Arts and public mental health: exemplars for Scandinavia

193 ПАНОРАМА ОБЩЕСТВЕННОГО ЗДРАВООХРАНЕНИЯ ТОМ 6 | ВЫПУСК 1 | 2020 Г. | 193 – 210 INTRODUCTION In this article we provide a scoping review of arts and health research and practice, and explore the use of arts activities for improving public mental health, using exemplars from Scandinavian countries to illustrate the potential benefits and weaknesses of such an approach. We refer to the term “creative public mental health,” by which we are explicitly referring to examples of how the public may benefit from forms of cultural and arts participation. Creative expression is fundamental to human existence across all cultures and civilizations. There is increasing evidence worldwide that not only are such activities intrinsic to being human, but they are also a contributing factor to health and well-being. While an element of this occurs through being part of an audience, and epidemiological research from the Scandinavian countries has found significant positive associations between going to the cinema, theatre, concerts etc. and perceived health, improved life satisfaction and reduced anxiety and depression (1, 2), the emphasis in this paper is on participatory creative and expressive artistic activities for public mental health. Even though Scandinavians may score highly on the various happiness surveys, mental health problems and social inequality in health are increasing in the region. In a  report commissioned by the Nordic Council of Ministers titled In the Shadow of Happiness, researchers found mental health to be one of the most significant barriers to subjective well- being (3). The report is based on data collected over five years, from 2012 to 2016, and concludes that 12.3% of people living in the Nordic region are struggling or suffering (according to the Cantril Scale used to assess general life satisfaction). It is particularly young people and people over 80 years old who are having mental health problems. REVIEW Arts and public mental health: exemplars from Scandinavia Anita Jensen1,2, Wenche Torrissen3,4, Theodore Stickley5 1 Competence Center for Primary Healthcare, Region Skåne, Sweden. 2 Aalborg University, Aalborg, Denmark. 3 Volda University College, Volda, Norway. 4 Norwegian Resource Centre for Arts and Health, Levanger, Norway. 5 University of Nottingham, Nottingham, United Kingdom. Corresponding author: Anita Jensen (email: Anita.Jensen@skane.se) ABSTRACT Introduction There is growing research evidence, both globally and in Scandinavia, to suggest that engagement with arts and cultural activities has a positive effect on mental health and well-being. Methods Through a scoping review using a five-stage method, this article identifies examples of arts practice that is supported by research for mental health and well-being in Scandinavia, exploring how engagement in arts and culture activities may be good for the mental health of the public through the different stages of life: childhood and youth, working life and older age. Results Examples of dance, music, arts on prescription, visits to museums and galleries, visual arts, literature and theatre encompass the variety of arts and culture activities that are used for improving mental health in the Scandinavian population. Benefits are identified as the improvement of psychosocial skills, including coping, self-esteem, resilience and communication, as well as developing relationships. Conclusion By embracing and recognizing the added health value and impact of arts engagement, policies could include access to arts and culture activities, targeting people with mental ill-health as well as public health promotion. Research suggests that arts engagement in Scandinavia is important for mental health and well-being throughout life. Therefore, it is crucial for public mental health and well-being strategies to be linked to regional and local policies to ensure appropriate implementation for local communities. Keywords: ARTS AND HEALTH, ARTS AND CULTURE ACTIVITIES, PUBLIC MENTAL HEALTH, SCANDINAVIA 194 ARTS AND PUBLIC MENTAL HEALTH: EXEMPLARS FROM SCANDINAVIA PUBLIC HEALTH PANAROMA VOLUME 6 | ISSUE 1 | 2020 | 194 – 210 In Scandinavia, as in other regions, people have become increasingly reliant on medication for dealing with mental and psychosocial problems and life’s difficulties, such as childbirth, ageing, unhappiness, exhaustion and loneliness, and these difficulties are being routinely and increasingly medicalized. Scandinavians consume high amounts of antidepressant pharmaceuticals per capita and have long waiting lists to see therapists (4, 5). The overprescription of antidepressant medication has been seriously debated and a recent reanalysis of a network meta-analysis by researchers at the Cochrane Centre (6) showed that previous studies on the effective use of antidepressants are found to have “many biases and methodological limitations in the evidence base for antidepressants for depression.” The study concluded that “the evidence does not support definitive conclusions regarding the benefits of antidepressants for depression in adults,” and that “it is unclear whether antidepressants are more efficacious than placebo.” Moreover, overprescribing has a  substantial cost, both socioeconomically and to those receiving the medication. Treatments may have iatrogenic effects, people become patients, common problems are given a  diagnosis, stigma proliferates, and people are often left with no tools to adjust to or understand their problems. However, other non-medical, holistic solutions are also in use, including community-based arts programmes designed to promote mental health. In Scandinavia, many studies show that engaging in arts and culture