WHO expert meeting on prevention and control of noncommunicable diseases: learning from the arts. Opera House Budapest, Hungary, 15–16 December 2022: meeting report.

iWHO expert meeting on prevention and control of noncommunicable diseases: learning from the arts Meeting report Opera House Budapest, Hungary | 15-16 December 2022 WHO expert meeting on prevention and control of noncommunicable diseases: learning from the arts This report summarizes the proceedings of an expert meeting held on 15–16 December 2022 in Budapest, Hungary, on the value of arts interventions for health, focusing on initiatives for mainstreaming arts into prevention and control of noncommunicable diseases (NCDs) in the WHO European Region. Participants included academics in a range of disciplines, civil society groups, Member State representatives and WHO staff. NCD prevention and control, a critical area of public health, is particularly well suited for arts interventions. Arts-based activities are multimodal, with psychological, behavioural and social effects, can be delivered in low-risk, cost-effective initiatives and can significantly improve health and well-being. They can provide insights into complex behavioural barriers and drivers, encourage participation and outreach, support healing and disease management, galvanize behaviour change and encourage a culture of health and well-being. They can be used in the context of many NCDs, including mental health, age-related disorders and chronic illness. The meeting identified various priorities for strengthening the intersection between arts and health, including building a strong community of practice and engaging in advocacy and awareness-raising. Participants discussed ways for supporting these priorities, such as capacity-building, thematic focus areas, funding and design considerations. Keywords: NONCOMMUNICABLE DISEASE MEDICINE IN THE ARTS CULTURE HUMANITIES © World Health Organization 2023 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). 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All photos: ©WHO Designed by: Iordanis Passas Design Document number: WHO/EURO:2023-8280-48052-71230 Abstract WHO expert meeting on prevention and control of noncommunicable diseases: learning from the arts iv v vi vii viii 1 1 1 2 4 4 5 6 7 8 8 8 9 10 11 11 12 13 14 14 16 19 20 22 24 Foreword Acknowledgements Abbreviations Executive summary 1 Introduction 1.1 Rationale 1.2 Meeting proceedings 1.3 Noncommunicable disease prevention and control: regional priorities and opportunities for the arts 2 What we can learn from the arts: situating the arts in health 2.1 General overview and key distinctions 2.2 Momentum in the arts and health sector: policy and advocacy from Culture Action Europe 2.3 Not just for elites. Participatory engagement in communities 2.4 Arts and health initiatives to change behaviour in complex health problems 3 European case studies 3.1 Spain: Intersectoral collaboration, extensive networks and co-creative principles (Madrid Salud) 3.2 Finland: The Arts Promotion Centre (Taike) 3.3 United Kingdom: The healing power of music – case studies from Scotland 3.4 Romania: Arts interventions to address postnatal depression 3.5 Hungary: Choirs for rehabilitation from respiratory illness – the SingLung method 3.6 Russian Federation: Story-telling for healthy lifestyles and health promotion in schools 3.7 A personal note on the healing arts: Christopher Bailey 3.8 Features of working with the arts 4 Emerging priorities and suggested actions 4.1 Summary of recommended actions and priorities 4.2 Priorities and suggested actions 5 Conclusion References Annex 1. List of participants Annex 2. Agenda Contents WHO expert meeting on prevention and control of noncommunicable diseases: learning from the arts v Foreword Noncommunicable diseases (NCDs) are the leading causes of death and disability in the WHO European Region, where they are responsible for 90% of all deaths, representing nearly 9 million people every year, and 85% of situations of disability. The four primary risk factors are tobacco use, alcohol consumption, unhealthy diets and physical inactivity. To address these and many other factors that determine health and well-being, social, cultural, political, psychological and economic systems and their component parts must all be considered. One of the four flagship programmes of the WHO Regional Office for Europe therefore addresses behavioural and cultural insights (BCI) for health. BCI includes the contextual and individual factors that affect health behaviour, and the programme seeks to develop policies, services and communication to improve health and well-being and reduce inequity. To meet the ambitious targets of the WHO European Office for the Prevention and Control of NCDs, we must act differently. Reducing the burden of NCDs necessitates new, innovative, evidence-informed approaches. Arts and health may provide creative solutions to complex health challenges, and the BCI initiatives therefore include arts and culture. Research on the effects of arts on health and well-being has increased during the past two decades. While work with the arts for health promotion is well known, targeted arts interventions can do much more. There is now a considerable body of evidence that arts interventions play a significant role in the prevention of ill health, promotion of good health and management and treatment of disease. Thus, the field of arts and health is promising, and creative solutions for complex health challenges, including those in NCD prevention and control, should be developed. The WHO expert meeting on NCD prevention and control: learning from the arts brought together a broad range of stakeholders, including artists, cultural institutions, health-care practitioners, academics, policy-makers and experts in behaviour. It provided a platform to share experiences and examples and to advance collaboration in harnessing the potential of the arts in NCD prevention and treatment, both in the Region and globally. The meeting sought to increase collaboration by building a multidisciplinary platform for sharing country experiences and best practices for preventing or reducing the burden of NCDs. There is a growing momentum to integrate the arts into the practices of the health-care sector. I welcome this opportunity to extend art interventions among Member States of Europe and Central Asia and hope that this might seed similar initiatives across the world. Dr Hans Kluge Regional Director WHO Regional Office for Europe WHO expert meeting on prevention and control of noncommunicable diseases: learning from the arts vi Acknowledgements This report is a summary of the Expert Meeting on Noncommunicable Disease Prevention and Control: Learning from the Arts, which was held in Budapest, Hungary, on 15 and 16 December 2022. WHO is grateful to the experts who presented their work and perspectives during this meeting: Chris Bailey, Arts and Health Lead, WHO headquarters; Nils Fietje, WHO Regional Office for Europe (BCI unit, Denmark; Kremlin Wickramasinghe, WHO NCD Office; Kornelia Kiss, Culture Action Europe, Belgium; Anna Kontsevaya, National Research Centre for Preventive Medicine, Russian Federation; Raymond MacDonald, Edinburgh University, United Kingdom (Scotland); Michael Pratt, University of California San Diego, United States of America (USA); Jill Sonke, University of Florida Center for Arts in Medicine, USA; Isto Turpeinen, Art Promotion Centre, Finland; Noemi Valdés, Universidad Complutense, Madrid, Spain; Katalin Vardi, Breathe For Soul Foundation, Hungary; Vicki Ware, Deakin University, Australia; and Rarita Zbranca, AltArt Foundation, Romania. WHO staff members and consultants who contributed to organizing the meeting and providing feedback on this report were: Olga Andreeva, Adriana Isabel Pinedo Carrilo, Anna Chaturvedi, Luis D’Souza, Nils Fietje, Kathrin Hetz, Viktoria Anna Kovacs, Kremlin Wickramasinghe and Olga Zhiteneva. The meeting was hosted by the WHO Country Office in Hungary, led by Szabolcs Szigeti, Haris Hajrulahovic and Éva Kertész. Audiovisual production was undertaken by Balázs Delbó and Gréta Fontányi of Delbeau Film. The meeting was graciously hosted on the premises of the Hungarian State Opera. The WHO thanks the Opera’s staff members and their Director, Szilveszter Ókovács, for their welcome and support. Several local artists and bands performed during the event’s “art breaks”: Adél Bihari, Hajnalka Lehóczky, Marianna Vékey, the Aphasia Choir led by Zsófia Fekete, László Kelemen, Emma Krizsán, Ágnes Pazzagli, Marianna Vékey and the Fool Moon Acapella Band. This document was produced by the WHO NCD Office. Ameer Shaheed provided rapporteur services and wrote the report. The meeting was led and financed by the WHO European Office for the Prevention and Control of