Political symposium on the arts and health in the Nordic region: state of the evidence: Copenhagen, Denmark, 22 March 2019

The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. Member States Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czechia Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan The former Yugoslav Republic of Macedonia Turkey Turkmenistan Ukraine United Kingdom Uzbekistan World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01 Email: euwhocontact@who.int Website: www.euro.who.int Copenhagen, Denmark, 22 March 2019 State of the evidence Political symposium on the arts and health in the Nordic region WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR EUROPE WELTGESUNDHEITSORGANISATION REGIONALBÜRO FÜR EUROPA ORGANISATION MONDIALE DE LA SANTÉ BUREAU RÉGIONAL DE L'EUROPE ВСЕМИРНАЯ ОРГАНИЗАЦИЯ ЗДРАВООХРАНЕНИЯ ЕВРОПЕЙСКОЕ РЕГИОНАЛЬНОЕ БЮРО Political symposium on the arts and health in the Nordic region State of the evidence Copenhagen, Denmark 22 March 2019 Abstract Over the last decade, the use of arts and culture interventions has become a viable option for improving health and well-being. A growing body of evidence shows that cultural participation holds promise as an effective, low-cost, low-risk therapeutic and preventative measure across a range of physical and mental health conditions. To explore this area of work further, the WHO Regional Office for Europe and Region Skåne, Sweden, jointly organized a political symposium which took place on 22 March 2019 at UN City in Copenhagen, Denmark. The symposium examined the leading role of the Nordic countries in this area and explored how the visibility and uptake of arts and health interventions at a policy level might be improved. Keywords ART CULTURE PUBLIC HEALTH POLICY MAKING SOCIAL DETERMINANTS OF HEALTH Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe UN City, Marmorvej 51 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office website (http://www.euro.who.int/pubrequest). © World Health Organization 2019 All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. 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The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the World Health Organization. Document number: WHO/EURO:2019-3477-43236-60597 Contents Abbreviations ................................................................................................................................................ 4 Introduction .................................................................................................................................................. 5 Opening and welcome by organizers ............................................................................................................ 5 Session 1. Background: WHO activities ........................................................................................................ 5 Session 2. HEN synthesis report on arts and health: the state of the evidence ........................................... 6 Session 3. Lessons from implementation: experiences from Region Skåne and the Nordic region ............ 7 Session 4. Roundtable: improving visibility and uptake of arts and health interventions at a policy level . 8 Conclusion ..................................................................................................................................................... 9 Annex 1. Symposium programme ............................................................................................................... 10 Annex 2. List of participants........................................................................................................................ 12 Abbreviations CCH cultural contexts of health and well-being DIR Division of Information, Evidence, Research and Innovation (DIR) HEN Health Evidence Network Political symposium on the arts and health in the Nordic region Page 5 Introduction Over the last decade, the use of arts and culture interventions has become a viable option for improving health and well-being. A growing body of evidence shows that cultural participation holds promise as an effective, low-cost, low-risk therapeutic and preventative measure across a range of physical and mental health conditions. To explore this area of work further, the WHO Regional Office for Europe hosted a political symposium with stakeholders from the Nordic countries on 22 March 2019 at UN City in Copenhagen, Denmark. The Regional Office’s Division of Information, Evidence, Research and Innovation (DIR) and Region Skåne, Sweden, co-organized the symposium. Their aim was to facilitate the sharing of knowledge and best practices, explore areas of collaboration, and inspire innovative thinking on the future of arts and health in the WHO European Region (see Annex 1 for the programme). By bringing together key stakeholders from academic, policy and clinical settings (see Annex 2 for the list of participants), the symposium set out to fulfil the following three objectives: 1. create a knowledge-sharing platform for arts and health policy-making; 2. provide an overview of the state of the evidence regarding arts and health interventions; and 3. discuss potential next steps that might further promote the implementation of arts and health initiatives in the Nordic region and beyond. Opening and welcome by organizers Dr Nils Fietje, Research Officer at the WHO Regional Office for Europe, and Ms Gitte Grönfeld Wille, Director of Cultural Affairs for Region Skåne, opened the symposium. Mr Ole Loehr Wilken was elected as Rapporteur and the programme was adopted. Participants were invited to briefly present themselves and share their main aspiration for the symposium. Their contributions highlighted the following five overarching themes of interest. 