and describes the relationship as a continuous variable, the “health-ease versus dis-ease continuum”. (Taken from Wikipedia, so bear that in mind). We are back to a continuum. I like his notion of a ‘sense of coherence’ enabling us to cope in bad times. I interpret this as agency, connectedness both internally and with the world around us, a sense of purpose and self-esteem. Perhaps that is the same as mental resilience.
Working with Public Health England in the South West has been useful in giving me a more nuanced understanding of these issues. If we are successful in our bid, the research project with Exeter University and Public Health England South West would allow us to work with a small number of arts and health projects to explore practitioner’s and participant’s perceptions of the benefits to generate a ‘bottom up’ analysis, while also doing a scoping review of existing evidence and mapping it onto a matrix of arts intervention, health issue, context and demographic. We will build on work already underway at Exeter to research existing measures for wellbeing, of which there are apparently over 70, validated in varying degrees. We will attempt to identify in a nuanced way which measures are relevant to which type of arts intervention, working with PHE to select measures relevant to commissioners needs. Then we will test the selected measures with a wider group of arts and health organisations across the region.
At the Peninsula Public Health Conference on March 13th Professor Richard Parish chaired a panel discussion on ‘Is the Evidence Base for Arts and Health Good Enough?’. Some of you will remember Richard’s excellent chairing of the debate at the Culture, Health and Wellbeing International Conference. He is now on the board of Public Health England and continues to champion arts and health. The panel was: Professor Norma Daykin from the University of West of England, Dr Sarah Goldingay from Exeter University and Heema Shukla from Public Health England. The debate took us away from the more familiar rather circular discussions I have heard in the past. There is a growing acknowledgement that the evidence base is probably good enough, although patchy, but it is not necessarily the main barrier to progress. More practical structural challenges face us. As one commissioner said: “I need to know how this work fits into care pathways”. I believe we should focus on clarifying our offer, on coherent frameworks for delivery and evaluation and on new commissioning models based on the learning from the Cultural Commissioning Programme. Within that we must understand the evidence base and use it in a convincing and articulate way.
Director, Arts & Health South West
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