Noncommunicable Diseases (NCD Office), in collaboration with the WHO Regional Office for Europe Behavioural and Cultural Insights (BCI) unit, the WHO Arts and Health lead, and the WHO Country Office in Hungary. WHO expert meeting on prevention and control of noncommunicable diseases: learning from the arts vii Abbreviations BCI behavioural and cultural insights EU European Union NCD noncommunicable disease NCD Office WHO European Office for the Prevention and Control of Noncommunicable Diseases OECD Organisation for Economic Co-operation and Development USA United States of America WHO expert meeting on prevention and control of noncommunicable diseases: learning from the arts viii Executive summary Noncommunicable diseases (NCDs) are the leading causes of mortality in the WHO European Region. New and innovative approaches are required to meet defined targets for NCD prevention and control. There is growing evidence that the arts can support health and well- being, from health promotion to disease prevention, treatment and management. The ambitious targets for reducing the burden of NCDs require new, innovative, evidence-informed approaches, which include arts- based initiatives. This report presents the proceedings of an expert meeting held on 15–16 December 2022 in Budapest, Hungary, on the value of arts interventions for health and on initiatives for mainstreaming arts into NCD prevention and control in the WHO European Region. Meeting participants included academics in a range of disciplines, civil society groups, Member State representatives and WHO delegates. Presentations and group discussions were complemented by live “art breaks”, illustrating a core principle of the meeting – that participating in the arts is itself healthy behaviour. The arts in relation to NCDs Many artistic activities address health topics that are directly relevant to NCD prevention and control, including mental health, age-related disorders and chronic illnesses. Such activities are often low-risk, cost- effective complements to treatments, which improve health and well-being. They can yield important insights into complex behavioural barriers and drivers; encourage participation and outreach; support healing and disease management; galvanize individual and collective behaviour change; and encourage the deeper shifts that create cultures of health and well-being. Emerging priorities and suggested actions NCDs are a critical area of public health and an important area in which to explore and further develop arts-based initiatives. Arts and health activities are particularly well- suited for NCD prevention and control because they are multimodal, acting at psychological, behavioural and social levels, all of which are important in the prevention and control of NCDs. Several considerations and principles should be kept in mind in introducing arts and health activities into NCD initiatives. They should include young people and the elderly. Social activities can help bridge the gap between culture and health, but they must be equitable, inclusive and accessible. Projects should be designed to align the unique features of the arts to the experiential and social space created by projects, resulting in both scientific and artistic results. Projects should balance size and scale and be tailored to the local setting. Involving young people is important for the success of projects, as they bring energy, initiative, networks and insights. Several cross-cutting support elements should also be considered. One is capacity-building to strengthen advocacy, awareness-raising, project implementation and research. This includes guidance material, tools, educational resources and training. Funding is an essential element for enabling and sustaining activities. Although the discussions at the meeting did not identify specific financial solutions, apart from certain strategic considerations, this was recognized as a priority for advocacy and a topic to be addressed expediently and in depth. A strong community of practice is necessary for arts and health activities to contribute successfully to NCD prevention and control, as it can federate the many disciplines and stakeholders involved, refine priorities, seed collaborations and maintain the momentum to build the sector. An initial step could be to organize a community of practice dedicated to NCD prevention and control within the WHO European Region. Such a group might be a subset of a larger, sector-wide community. Two priorities were identified for strengthening, normalizing and expanding the field: advocacy and awareness-raising. The two are linked and can be organized from community to regional level and from the level of the general public to experts and decision- makers. The WHO NCD Office, the BCI team and the Arts and Health lead indicated their readiness to support Member States and invite them to contact them for further information and consultation on engagement. Individuals and institutions in all arts and health sectors are encouraged to peruse the references and resources for further information. Arts and health is a growing discipline. The meeting was one of several recent events that recognized the role of novel, innovative, transdisciplinary solutions to complex challenges and to promoting a shift towards a culture of health and well-being. WHO expert meeting on prevention and control of noncommunicable diseases: learning from the arts 1 Introduction 1.1 Rationale Noncommunicable diseases (NCDs), in particular cardiovascular disease, cancer, chronic respiratory illnesses, diabetes and mental disorders, are responsible for approximately 90% of all deaths and to 85% of years lived with disability in the WHO European Region (1). Many of the contributing factors – including tobacco and alcohol use, unhealthy diets and physical inactivity – are related to social, cultural, political, psychological or economic factors. Therefore, the WHO Regional Office for Europe has selected behavioural and cultural insights (BCI) for health as one of its four flagship initiatives, to complement the European Programme of Work, “United action for better health in Europe”, setting out health priorities for 2020–2025 (2). Insights into the behavioural and cultural contexts of health and well-being can change attitudes, actions and norms from the individual to the policy level. The ambitious targets for reducing the burden of NCDs will require new, innovative, evidence-informed approaches, and arts-based initiatives may be promising in this regard. Arts interventions are defined as activities that involve engaging with the arts in order to address problems such as physical and mental health, peace and reconciliation. They can play a significant role in preventing ill health, promoting good health and managing and treating diseases throughout life (3). While existing initiatives span a wide range of artistic disciplines and health topics in diverse contexts, the field as a whole is still in its early stages. Activities and funding remain relatively disparate, with support mainly for small, short-term projects. The field requires greater consolidation and integration into policies to ensure longer-term, more sustainable initiatives. The expert meeting was convened by the WHO European Office for the Prevention and Control of Noncommunicable Diseases (NCD Office) in collaboration with the WHO BCI unit to explore how the arts and health field can be applied to NCD prevention and control and to understand the possibilities for wider implementation, particularly in policy. It provided participants with information on the state of play of arts and health interventions, case studies and best practices and opportunities to discuss how such interventions could be scaled up. 1.2 Meeting proceedings The objectives of the meeting were to examine the evidence, discuss considerations related to arts and health interventions and explore how to consolidate, develop, expand and normalize the arts and health field, initially in the context of NCD prevention and control in the WHO European Region. The 28 participants represented 17 countries (Annex 1) and included academics, civil society groups and representatives of WHO European Region Member States and disciplines ranging from public health to socially engaged forms of artistic and cultural practice. The academics and representatives of nongovernmental organizations and health associations in the group were selected for their involvement in activities related to arts and health interventions and advocacy. They provided a rich, practical repository of field experience, ranging from small-scale pilot projects in regions with little policy support, to municipal and national programmes. Many examples are included in section 3 of this report. WHO expert meeting on prevention and control of noncommunicable