1. Collaboration: networking and connecting with new potential partners 2. Entrepreneurship: exploring entrepreneurial, political and financial opportunities for leveraging the arts and culture to improve health and well-being 3. Inspiration and knowledge sharing: gaining new insights into overlapping trends, challenges and opportunities at the intersection of health care, arts and culture 4. Political support: increasing awareness among and gaining support from political stakeholders 5. Research: understanding the state of the evidence on arts interventions for health and well- being Session 1. Background: WHO activities In 2016, the Regional Office launched a project to investigate the cultural contexts of health and well- being (CCH). The project systematically researches how culture affects perceptions of, access to and experiences of health and well-being to enable more effective health interventions and health policy- making. Supported by an expert group, the project works horizontally within the Organization and provides technical assistance to various WHO programmatic areas of work. It draws on scholarship from the humanities and social sciences to promote a more nuanced, contextual understanding of a variety of public health challenges. Political symposium on the arts and health in the Nordic region Page 6 At a recent WHO expert group meeting on CCH, members recommended that arts and health become a priority area for further exploration.1 Consequently, DIR commissioned a Health Evidence Network (HEN) synthesis report to review evidence across the WHO European Region on how arts interventions can improve health and well-being. Through the writing of this report, it became clear that the field is continuously growing and that the Nordic region in particular is pioneering work in this area. Session 2. HEN synthesis report on arts and health: the state of the evidence Participants at the symposium learned about the preliminary findings and conclusions of the forthcoming HEN report on arts and health. Notably, the report highlights the significant evidence base documenting the positive role that art can play in the promotion of good health, the prevention of a range of mental and physical health conditions, and the treatment or management of acute and chronic conditions arising across the lifespan. In addition to their proven effectiveness across a range of mental and physical health conditions, arts and culture interventions come at a low cost and low risk to their beneficiaries, and are in line with broader societal value commitments (see Box 1. for more information). Box 1. Why are the arts important for global health? The arts provide cost-effective interventions for complex health challenges that may not have current health-care solutions, while alleviating pressures on limited health resources. The arts support the priorities of Health 2020,1 the European policy framework for health and well- being, by: • catalysing action in other sectors; and • helping to build resilient communities. The arts support WHO’s Thirteenth General Programme of Work2 by: • increasing multisectoral action for health; • focusing on increasing human capital; and • accelerating action on noncommunicable diseases and mental health. Finally, the arts contribute to the achievement of the Sustainable Development Goals3 by: • supporting good health and well-being; • providing quality education; and • building communities. 1 Health 2020. A European policy framework and strategy for the 21st century. Copenhagen: WHO Regional Office for Europe; 2013 (http://www.euro.who.int/__data/assets/pdf_file/0011/199532/Health2020- Long.pdf?ua=1, accessed 8 July 2019). 2 WHO Thirteenth General Programme of Work 2019–2023. Promote health, keep the world safe, serve the vulnerable. Geneva: World Health Organization; 2019 (https://apps.who.int/iris/bitstream/handle/10665/324775/WHO-PRP-18.1-eng.pdf, accessed 8 July 2019). 3 Sustainable Development Goals [website]. New York: United Nations; 2019 (https://sustainabledevelopment.un.org/sdgs, accessed 8 July 2019). 