activities is beneficial for mental health and well-being (2, 7, 8). In Sweden and Norway, there is also growing political awareness of how engagement with arts and culture activities may benefit the mental health of the public and how the arts can contribute to addressing public health challenges. Nonetheless, arts and cultural activities are still undervalued in the ongoing efforts to address key health and well-being challenges of the region. In this article we provide examples from across the Scandinavian countries to understand the relevance of participating in arts and culture activities for mental health and well-being from a  life-course perspective. We cover the different stages of life: childhood and youth, working life and older age, and in the discussion we draw attention to how arts engagement can contribute to supporting the World Health Organization’s (WHO) Thirteenth General Programme of Work’s focus on healthier populations and improving human capital (9), and Sustainable Development Goal 3: Good health and well-being (10). METHOD A scoping review approach was used. While a systematic review might typically focus on a  well defined question, a  scoping study addresses a  broad topic where different study designs have been used (11, 12). The aim is neither to describe research findings in any detail nor to attempt a quality assessment of the research. Instead, this scoping review maps existing evidence of creative public mental health from Scandinavian contexts. The use of arts for public mental health in the Scandinavian countries has never been mapped before, so the aim was to include all types of evidence available. Published research as well as reports from grey literature have been included, both in Scandinavian languages and in English. In conducting this review, we followed Arksey and O’Malley’s model (11) and used their first five stages. Stage 1: Identifying the research question. We identified the research question as follows: What is the evidence for participatory arts engagement in promoting public mental health and well-being in Scandinavia? As the focus of the review is on Scandinavia, we limited the search to Scandinavian studies that identified arts practices in the community that sought to improve mental health and well-being. Stage 2: Identifying relevant studies. We searched for research evidence in different sources, such as electronic databases, reference lists, by hand-searching key journals, and we made enquiries into existing networks and relevant organizations. Stage 3: Study selection. We selected articles that specifically related to the practice of arts interventions that sought to promote mental health. While there are many more articles addressing physical health and activities delivered in hospitals, articles that did not relate to our focus on public mental health were excluded. Stage 4: Charting the data. In this stage we focused on what we could identify as to what helped, who and how. This stage focused primarily on the peer-reviewed academic journal articles. Stage 5: Collating, summarizing and reporting the results. A  scoping review does not seek to synthesize evidence and tends to identify themes instead (12). Therefore, we decided that the best way to present the findings to inform a discussion on public mental health is to consider the evidence from a life- course perspective. This then enables an informed discussion 195ARTS AND PUBLIC MENTAL HEALTH: EXEMPLARS FROM SCANDINAVIA ПАНОРАМА ОБЩЕСТВЕННОГО ЗДРАВООХРАНЕНИЯ ТОМ 6 | ВЫПУСК 1 | 2020 Г. | 195 – 210 relating to the general population, where anyone can be susceptible to mental health problems. This review gathers existing evidence, seeking to identify examples of how creative and artistic approaches in Scandinavia may have helped to promote public mental health and well- being, as well as how this evidence could help to define areas for future research. RESULTS: EXEMPLARS FROM SCANDINAVIA CHILDHOOD AND YOUTH Conventional child and adolescent mental health services have developed slowly in response to the increasing mental health problems in these age groups, and are on too modest a scale to aid more than a minority of the at-risk population (13). Public health interventions for children and young people are few and far between, and more preventive interventions capable of promoting normal psychosocial development, developing social and emotional skills and reducing the risk of mental disorder are needed (14). In this context, arts-based projects have shown great promise. Music and community music therapy are used across Scandinavia to address public mental health issues within communities. In a  music intervention for fifth- and sixth- graders in a  school in Stockholm, aimed at stimulating togetherness in the class, a  controlled experiment showed that salivary cortisol levels during school hours were reduced when the class were given an extra hour of music every week, which indicates lowered levels of stress in the class (15). In a  Norwegian qualitative case study, a  community music therapy group was introduced for disadvantaged adolescent students. Focus group interviews with staff revealed that the intervention promoted improved relationships and experiences of individual freedom (16). In Denmark, recent qualitative research using narratives and observation has shown that the quality of life among youth on the edge is significantly improved through engagement with community arts projects (17). The study shows that young people who are involved in music, theatre, film and radio projects get the opportunity to use resources that they normally do not use, and this enables them to focus on the things they can master. This strengthens their self-esteem and hope for