diseases: learning from the arts 2 1. Participants were divided into groups which moved among several “stations”, spending an allotted time with the person managing the station to address the question allotted to that station. The groups rotated during the activity so that feedback on each question could be obtained from several groups. Each question was posed at two stations to further maximize group feedback. The 2-day agenda (Annex 2) was designed to achieve balance among the presentations, discussions and artistic activities through active engagement and group dynamics. Day 1 was largely dedicated to presentations on the arts and health field and several case studies. Presentations were delivered by WHO staff members and by subject experts from Australia, Finland, Hungary, Romania, the Russian Federation, Spain, the United Kingdom, and the United States of America (USA). Day 2 was devoted to group work to define the challenges and opportunities for the field. In one session, challenges and opportunities for greater integration of arts and health interventions were discussed, while a second session was in a “world café” format1 and addressed specific questions on the priorities in which to invest, more effective awareness-raising, sharing the growing evidence base, and specific actions that WHO could take. As the arts require more than intellectual understanding, presentations and group discussions were complemented by live “art breaks”, which provided engaging examples of artistic activities to promote health and well-being. This report is not a chronological summary but rather covers the major topics raised in individual presentations and group discussions. The first section describes general reviews, country case studies and the distinguishing features of projects involving arts engagement, defined as any form of engagement in and with the arts, including practising or being exposed to an art form. The section on emerging priorities and suggested actions summarizes the major outcomes of the group work and panel discussions, which include guiding principles and considerations for arts and health interventions. 1.3 NCD Prevention and Control: regional priorities and opportunities for the arts Dr Kremlin Wickramasinghe, Head a.i. WHO European Office for the Prevention and Control of Noncommunicable Diseases The strategic objectives of the WHO NCD Office are to reduce the burden of NCDs, reduce health inequalities and increase participatory governance of health, as defined in the European Programme of Work 2020–2025 (2). The aim of the NCD Office is to meet SDG target 3.4 on NCDs and mental health: “By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being” (4). To meet this ambitious target and to address the key behavioural and biological risk factors requires comprehensive, innovative, bold solutions. Exploring how the growing arts and health field could apply to NCDs may yield important contributions to those objectives. NCDs are a critical public health issue, both globally and regionally, and, although only a few contributing factors are well defined, addressing them effectively is complex. NCDs are responsible for approximately 90% of all deaths in the WHO European Region, the majority of which can be attributed to cardiovascular diseases, cancers, chronic respiratory disease and diabetes (5). The causes of the main NCDs are linked to a number of behavioural risk factors, including tobacco use, harmful alcohol consumption, an unhealthy diet and insufficient physical activity, which lead to biological risk factors such as high blood pressure, high blood glucose, high blood cholesterol, as well as overweight and obesity (Fig. 1) (5). The major activity in NCD prevention and control is addressing their behavioural and biological risk factors (Fig. 2), many of which can be classified as “complex” and “systemic” challenges (1), which require shifts in individual and collective behaviour, attitudes, norms and culture. WHO expert meeting on prevention and control of noncommunicable diseases: learning from the arts 3 Tobacco Alcohol use Dietary risks High body-mass index High systolic blood pressure High fasting plasma glucose High LDL cholesterol Low physical activity Air pollution Both sexes Female Male % of total DALYs 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 20% 8% 7% 11% 11% 10% 12% 11% 11% 10% 14% 13% 14% 9% 9% 9% 7% 6% 1% 1% 1% 4% 3% 4% 8% 3% 14% 19% Fig. 1. Burden of disease in the WHO European Region attributable to selected risk factors, 2019 Source: Institute for Health Metrics and Evaluation (6). DALY, disability-adjusted life year; LDL, low-density lipoprotein The NCD Office uses a comprehensive strategy to find innovative solutions for effective behaviour change. Engaging with the arts may complement current activities in NCD prevention and control and contribute to the fourth flagship initiative of the European Programme of Work: BCI. BCI and arts-based approaches can catalyse the shift from access to healthy choices and awareness of risk factors to actual individual and collective change. As illustrated by this meeting, substantial evidence indicates that various modes of knowing, engaging and understanding – including working through aesthetics, emotions and collective activities – can improve health and well-being, ensure effective communication, help to overcome behavioural barriers, generate novel solutions and stimulate participation. This is illustrated by the field of climate change, in which it has been found that raising awareness of the facts is insufficient and that deeper shifts in culture and norms are required, as well as creative approaches, to change public attitudes and policy significantly. On the basis of these objectives and considerations, the present meeting was designed to promote recognition of the value of arts and health projects, to explore ways in which the field can be applied to NCD prevention and control and, most importantly, to advance their application at policy level. It is hoped that this meeting has identified barriers, priorities, entry points and messages and generated momentum for collaboration and strengthening of the community of practice. 25% relative reduction in the overall mortality from cardiovascular diseases, cancer, diabetes, or chronic respiratory diseases (SDG) 10% relative reduction in the harmful use of alcohol, as appropriate, within the national context (SDG) 10% relative reduction in prevalence of insufficient physical activity 30% relative reduction in mean population intake of salt/sodium 30% relative reduction in prevalence of current tobacco use (SDG) Halt the rise in diabetes and obesity (SDG) 25% relative reduction in the prevalence of raised blood pressure or contain the prevalence of raised blood pressure, according to national circumstances At least 50% of eligible people receive drug therapy and counselling (including glycaemic control) to prevent heart attacks and strokes 80% availability of the affordable basic technologies and essential medicines, including generics required to treat major noncommunicable diseases in both public and private facilities NCD Global Monitoring Framework: 9 global targets by 2025 and SDGs by 2030 Fig. 2. NCD Global Monitoring Framework Source: WHO (7) SDG, Sustainable Development Goal WHO expert meeting on prevention and control of noncommunicable diseases: learning from the arts 4 What we can learn from the arts: situating the arts in health 2.1 General overview and key distinctions Arts and health: creative solutions to complex health challenges Dr Nils Fietje, Technical Officer, WHO, and Dr Jill Sonke, Research Director, University of Florida Center for Arts in Medicine, USA Increasing evidence demonstrates a role for the arts as non-invasive, low-risk, cost-effective treatment options to supplement biomedical forms of treatment and healing (8). The arts are particularly useful in addressing the complex challenges in current medical and public health interventions, many of which involve individual and collective behaviour change (9,10). WHO has become increasingly interested in the practical benefits of engagement in the arts. A systematic review of the field in 2019 (3) included over 3000 interventions, representing a wide range of ways in which arts-based approaches could improve health and well-being, from prevention and promotion to treatment and management. A policy brief on arts interventions among forcibly displaced populations showed improvements in psychological, behavioural and social processes, which improved health and social cohesion in host communities (11). A WHO brief published in 2019 (12) made the case for greater integration of the arts into health, underlining the importance of intersectoral collaboration and raising questions about funding and ownership in this cross-cutting