1 Embedding a Cultural Context of health approach across the WHO European Region. Copenhagen: WHO Regional Office for Europe; 2018 (http://www.euro.who.int/en/data-and-evidence/cultural-contexts-of- health/publications/embedding-a-cultural-contexts-of-health-approach-across-the-who-european-region-2018, accessed 10 July 2019). Political symposium on the arts and health in the Nordic region Page 7 Participants welcomed the rich evidence base in the forthcoming HEN report. They noted that this is the first of its kind published by WHO, and could serve as a valuable resource to legitimize the use of these interventions across the WHO European Region. As countries set out to scale up arts and health initiatives to the national level, the Regional Office could be an important facilitator of knowledge sharing and source of technical support for Member States. To enhance the value and uptake of the HEN report, participants emphasized the need to adapt and translate the findings for policy-makers. As a priority action, they suggested the creation of short information leaflets containing key messages, guidelines on best practices and policy options using non- expert language. Participants also flagged the need for more information on how to scale up and export arts and health interventions. They noted that such interventions are interwoven with the communities they are based in and the populations they serve. As such, arts and health interventions are not a one-size-fits-all solution, and should not be promoted as such. With this in mind, best practices should be adapted to specific groups and populations. For instance, when engaging people with Parkinson’s disease in dance practice, the music and dance styles they appreciate will vary from region to region. Interventions should therefore seek out local expertise and consider local relevance. Notwithstanding the large amounts of supportive evidence on arts and health interventions, engaging political stakeholders and the wider public on this topic remains a significant task ahead. Work in this area should include the targeted dissemination of evidence and the promotion of arts and culture, particularly in the areas of exercise and social well-being. Session 3. Lessons from implementation: experiences from Region Skåne and the Nordic region There is considerable political and academic interest in the field of arts and health in the Nordic region. In Region Skåne, integrating arts and health into policy has been particularly successful. In 2014, the regional parliament approved an overall strategy for culture and health with a focus on children, older people and people with mental ill health. In practice, this has resulted in the implementation of several promising interventions (see also Box 2), including: • arts in hospitals (engaging patients with the world of art through dialogue and co-creation with artists); • hospital clowns (stimulating patients with a focus on humour and fantasy); and • culture on prescription (a type of social prescribing that enables health-care practitioners to refer people to arts and creative activity programmes). A key challenge to the implementation of these schemes in Region Skåne and elsewhere has been meeting the rigorous evaluation standards often used in health care. Evaluation studies tend to be both costly and time consuming, which can create barriers for those working with a limited budget. Given the existing evidence base and low risks associated with arts and cultural participation interventions, participants questioned the added value and continued need for these evaluations. They also recognized that not all arts and culture interventions are suitable for standardized health-sector evaluation. Political symposium on the arts and health in the Nordic region Page 8 Box 2. Literature promotion and social inclusion through Shared Reading Shared Reading (SR) is growing in popularity, and is being championed by organizations such as the International Centre for Shared Reading (United Kingdom); Læseforeningen (Denmark), Leserne (Norway); and the Shared Reading Network (Sweden). SR focuses on connecting people through literature and allowing shared meaning to emerge in a casual, nonthreatening environment. SR activities usually involve 8–12 participants and a reading group facilitator. Reading group materials can be poems, short stories or extracts from novels that revolve around a range of existential themes. In addition to the benefits of accessing a social network, participating in SR activities can provide a new language for thinking about what it is to be human, including how one might understand and live with an illness. The group identified three particular barriers in the field: • a lack of national arts and health strategies; • the inconsistent application of systematic evaluation approaches; and • a need for more cross-sectoral working and political support. Participants discussed the importance of good collaboration and dialogue across traditional sectoral boundaries (for example, between the health, culture and educational sectors) and among different stakeholders (health practitioners, social workers, artists, patients/service users and their caretakers, etc.) to the success and sustainability of arts and health initiatives. When these are in place, arts and health interventions exemplify the cross-sectoral, bottom-up and people-centred aspirations promoted in numerous global frameworks (see also Box 1). Participants also considered Nordic collaborations and sustainable arts and health initiatives embedded in the Nordic welfare model. Session 4. Roundtable: improving visibility and uptake of arts and health interventions at a policy level In the final session of the day, participants were invited to share their thoughts on the main challenges and opportunities in scaling up arts and health interventions to national and regional levels. Impulse statements to initiate the panel discussion were provided by three symposium participants. The group reflected on the progress that has been made in the field of arts and health in the Nordic