the future. In Norway, theatre projects have been used to promote the integration of asylum seekers and people who have dropped out of high school. One such project, Ville Veier based in Stavanger, uses theatre activities to promote social and emotional competences that can lead to educational and employment opportunities. Results from this qualitative study show that the majority of the people who have been involved in the project are now in regular employment or pursuing an education (18). In Sweden, dance projects to improve the mental health and well-being of adolescent girls have become widespread in recent years. Girls aged between 13 and 18 years who were experiencing mental health issues such as anxiety and depression, and physical symptoms such as stomach pain and headaches, and who visited school nurses, were often invited to participate in a dance project where they could move however they liked. Researchers found that the girls who participated saw their self-esteem improve compared to the control group and, notably, compared to the control group, the girls in the dance intervention group experienced increased self-rated health, decreased somatic symptoms, emotional distress and use of medication, and increased feelings of self-trust. Moreover, the intervention was considered cost-effective and played a  role in sustaining new positive active habits. The positive effect was evident at both four- and eight-month follow-ups after the dance training ended. Results from studies into the project also showed that the twice-weekly sessions led to improvements in self-assessments, and reduction in their symptoms and painkiller use (19). Over 300 instructors have now been trained in this method in Sweden. The Drama Improves Lisbon Key Competences in Education project examined whether theatre and drama education had a positive effect on five of the eight key competences defined by the 2006 Recommendation of the European Parliament and of the Council on key competences for lifelong learning. These five competences are: communication in the mother tongue; learning to learn; social and civic competences; sense of initiative and entrepreneurship; and cultural awareness and expression (20). Norway and Sweden participated in this quasi-experimental study that followed 5 000 students aged 13 to 16. Students who participated in the theatre and drama programmes improved their verbal skills more than those not in such programmes. Interpersonal communication, humour, creativity, school enjoyment, perspective-taking, problem- solving, stress control, and tolerance towards minorities, among others, were also found to be improved in those participating. The study shows that theatre education can improve social skills, positive emotion regulation and adoption 196 ARTS AND PUBLIC MENTAL HEALTH: EXEMPLARS FROM SCANDINAVIA PUBLIC HEALTH PANAROMA VOLUME 6 | ISSUE 1 | 2020 | 196 – 210 of the perspectives of others, thus increasing the psychological understanding of the mental states of others (21). WORKING LIFE In the Scandinavian context, there is a  growing awareness and understanding of how participating in arts and cultural activities can improve mental health and well-being. Some of these activity programmes are offered as Arts on Prescription (AoP). AoP programmes typically last ten weeks, offering participants with mental health issues a variety of arts and cultural activities twice a week for approximately two hours in groups of 8−12 people. The activities vary from programme to programme and can include visual art-making, music and singing, theatre and museum or gallery visits. In a study from Sweden, service users who were registered at selected health centres in the Skåne region were offered a ten-week programme with various arts and culture activities (22). The results, based on 123 participants, showed that 29% of the participants had achieved a  clinically relevant change in health-related quality of life and/or work capacity at the 12-month follow- up. A qualitative study from the Danish AoP project Culture Vitamins used interview methods among participants and showed mental health benefits such as increased energy levels and improved self-esteem; more joy in life; fewer panic attacks; increased motivation and self-care; a better understanding of personal needs, and some participants also felt closer to the labour market. The study concluded that programmes such as AoP can improve an individual’s mental health and well-being and can be a catalyst for change in life. The salutogenic theory was used to analyse the data for the study, focusing on the individual’s strengths, and demonstrated that AoP promotes health through the strengthening of resources and competences that the individual possesses (23). A 2016 review focusing on practices in Denmark, Norway and Sweden showed that, while there is an interest in the initiatives, it is still a relatively new way of thinking about health and it will take time to develop AoP practice in the Scandinavian context (24). However, in line with the increased focus on public mental health and well-being, AoP initiatives are becoming more mainstream in the Scandinavian context and are delivered by regional and local authorities, often aimed at people with mild-to-moderate depression, stress or anxiety. Benefits have been found to include increased social belonging and improved confidence. The initiatives can also act as a  catalyst for change and self- esteem building (23, 24). Choral singing is a common activity in parts of Scandinavia. In the project “Sound of Well-Being,” employees at two county hospitals in Norway were invited to participate in a choir-singing programme. A total of 700 people participated in 21 choirs in 2011. After the