field. A project on “music and motherhood” has been tested in a number of countries, providing insights into the impact of such interventions and how they can be applied in different cultural contexts (13). (See also section 3.4.) Arts interventions take many forms and have a wide range of application. They differ in the scale at which they are conducted, such as “general” and “targeted” interventions. General interventions are not designed for a particular person or group. They include such activities as going to a museum or joining a choir, which have been shown to improve mood, lower cortisol levels, increase serotonin levels and promote social behaviour (14–17). In “targeted interventions”, arts engagement is used to address specific diseases, health factors or communities. A similar distinction can be made between “population” and “individual” interventions and effects. Population activities are designed to improve health indicators with non-specific interventions to reduce depression, increase healthy ageing and reduce mortality rates. Individual benefits can be measured in targeted interventions, such as dance projects, which have greater effects on Parkinson and cardiovascular diseases than standard physical exercise programmes; pain management has been improved with music therapy (8,18–21). The arts can be applied to the health sector in various ways, from evidence-based clinical interventions to prevention, management and promotion activities in public health and to social prescription, in which patients are referred to arts-based activities. Arts interventions can also be differentiated according to their design, setting and focus. Further distinctions can be made between use of the arts in health care (when artists bring their skills and knowledge to a health-care setting), arts in public health (when arts are integrated into population interventions) and creative arts therapy (in which clinicians use art forms of therapy). WHO expert meeting on prevention and control of noncommunicable diseases: learning from the arts 5 Social prescriptions are an important area for further development in this field. The term refers to integration of non-clinical services into health care through prescription by health-care professionals. Social prescriptions are relatively well established in the context of promoting physical activity (e.g. gym membership) and are a useful means for introducing arts and health activities that are outside the clinical domain. A toolkit for integrating social prescriptions, while not specific to the arts, has been published by the WHO Regional Office for the Western Pacific (22). Social prescriptions must, however, be carefully designed and managed and be considered only one of many arts-based approaches in public health. Socially prescribed activities should be recognized by and aligned within health systems, and equity must be ensured to avoid disparities in access to either health care or the arts. Activities should be as local as possible. 2.2 Momentum in the arts and health sector: policy and advocacy from Culture Action Europe Ms Kornelia Kiss, Projects and Operations Director, Culture Action Europe, European Commission Culture Action Europe is an intersectoral “network of networks” that advocates for culture as a component of inclusive, sustainable societies. Arts and health is an expanding area in its activities, reflecting a growing interest among European Union (EU) policy-makers. The current priorities of the arts and health sector in the EU include: dedicated strategic and financial support for the sector, more knowledge and awareness-raising, training and peer-learning, greater involvement of EU Member States, and a dedicated platform for a community of practice. Key health priorities for EU policy- makers include: health promotion and prevention, the mental health crisis, youth, burn-out in the working-age population, ageing populations, ill health, inequality and forcibly displaced people. The growing momentum of arts and health activities is reflected in recent activities such as publication of the CultureForHealth report (23) and a European Parliament session in November 2022. The upcoming 2023–2027 EU work plan is to include the topic of culture and health. Activities of the Organisation for Economic Co-operation and Development (OECD) on the “well-being economy” include recognition of social determinants of health. Arts and health are integrated into the EU mental health strategy, to be finalized by July 2023. The priorities of Culture Action Europe are directly relevant to arts initiatives for NCD prevention and control in the WHO European Region, as they include social determinants of health, mental health and well-being, extending to many spheres, including the economy. WHO expert meeting on prevention and control of noncommunicable diseases: learning from the arts 6 2.3 Not just for elites. Participatory engagement in communities Dr Vicki Ware, Lecturer, Master of International and Community Development, Deakin University, Australia While the arts may be associated with privilege in many societies and even used for detrimental purposes such as social manipulation and propaganda, this is arguably due more to their practical application than to their inherent nature. Art may in fact be more universal, accessible and communal. Applied in the right manner, arts-based initiatives can provide insights into community dynamics, drivers and knowledge and also catalyse collective and individual behaviour change. As illustrated by Dr Ware’s research in Southeast Asia (24–26), participatory arts-based initiatives can be used in many ways, such as shifting power dynamics to counter top–down mediation. Artistic experiences are naturally engaging, fun and memorable, encouraging participation and leaving strong impressions. Arts-based methods also allow participants to navigate ambiguity and can lead to multiple interpretations. These initiatives are inclusive, giving a voice to disadvantaged groups. They can also result in unanticipated insights and changes. The “social field” is conducive to encounters, emergence, discovery and individual and collective change. The process of engagement is more important than the product. Understanding and influencing individual and collective behaviour is an important component of NCD prevention and control. Participatory arts- based initiatives can provide significant benefits for community public health activities, provide insights into community dynamics and drive and catalyse collective and individual behaviour change. WHO expert meeting on prevention and control of noncommunicable diseases: learning from the arts 7 2.4 Arts and health initiatives to change behaviour in complex health problems Prof Michael Pratt, University of California San Diego, USA Approaches based on the arts and culture have significant advantages over more traditional health interventions in addressing complex challenges that cannot be resolved by linear, convergent or one-dimensional solutions (27,28). Systems-based and multimodal approaches are important for tackling such challenges and particularly those that require behavioural insights and those for individual and collective change, as is the case in many areas of NCD prevention. A recent report by the NCD Office (1) noted that the aim of systems thinking is to look at the “bigger picture”, in which real-world phenomena occur in systems composed of dynamic agents such as people, populations and organizations, all acting and evolving in response to each other and their contexts. Public health initiatives to address complex challenges and influence behaviour require work with other sectors, particularly those related to natural drivers and motivators of human behaviour, such as marketing, arts and culture, sports and anthropology. One of the reasons that public health recommendations do not always result in behaviour change is that the interventions cannot always ensure happiness, engagement, captivation or fun, as observed repeatedly in interventions to increase population physical activity (29,30). Interventions must be locally relevant to be appreciated; for example, what works in rural Colombia will not necessarily work in urban Brazil or in peri-urban Finland. “Country, culture and context” are the key elements. The arts and health field could take lessons from the field of physical activity, as they have much in common and may reinforce each other. NCD prevention and control frequently faces complex challenges, including understanding and influencing behaviour change, as reported in studies of obesity and physical activity (9,31,32). Participatory arts-based initiatives may provide important insights in this regard. Collaboration with initiatives to increase physical activity could further strengthen their pertinence