region. Given the innovative nature of the work, participants suggested that there may be opportunity for the Nordic region to take a leadership role in promoting these activities internationally and globally. As other Member States in the WHO European Region set out to implement similar interventions, there would be ample space for Nordic countries to share their knowledge and experience. Participants identified the Nordic Council of Ministers as a suitable platform for leading this effort, and suggested reaching out to explore the potential for collaboration in this regard. The group also emphasized a need to clarify what is meant when referring to arts and cultural participation. Whether it is writing a diary, dancing or playing an instrument, definitions matter in terms of the evidence needed to assess and evaluate arts and health initiatives. Moreover, definitional stability is crucial for rendering such initiatives attractive as vehicles for investing in health and well-being. Political symposium on the arts and health in the Nordic region Page 9 While there is great scope for integrating and using the arts and culture as instruments to improve health and well-being, participants also noted that some forms of art cannot and should not be used to this end. It is important protect the intrinsic value of the arts, and to maintain artists’ creative independence and freedom of speech. Participants noted the importance of ensuring a high quality of artistic engagement in health care to maintain standards and to incentivize artists to participate in health interventions. Indeed, arts and health schemes could play an important role in supporting local artists. Specifically, policy-makers at a regional level would need to commit to funding and supporting arts and culture in health activities. Participants also emphasized the importance of anchoring such efforts at a local level to ensure shared ownership of the agenda. On a national level, mechanisms are needed to support collaboration across sectors and fields of expertise. Participants encouraged the Regional Office to use its reach to help mobilize support and facilitate collaboration. On both regional and national levels, successful arts and health initiatives should be leveraged as success stories to capitalize on their achievements and ensure more sustainable funding sources. The economic arguments behind arts and health initiatives, including the significant potential cost savings in the health sector, should also be promoted to decision-makers. Finally, participants noted that public health is not only about public policy; it is also a matter of interest to businesses and young entrepreneurs. More could be done to engage with businesses, entrepreneurship networks and incubators to explore opportunities for collaboration to support health- related cultural practices. Conclusion The political symposium on arts and health in the Nordic Region allowed the WHO Secretariat to better understand some of the key challenges and opportunities faced by Member States within the area of arts and health. By bringing together voices and perspectives from policy-makers, researchers and practitioners, it yielded potential priority actions that will be explored further over the coming months. Upon the closure of the symposium, participants advised the Regional Office to: • share knowledge and reports produced by the CCH project, particularly within the area of arts and health; • translate the project’s research publications into policy-friendly information; and • promote and advocate for the added value of arts and health more broadly in the WHO European Region. Political symposium on the arts and health in the Nordic region Page 10 Annex 1. Symposium programme Friday, 22 March 2019 Opening and welcome by organizers • WHO Secretariat (Nils Fietje) • Gitte Grönfeld Wille Session 1. Background: WHO activities Presentations • Nils Fietje: Evidence for health and well-being in context Discussion and feedback Session 2. HEN synthesis report on arts and health: the state of the evidence Presentation • Daisy Fancourt Discussion • What is the best available evidence on the effectiveness of cultural participation and health? • What criteria beyond effectiveness should be considered when implementing these interventions? • What is the relevance and applicability of this work to the Nordic region and the WHO European Region at large? Session 3. Lessons from implementation: experiences from Region Skåne and the Nordic region Presentation • Gitte Grönfeld Wille: Strategies that work: perspectives from Region Skåne • Anders Ohlsson: Literature promotion and social inclusion through Shared Reading • Anita Jensen: Arts and health in the Nordic countries: developments over the past 10 years Discussion • What advantages and challenges lie at the intersection of culture and health? • What are the optimal strategies and partnerships for mainstreaming arts and health within the culture and health sectors? • How can these efforts be scaled up and adopted in different contexts and settings? • Is it possible/desirable to increase the cooperation between the Nordic countries in the field of arts and health? Why? How? Session 4. Roundtable: improving visibility and uptake of arts and health interventions at a policy level Impulse statements • Eline