programme, 1 431 employees (57.4%) completed a survey questionnaire. Of these, 426 (29.8%) had engaged in the singing. The results showed that those who had participated in the singing initiative reported an improved psychosocial work environment and better self-assessed health (25). The NaKuHel (NaturKulturHelse) [NatureCultureHealth] foundation was established in 1994 in Norway. Today, NaKuHel organizations throughout the country use nature and cultural activities as a public health strategy. Qualitative research shows that nature and culture activities can promote health, quality of life and better environments for individuals and communities (30). Throughout Denmark and Sweden, there are examples of the positive effect of shared reading on mental health and well- being. Shared reading, a  concept pioneered by The Reader organization in Liverpool, United Kingdom (26), has gained traction across Scandinavia and numerous shared reading guides have now been trained. Research studies from the Scandinavian context and beyond show that using literature as a tool to provide mental health and well-being has positive effects, with participants reporting positive changes in terms of psychological well-being, and that the groups can act as community-building tools and catalysts for change (26, 27). OLDER AGE In the years 2012–2014, the the Swedish Arts Council tasked the local regions with distributing assistance for promoting cultural activity in elderly care. The aim was to develop sustainable models and methods for promoting the participation of older people in cultural life. It was intended as a  cultural policy venture and a  way of safeguarding the right of every citizen to culture regardless of their condition. With funding from the regions, many initiatives emerged across Sweden. In the Skåne region, the cultural agency hosted seminars to inspire caregivers and artists working with older people, in addition to providing a  stream of funding for projects. One practical example involved clown care for older people with dementia. A qualitative study from Sweden demonstrated that both verbal and non-verbal communication improved after interaction with the clowns. By using music, theatre and singing, the clowns stimulate the senses and autobiographical aspects, which in turn can support a stronger sense of identity among older people living with dementia (28). In a qualitative study in Norway, upon observing interactions between the clowns and the residents, and interviewing the 197ARTS AND PUBLIC MENTAL HEALTH: EXEMPLARS FROM SCANDINAVIA ПАНОРАМА ОБЩЕСТВЕННОГО ЗДРАВООХРАНЕНИЯ ТОМ 6 | ВЫПУСК 1 | 2020 Г. | 197 – 210 staff, researchers found that the use of clowns in dementia care engages residents in ways that improve their quality of life (29). Since 2008, the Alzheimer Association has trained over 1 000 care staff in 500 residential homes within 81 local authorities across Denmark to engage in reminiscence dance with the residents. The method is based on the reminiscence concept, where the purpose is not to learn to dance but to listen to familiar music, observe other people dancing and activate memories to encourage participation in the dance. Well known songs can activate memories and movement patterns, and create joy and social engagement for residents, staff and relatives. Apart from the obvious physical benefits such as movement and coordination training, the activity also has been shown to promote meaningfulness, well-being and social contact (30). The use of music in residential homes is widespread across Scandinavia. Music is used for various purposes, including entertainment, anxiety reduction, lifting spirits, care work, and making social connections, and it is facilitated by music therapists, musicians or care workers (2). In Norway, music- based caregiving is a  method used in dementia and elderly care that has been proven to have positive mental well-being effects on people living with dementia (31). The method was developed on behalf of the Norwegian Directorate of Health by the Norwegian Resource Centre for Arts and Health that also delivers professional training as part of the method. Today, music-based caregiving is used in many residential homes across the country. Numerous museums in Scandinavia have arts and cultural activities addressed to older people, with a focus on the public health of the older generation in terms of well-being and quality of life. These initiatives are primarily coming from within the museums and are not policy-driven. A few examples of practice can be found at the Frederiksberg Museums in Denmark, where there is a substantial focus on older people, particularly regarding loneliness (32). Furthermore, in the years 2013–2015, 88 museums in Sweden engaged in a  collaboration with the Alzheimer Foundation to deliver museum activities for people living with dementia (33). Many of the museums continued the work after the project period had ended. In Norway, KODE Art Museums in Bergen provides dementia-friendly tours for older people and their caregivers, providing participants with an opportunity to exercise their cultural citizenship and become co-creators (34). DISCUSSION In this scoping review, we have mapped the current evidence of creative public mental health in Scandinavian contexts. The findings suggest that arts engagement can help promote public mental health for the Scandinavian population, supporting the Sustainable Development Goal of good health and well-being for all. The findings show that children and youth experienced mental health benefits from participating in dance, music and theatre activities. The mental health and well-being of people of working age improved as a  result of participating in AoP programmes, nature