for NCDs. WHO expert meeting on prevention and control of noncommunicable diseases: learning from the arts 8 European case studies 3.1 Spain: Intersectoral collaboration, extensive networks and co-creative principles (Madrid Salud) Dr Noemi Avila Valdés, Associate Professor, Universidad Complutense, Madrid, Spain Madrid Salud is a successful example of interdisciplinary municipal arts and health programmes. This ongoing project was initiated in 2011 as a partnership between the University of Complutense and 16 health centres in Madrid. It conducts activities in public spaces to maximize outreach and equity and involves collaboration among artists, health professionals, community members and interdisciplinary participants of various ages and social strata (33). Various initiatives have been conducted. A calligraphy workshop helped to connect with Chinese-heritage women, who were less likely to visit health centres. Similarly, a watercolour workshop engaged young mothers with a Roma background to discuss maternal health. The health centres also organized group activities, such as visiting museums, which provided occasions for forming social bonds and discussion of topics relevant to community health and well-being. The initiative has created a space in which people and sectors can meet and talk in a common language, mediated by art and culture. An atmosphere of recreation and joy engages people, catalysing positive change and action. The project is based on the principles of co-creation, equity and the concept of “artivism”, whereby social change is enabled through art (34). Young people – particularly early career researchers – have been critical to its success, as they bring the drive, initiative, creativity, energy and networks that are essential to create and manage the intersectional space. Madrid Salud represents many of the key considerations for successful arts and health projects. Its approach provides important insights for NCD initiatives involving community engagement, stigmatized themes and initiatives for populations who rarely access the health system, such as drug users and people with obesogenic and carcinogenic lifestyles. 3.2 Finland: The Arts Promotion Centre (Taike) – an expert service to connect grass-roots arts with national policies Dr Isto Turpeinen, Special Adviser, Art Promotion Centre, Finland The Art Promotion Centre (Taike) is the main coordinating body for socially engaged arts programmes in Finland, connecting artists with decision-makers, third- and fourth-sector stakeholders, regional networks and researchers. Under the auspices of the Ministry of Culture, its mission is to promote the arts both nationally and internationally and also to promote aspects of culture that are not covered by another official body. One of its primary objectives is to promote well-being. The activities of the Centre reflect Finland’s national policies and priorities for arts-based initiatives for WHO expert meeting on prevention and control of noncommunicable diseases: learning from the arts 9 health and well-being. Young people and older adults were identified as the main target populations, as arts interventions are recognized as supporting cognitive, auditory and motor functions in older adults and addressing mental health and depression in all age groups. Arts-based programmes supplement and even reduce the need for certain drug treatments, particularly for mental disorders. Extracurricular art classes to promote the well-being of young people are popular, with membership and support growing throughout the country. A core feature is entertaining, engaging interventions, and the social space they create provides many other benefits, resulting in both better health and overall well-being. Many of the risk factors and priorities addressed by this initiative in the Finnish context are common to other countries in the WHO European Region and are relevant to NCD prevention and control, such as age- related disabilities, obesity, physical exercise and mental health and well-being in young and elderly populations. The Art Promotion Centre and the Finnish model represent good practices of integrating arts and health into national policy. 3.3 The United Kingdom: healing power of music – case studies from Scotland Prof Raymond MacDonald, Chair, Musical Psychology and Improvisation, Edinburgh University, United Kingdom (Scotland) Music can promote health and well-being in many ways, from first-order effects such as psychological and physical benefits to second-order effects such as greater interpersonal engagement and social cohesion. The emotional dimension is central to the effects of music, and music is frequently used to regulate mood. Its subjective meaning is unique to each individual, independently of its external or inherent structure. Music interventions in health-care settings in Scotland have been found to affect cognitive ability, social bonds, mental health and even the perception of pain. For example, significant improvements in cognitive indicators were observed among children with learning disabilities after they had participated in a 3-month community music intervention (35). Group music sessions involving cancer patients were found to be a constructive medium for expressing unconscious thoughts and emotions, promoting interpersonal bonding and becoming literally “in tune” with others (36). In an experimental investigation, reduced pain perception was observed when participants were listening to their favourite music (37). Many of the first- and second-order effects of music described above are relevant to NCD prevention and control, including promotion of interpersonal bonding and cohesion, improved neurocognitive functions and chronic disease management. WHO expert meeting on prevention and control of noncommunicable diseases: learning from the arts 10 3.4 Romania: Arts interventions to address postnatal depression Ms Rarita Zbranca, Director, AltArt Foundation, Romania A music-based pilot project has been conducted to address postpartum depression in Cluj-Napoca, Romania, as part of a study that also included Denmark and Italy (13). The results demonstrate the strengths of arts and health interventions, even in challenging environments. The intervention was conducted as a collaboration between women with postpartum depression, artists and health experts. Two groups of young mothers, one Hungarian- and the other Romanian-speaking, attended a 10-week programme with their babies and sang together once a week. The effects were measured on various scales of perceived social support, postnatal depression and well-being and also in focus groups and participant journals. Clear benefits were found, including statistically significant increases in well-being and social support and reductions in self-reported postpartum depression. The participants stressed the importance of having a unique social space that allowed them to connect with one another. One mother said The pilot study helped the project team to understand considerations for and the challenges of such projects. Consideration must be given to equity and social inclusion by ensuring the representation of different groups, such as Roma women, and a participatory approach to the design and implementation of the project, by consulting the diverse group of women with postpartum depression, health experts and artists. Ensuring local institutional support, data protection and privacy are also necessary. Training and support were necessary to familiarize the music instructors with the health dimensions of the activity. The main challenges faced were lack of policies, funding and enabling environments for arts and health interventions and cultural norms such as stigmatization of mental health issues. The project team will consider how to scale up similar projects, address social norms and promote the inclusion of such activities in decision- makers’ budget plans. This initiative applies rigorous methods to explicitly address an NCD (depression) in several countries. It provides a model for piloting future arts and health projects, and to this end, is being used as the basis for a forthcoming report. The report is being launched during a WHO conference on this same topic, to be held in October 2023. I was just happy that us, mothers, can come and have this space to talk to each other…the singing hour quickly became the most anticipated time of the week. It was a much-needed healing experience. WHO expert meeting on prevention and control of noncommunicable diseases: learning from the arts 11 3.5 Hungary: Choirs for rehabilitation after respiratory illness – the SingLung method Dr Katalin Vardi, Hungarian Breathe for Soul Foundation, Hungary In the SingLung method, singing is used to improve lung function. The method was developed by Dr Vardi in partnership with the