Wernberg Sigfusson • Tony Woods • Kai Lehikoinen Political symposium on the arts and health in the Nordic region Page 11 Discussion • What are some of the obstacles to mainstreaming arts and culture for health at a national level? • How can the WHO Regional Office for Europe provide support to overcome some of these challenges? What networks and stakeholders should WHO connect with? • What can regional and national policy-makers do to provide support and accelerate change? Wrap up and conclusion Optional guided tour of UN City Political symposium on the arts and health in the Nordic region Page 12 Annex 2. List of participants Louise Eklund First Vice-Chair (Liberalerna) Regional Development Committee Region Skåne Sweden Email: louise.eklund@liberalerna.se Daisy Fancourt Senior Research Associate Behavioural Science and Health Institute of Epidemiology & Health University College London United Kingdom Email: d.fancourt@ucl.ac.uk Tine Garsdal Development Consultant Culture and Leisure Administration City of Copenhagen Denmark Email: tinega@kk.dk Mats Hallberg Deputy Director of Cultural Affairs Department of Culture Region Skåne Sweden Email: mats.hallberg@skane.se Odd Håpnes Managing Director Norwegian Resource Centre for Arts and Health Norway Email: odd@kulturoghelse.no Anna Hassel Architect Lokale og Anlægsfonden Denmark Email: ah@loa-fonden.dk Karoline Haulund Vice Director Creative Business Network Denmark Email: kah@cbnet.com Political symposium on the arts and health in the Nordic region Page 13 Elma Huskic Political Secretary (Liberalerna) Region Skåne Sweden Email: elma.huskic@skane.se Mats Isgren Board Member (Socialdemokraterna) Trelleborg Hospital Board Region Skåne Sweden Email: misg0001@gmail.com Anita Jensen Arts & Health Strategist Region Skåne Sweden Email: anita.jensen@skane.se Pilvi Kuitu Managing Director PiiPoo Accessible Centre for Art and Culture Finland Email: pilvi.kuitu@kulttuuripiipoo.fi Kai Lehikoinen Vice-Director, ArtsEqual Research Initiative Director, Center for Educational Research and Academic Development in the Arts University of the Arts Helsinki Finland Email: kai.lehikoinen@uniarts.fi Max Liljefors Professor Department of Arts and Cultural Science Lund University Sweden Email: Max.liljerfors@kultur.lu.se Magnus Lunderquist Chair (Kristdemokraterna) Culture Committee Region Skåne Sweden Email: lunderquist@gmail.com Political symposium on the arts and health in the Nordic region Page 14 Anna Mannfalk First Vice-Chair (Moderaterna) Healthcare Committee Region Skåne Sweden Email: anna.mannfalk@skane.se Camilla Mårtensen Chair (Liberalerna) Skåne University Hospital Board Region Skåne Sweden Email: camilla@martensen.se Lucie Matejkova Head of Network Relations Creative Business Network Denmark Email: lum@cbnet.com Niclas Nilsson Board Member (Sverigedemokraterna) Kristianstad Hospital Board Regional Development Committee Region Skåne Sweden Email: niclas.nilsson@sd.se Anders Ohlsson Professor of Literary Studies Centre for Language and Literature Lund University Sweden Email: anders.ohlsson@litt.lu.se Eva Pulverer-Marat Manager Primary Care Education Unit Region Skåne Sweden Email: eva.pulverermarat@skane.se Vegar Rangul Postdoctoral Student HUNT Research Centre Norwegian University of Science and Technology Norway Email: vegar.rangul@nord.no Political symposium on the arts and health in the Nordic region Page 15 John Roslund First Vice-Chair (Moderaterna) Skåne University Hospital Board Region Skåne Sweden Email: john.roslund@malmo.se Birgitta Miegel Sandborg Developer, Arts & Health Department of Culture Region Skåne Sweden Email: birgitta.miegel-sandborg@skane.se Eline Wernberg Sigfusson Deputy Director Nordic Culture Fund Denmark Email: elsi@norden.org Wenche Torrissen Associate Professor Volda University College Norway Email: torrissen@hivikda.no Rasmus Wiinstedt Tscherning Founder and Chief Executive Officer Creative Business Network Denmark Email: rwt@cbnet.com Gitte Grönfeld Wille Director of Cultural Affairs Department of Culture Region Skåne Sweden Email: gitte.wille@skane.se Tony Woods King’s Creative Health Programme Manager Wellcome Trust United Kingdom Email: a.woods@wellcome.ac.uk Political symposium on the arts and health in the Nordic region Page 16 WHO Regional Office for Europe Nils Fietje Research Officer Division of Information, Evidence, Research and Innovation Email: fietjen@who.int Andrea Elisabeth Scheel Consultant Division of Information, Evidence, Research and Innovation Email: scheela@who.int Priya Umachandran Consultant Division of Information, Evidence, Research and Innovation Email: umachandrans@who.int Rapporteur Ole Loehr Wilken Independent Consultant Denmark Email: olewilken@gmail.com Expert group meeting to enhance Health 2020 monitoring and reporting World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01 Email: euwhocontact@who.int Website: www.euro.who.int Piecing together the health information puzzle Copenhagen, Denmark, 1–2 September 2016 The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. Member States Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czechia Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands North Macedonia Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan Turkey Turkmenistan Ukraine United Kingdom Uzbekistan WHO/EURO:2019-3477-43236-60597