activities, choral singing and shared reading groups. The use of clowns in dementia care, reminiscence dance, theatre, music and music-based caregiving, as well as visits to museums have improved quality of life, enabled social contact and increased mental health and well-being among the older population. By providing evidence from Scandinavian contexts, the review also supplements the growing global evidence base that supports arts engagement for mental health and well-being (35). All the projects identified in this study follow a  strength- based approach, where the key goal is to build and increase well-being and human capital. This focus is consistent with the main priorities of WHO’s Thirteenth General Programme of Work (9) and represents an important approach to mental health promotion. Through participation in arts activities, people can acquire psychosocial resources such as self-esteem, resilience, emotional skills, coping skills, communication skills and relational skills (2, 19, 24, 36). The majority of people who engage in arts activities claim that these activities have improved their quality of life and that they, with the help of such activities, have made human connections and developed hope and meaning, imperative for mental health and well- being (7, 17, 19, 22, 23, 28, 32, 37). Despite the growing evidence base in support of creative public mental health, the review has also identified research gaps and policy issues that must be addressed to take advantage of the added mental health benefits of arts participation in ways that can support WHO’s Thirteenth General Programme of Work (9) and the 2030 Agenda for Sustainable Development (10). The projects identified in this study do not tell us how arts interventions may address health inequalities. WHO’s Thirteenth General Programme of Work (9) outlines healthy life expectancy and equity as measurable impact targets. Health and poverty are intertwined, and people with mental ill-health are more likely than the general population to experience poverty and to have a shorter life expectancy (9). As 198 ARTS AND PUBLIC MENTAL HEALTH: EXEMPLARS FROM SCANDINAVIA PUBLIC HEALTH PANAROMA VOLUME 6 | ISSUE 1 | 2020 | 198 – 210 many studies show, engaging with arts and culture activities can improve mental health and well-being for all ages while also providing a  way of addressing inequalities (35). While mental ill-health continues to correlate with poverty and lower social status, it is apparent that the arts can strengthen and unite communities and individuals if people are offered increased opportunities to engage with arts programmes such as those identified in this review. Many of the projects covered by this review are small-scale and the question remains how to scale up these programmes and make them widely available as public health initiatives to increase the number of beneficiaries, especially those from poor or disadvantaged communities. At the same time, it is imperative for global mental health and well-being strategies to be linked to regional and local policies to facilitate implementation that can truly make a  difference, avoiding a one-fits-all approach. Developments must also be made at policy level. As this review has shown, there are many public mental health benefits from engaging in the arts. However, the sustainability of many of the projects we have referred to in this article is threatened by a  lack of financial security and institutional support. Political willingness and policy-driven initiatives are therefore imperative to ensure sustainability and to strengthen further development, research and interdisciplinary work in the field. As for weaknesses in this expanding field of practice, there are few negative side-effects reported in the studies considered in this review. Naturally, not everyone may wish to engage in arts activities or respond positively to them; but where there is participation, there is much evidence for positive outcomes in public mental health (2, 35). One potential negative outcome is the sense of feeling deflated once the programme has finished (24). Therefore, the importance of collaboration with social, educational and health settings to provide further opportunities and progression routes for participants should be emphasized. More research is needed to secure the evidence base for creative mental health in Scandinavia. The field would benefit from more strategic long-term approaches, including longitudinal studies and studies that include larger populations, focusing on the perspectives of individuals from the three stages of life. In the material identified in this study, there is a  particular need for more and larger studies that identify the benefits of the arts for children and youth in a public health perspective. Given the rise in mental health problems experienced by youth in the Scandinavian countries, and the promising results that arts programmes have shown in promoting well-being, this must be a priority in the work towards meeting the 2030 Agenda for Sustainable Development. To this end, major funding to support arts and health research in Scandinavia must be prioritized. Furthermore, a widespread change of attitude needs to continue; one that does not seek answers solely from biomedical science, but also from grassroots health initiatives that encourage people to have fun, enjoy themselves, create personal and community connections, and be creative together. Acknowledgements: None declared. Conflicts of interest: None declared. Sources of funding: None declared. Disclaimer: The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions or policies of the World Health Organization. REFERENCES1 1. 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