conductor Györgi Philipp for rehabilitation of patients with respiratory illness (38). Patients can choose to join the choir, in addition to their usual treatment and activities. Several rehearsals are organized with professional musicians, dancers, yoga teachers, physiotherapists and volunteers, culminating in a public performance. More than 150 patients have participated in the programme in the past 4 years. The project includes several indicators of impact, including the well-established 6-min walk test (39) and self-reported indicators of mental health and well- being. The scores on the test were as good as those for classical physical therapy, and mental health tests indicated improvements in well-being, particularly reduced depression and stress. One of the benefits of the SingLung method over traditional physical therapy is that it is more motivating, fun and engaging for patients. The social space created by this multidisciplinary collective project is an important feature through which other benefits are mediated. The fact that the project builds towards a public performance strengthens patients’ sense of achievement. The main challenges remain funding and lack of support, particularly from the health sector. Respiratory illnesses are responsible for a significant proportion of the NCD burden, and this project is a model that can be adapted to other contexts within the WHO European Region and beyond. 3.6 Russian Federation: Story-telling for healthy lifestyles and health promotion in schools Dr Anna Kontsevaya, National Research Center for Preventive Medicine, Russian Federation The National Research Center for Preventive Medicine launched a pilot project for using creative means to increase health literacy among schoolchildren. An open call for artistic approaches to convey healthy lifestyles was met with great interest from socially engaged artists in various fields. The shortlisted project was implemented in a school in Vologda Oblast, where students read fairy tales that imparted lessons on healthy lifestyles. The project team noted greater awareness of a number of health factors, including the role of a healthy diet and the dangers of prolonged exposure to digital media. The initiative also promoted intersectoral collaboration between the regional health and educational sectors. Other regions have indicated their interest in similar activities. The experience demonstrates the potential for greater involvement of the education sector in health activities for young people. The project reflects use of arts-based interventions for health promotion and for cross-sectoral collaboration. Such practices are also applicable to NCD prevention and control, particularly in promoting healthy lifestyles and health literacy in young people. WHO expert meeting on prevention and control of noncommunicable diseases: Learning from the arts 12 Hope is a creative act. Story-telling is a huge part of the cancer journey...the entire world had changed...and yet it was physically the same; you break out of this logical world that has failed you and you accept the absurdity of it. 3.7 A personal note on the healing arts: Christopher Bailey Mr Christopher Bailey, WHO Arts and Health lead Mr Bailey, an artist in his own right, recounted his experience of blindness, obesity and cancer, combining performance and poetry recitations. He provided both an intellectual and an emotional sense of how the arts can contribute to healing, insight, connection and change. With regard to obesity, Mr Bailey described his experience of weight fluctuations, first as an actor who faced pressure to conform to standards of beauty and then as a WHO official experiencing the stigma associated with rapid weight gain and obesity. He noted that public health initiatives tend to focus on individual choices and behaviour rather than criticizing the underlying ecosystems, such as policies related to the food industry. Food can be an art form and an aesthetic experience and therefore shares features with other arts interventions. Community kitchens in the USA promote social cohesion in neighbourhoods where there is racism. Such initiatives need not explicitly address problems, as solutions emerge implicitly in the space created by the shared experience. After receiving a diagnosis of cancer, Mr Bailey found it essential to develop a narrative that allowed him to make sense of his new reality. He said, Feeling compelled to have a creative outlet during his sick leave, Mr Bailey wrote a play centred on the HIV epidemic in the USA. He described the powerful effects of this experience: While the aesthetic experience may have nurtured healing of his mind and body, the link between arts and health was deeper than one that could be explained by a purely medical correlation. Arts engagement provided “paths through meaninglessness and chaos”. He stressed that the arts, while not curative in the same way as modern medicine, can have results that – regardless of the physical outcome – bring healing and well-being. In conclusion, Mr Bailey noted that arts and health programmes, including social prescriptions, should be based on an understanding that “most of the benefit...is not linear…it is complex”. More holistic public health would not just “lengthen life at all costs, no matter how much suffering we go through”; rather, it should help “make sure that you have actually lived a life in the first place...and that is what the arts can do”. when I was on stage with the actors, I had this profound sense of well-being.... It was as if the chemotherapy had disappeared for that period.... In that moment of performance…I was well. The arts don’t cure cancer...they heal, which is different. Even if I had passed, my journey would have had authentic personal meaning because of that artistic engagement. WHO expert meeting on prevention and control of noncommunicable diseases: learning from the arts 13 3.8 Features of working with the arts A number of cross-cutting themes emerged from the presentations, indicating features to be considered in designing, implementing and evaluating arts- based projects. In many ways, artistic and cultural practices cannot be seen through the same lens as purely medical interventions. They are a distinct sphere of human activity, predating medicine, science and even complex civilization. They have an inherently engaging and enjoyable quality, which naturally encourages participation and attention. The arts are multimodal, combining physical, emotional, cognitive, psychological and social benefits. They have deeply subjective dimensions, forming a bridge between “outer” and “inner” worlds. They can help people to aspire and to imagine, with different ways of knowing, understanding and sensing. These features are found by both individuals and groups and therefore provide a window into “shared subjectivity” – the collective narratives, priorities and frameworks that shape societal norms, policies, institutions and behaviour. Local context and knowledge are essential in the design, implementation and scaling up of arts interventions. To ensure that projects are sustainable and effective, they should be based in the communities they serve and implemented by partners who are aware of their community’s needs and realities. Another consideration is the size of arts and health projects: one size does not fit all, and bigger is not better. Small or medium-sized arts interventions may be most effective, according to the context of the target population. This raises questions about the balance between global and local dimensions and how initiatives can be scaled up while respecting the importance of context. Arts-based activities create a social space for encounters. All the case studies presented illustrate how arts interventions create a space in which many other processes and effects are mediated. In these spaces, people connect with one another and create a dynamic that can give rise to insights and changes, many of which could not have been predicted from the outset. This is particularly valuable for understanding a particular issue and for enabling and catalysing behaviour change. Such spaces also permit the arts and artists to drive social change and may be integral to creating a culture of health and well-being. One participant noted, While any public health initiative involving the arts could include these features, they apply particularly to NCD prevention and control. Many of the subjects addressed, such as lifestyle choices, are subjective, sensitive, stigmatized or related to drivers and motivators of behaviour change and cannot be accessed readily. The implications of these findings for project design, implementation and evaluation are further discussed in section 4.2.5. the arts can be very instrumental to driving the kind of social and cultural changes we need to move the needle on some of the most critical public health issues today. WHO expert meeting on prevention and control of noncommunicable diseases: learning from the arts 14 Emerging priorities and suggested actions 4.1 Summary of recommended actions and priorities The aim of this first WHO meeting on arts and health was to discuss the value of arts and health interventions and how to extend and normalize the practice in the context of NCD prevention and control in the WHO European Region. The first objective was to review the evidence and considerations related to arts and health interventions. Presentations by experts situated the arts in public health (section 3), illustrating different forms and functions of arts and health interventions in various contexts. Participants recognized that such projects have clear benefits, as low-risk, cost- effective complements to other initiatives for health and well-being. They can provide important insights into complex challenges, encourage participation and outreach, provide a range of benefits, from prevention to management and healing, galvanize individual and collective behaviour change and enable the deeper shifts that create a culture of health and well-being. The second objective was to consider how to consolidate, develop, expand and normalize the field. The recommendations addressed several priorities, specific activities, cross-cutting considerations and guiding principles. Participants agreed that NCDs are an important area of public health for arts-based initiatives and a strategic entry point for normalizing the field. Arts activities are well-suited for NCD prevention and control as they often encompass psychological, behavioural, cultural and social dimensions. This association is observed in the case studies presented at the meeting, touching upon chronic disease, obesity, mental health, age-related illnesses, as well as social ecosystems and cultures of health and well-being. While the meeting focused on NCD prevention and control, many of its outcomes are also applicable to public health in general, because development of arts and health practices in any context presupposes development in the wider context of public health. While momentum is growing, the field is still relatively disparate and unfamiliar to the public and decision- makers and will require coordination and capacity- building. The first recommended action is to nurture a community of practice to help federate the diverse disciplines and stakeholders involved, refine priorities, seed initiatives and collaborations, update the evidence base, and maintain the growing momentum in communities and at policy level. An initial step could be to organize a network for NCD prevention and control in the WHO European Region or as a subset of a larger, sector-wide community. At the heart of any community of practice is the practice itself – of arts and health interventions. While the meeting did not recommend specific projects or research topics, participants outlined a number of considerations and principles to guide such activities. Two further priorities are to strengthen and expand advocacy and awareness-raising. These elements mutually reinforce one another and can be done at several levels, from the community to the region and for the general public to experts and decision- makers. Participants identified several cross-cutting WHO expert meeting on prevention and control of noncommunicable diseases: learning from the arts 15 support elements. One is capacity-building to strengthen advocacy, awareness-raising, project implementation and research, accompanied by guidance material, tools, educational resources and training. Sustainable funding is a vital element for conducting and maintaining activities. The group did not identify specific solutions, beyond certain strategic considerations, such as the possibility of aligning existing systems and reallocating existing resources – particularly with regards to social prescriptions. The outcomes can be viewed within a framework (Fig. 3). At the core is a multi-stakeholder community of practice, with several priorities, including advocacy, awareness-raising, projects and research. The other recommendations are cross-cutting support elements: principles to guide advocacy, awareness- raising, projects and research; capacity-building; and funding. Communities of practice can be viewed as nested within one another; for example, NCDs can be seen as a subset of community actions in the general field of arts and health. Fig. 3. Framework of emerging priority actions and cross-cutting support elements WHO expert meeting on prevention and control of noncommunicable diseases: learning from the arts 16 4.2 Priorities and suggested actions 4.2.1 Establishing a community of practice While the evidence base and momentum for the sector are growing, arts and health is still a relatively disparate field. This is due partly to its interdisciplinary nature, astride two fields – arts and public health, which are themselves multidisciplinary and diverse. A dedicated network could be an important node, federating its diverse disciplines and stakeholders to refine priorities, seed initiatives and collaboration, update the evidence base, and maintain the growing momentum to build the sector from communities to policy level. Such a group could have functional subdivisions, such as resource mobilization, advocacy, awareness-raising, and research. Participants could include art institutions and practitioners (including socially engaged artists), health professionals, social workers, Member State representatives, nongovernmental organizations, advocacy groups, researchers, students and early- career professionals. Importantly, any new initiative should avoid duplication and complement existing initiatives.2 Initially, such a community could focus on NCD prevention and control in the WHO/European Region, or WHO could help initiate a wider network that would include NCD prevention and control as a subset and strategic focus area. The NCD Office currently has four similar networks, for salt reduction, restrictions on marketing of unhealthy foods to children, for reducing sugar and calorie intake, and for physical activity. Work could be done with these networks to identify initiatives and champions in the nexus of arts and NCDs. Subsequently, with support from a Member State, a fifth network could be established to address arts and health. 4.2.2 Awareness-raising Arts and health is still relatively unknown to the wider public, decision-makers and even practitioners in both the health and the arts sectors, and policy support and knowledge differ significantly by country and region. Raising awareness of the many forms and benefits of arts-based initiatives could normalize the field, raise interest, increase the community of practice and contribute to advocacy by influencing policy-makers. Awareness-raising can be conducted at several levels. At national and regional levels, WHO and its institutional partners could lead initiatives, convene stakeholders to dedicated gatherings and present the field to other sectors to further raise awareness and support. Awareness could be raised in the general public through live and digital campaigns and events, activities and content shared via analogue and digital media, and an online platform that could include “virtual town halls”, online gatherings and repositories for relevant information. Awareness-raising among individuals, experts and institutions in the arts and health could include focused outreach to health practitioners, artists, students and early-career professionals (for supporting material, see section 4.2.4). The health sector is a key target, as increasing the interest of specialists can raise support at higher levels of policy-making, including ministries of health, arts and culture, finance, and education. Activities could be directed to practitioners in NCD prevention, for example in forums and among specialists in respiratory and chronic diseases and mental health. The proposed activities include campaigns with particular themes in the arts and NCDs that address the health topics most relevant to the setting, involve community organizations and ensure equity and accessibility. The initiatives could start in WHO European Region countries and address local priorities for NCD prevention and control. Campaigns could be conducted online and/or in person. They should include stakeholders from the arts and health sectors and include artistic productions and activities. Such initiatives could also be used to collect data on local needs and key actors. When possible, complementary campaigns, including partnerships between regions and topics, could be coordinated to strengthen their reach. The evidence base could be shared in various formats, including information packages for health professionals and decision-makers, and multimedia during communication campaigns drives (see section 4.2.4). 2. Notable examples include the NeuroArts Blueprint, academic institutions such as the University of Florida Center for Arts in Medicine, Johns Hopkins Art+Mind Lab, the WHO Collaborating Centre on Art and Health at University College London, the Jameel Arts and Health Lab and advocacy organizations such as CultureActionEurope. WHO expert meeting on prevention and control of noncommunicable diseases: learning from the arts 17 4.2.3 Advocacy Advocacy is a key component of initiatives to ensure more supportive policy environments and more resources for the field of arts and health. Participants identified various levels at which such activities could be conducted and principles for effective advocacy. Advocacy should be conducted regionally, nationally and sub-nationally. WHO could support work to make the case regionally and nationally, connecting Member States with stakeholders such as academic experts, practitioners, community representatives and networks in the arts and health sectors. Subnational advocacy for arts and health should be conducted in various spheres of influence, adapted to individual communities and local health priorities. Champions, whether individuals or collectives, were identified as important for effective advocacy. A strong community of practice should have focal points that can advocate for the cause at different levels, from specific sectors to national bodies of Member States. Awareness-raising drives and gatherings such as the meeting reported here are important forums for identifying champions. Strategies must be tailored to each context and level of support. Advocacy should be adapted to local priorities for health and development, the cultural context and the levels of support and funding. The country case studies presented in section 3 demonstrate that projects can be successful at various scales and in different enabling environments. The priorities identified by Culture Action Europe (section 2.2) are examples of adaptation of specific health areas to the context, which can guide activities in Europe. The proposed activities include holding regional and national meetings to identify areas for advocacy on NCD prevention, either in the WHO European Region or according to the priorities of a selected country or region. An example of such an initiative is a WHO conference in October 2023 to present the findings of a multi-country pilot project entitled “music and motherhood” (as outlined in section 3.4), on the impact of singing groups among mothers with postpartum depression. Participants also identified a number of outputs to strengthen advocacy: • a charter or declaration on arts and health; • initiatives and policies to recognize engagement in the arts as health behaviour and access to art and culture as a social determinant of health; • integration of the concept of “art breaks” in the WHO guide on planning healthy, sustainable meetings, published by the NCD Office (40); • official recognition of the arts and health field in the systematic landscape of NCDs; and • material to guide decision-makers in applying interventions in their context and effective arguments and studies for making the case for arts and health activities (see section 4.2.4). 4.2.4 Capacity-building Capacity-building is an important cross-cutting activity for priorities such as advocacy, awareness-raising, research and interventions. Compelling arguments should be developed for the sector and to support its growing workforce. Material for awareness-raising and advocacy could be prepared by compiling the evidence, with arguments for specific priorities, and conducting additional studies and analyses to fill gaps in the evidence. The material should to be available in various formats, adaptable to the needs of different institutions, bureaucratic systems and target audiences. Specific outputs could include: • guidance for decision-makers and implementers of interventions in their context, such as reviews or catalogues of case studies and interventions that constitute “best buys”; • information packages and arguments for government bodies, health professionals, artists and community representatives or for public campaigns; • studies or reports on the financial aspects of arts and health interventions, including studies of budget impact and cost-effectiveness, to present the added value of arts interventions in public health; and • compelling, targeted visual information adapted to various regional and national contexts, designed for multimedia application. Tools and training for professional development and education are necessary as fields grow and are particularly important in intersections between fields, where some boundaries may not be covered by the mainstream fields to which they are connected. Socially engaged artists could be trained in certain health topics, and health professionals could be trained in working with the arts. Initiatives could take the form of training modules, certificates and higher education programmes. As there are already some initiatives in this regard, future activities must avoid duplication. WHO expert meeting on prevention and control of noncommunicable diseases: learning from the arts 18 4.2.5 Considerations for activities in arts and health The discussions generated a number of considerations to guide future arts and health projects, research, advocacy and awareness-raising. With respect to principles and design considerations, the participants agreed that the principles of equity, social inclusion, accessibility and openness are essential for successful arts and health projects. This will not avoid disparities but will maximize the possibility of participation for gaining insights and enabling individual and collective change. Projects should be aligned with distinctive features of the arts (section 3.8). While interventions must have specific aims, they should be flexible and also account for experiences and the multiple levels of the arts, perhaps by using mixed methods, inclusive, adequate indicators, and objective and subjective measures to obtain both scientific and artistic results. An important balance must be achieved between the size and scale of arts and health activities. While a wider community of practice is necessary, with national, regional and international coordination, individual programmes and projects are most effective when they are tailored to the local level. By their nature, arts-based activities must be community-centred, reflect local needs and be culturally appropriate and relevant. Projects, particularly when creative, may be optimally dynamic and effective when they are small to medium sized. This topic should be further explored, including finding a balance between wider systems of coordination that allow smaller, local activities. NCDs are an important area of public health for arts- based initiatives and a strategic means to extend the arts and health sector. The public health entry points depend on the context and on local priorities and needs. Organizing arts and health interventions to target the health-care sector may demonstrate how arts interventions can supplement health policy and relieve strain on the system. They could include interventions in health-care facilities involving both patients and health- care staff. Young people could play key roles in this sector. The energy, initiative, networks and creative insights of students and early-career professionals can ensure success. Key target populations are young people (particularly schoolchildren) and older adults. Arts interventions can be particularly useful for addressing healthy lifestyles, mental health issues and well-being in both these populations. Young people have the added advantage of accessing arts education in schools, particularly in higher-income settings. Social prescriptions are an important mechanism for delivering arts interventions and for bridging the gap between the culture and health sectors. Social prescriptions can be customized and implemented at various scales, depending on the available support, resources and insurance coverage. It is worth considering whether social prescriptions should be managed exclusively from within the health-care sector, as this might exclude certain populations. Furthermore, medical professionals may lack the necessary skills to prescribe non-medical activities adequately. Intermediary sectors and mechanisms might be found for connecting communities to arts initiatives. Lessons could be learnt from “link workers” in the United Kingdom (41). 4.2.6 Funding considerations Although participants did not propose specific funding strategies, the topic was recognized as critical to advancing the sector. Funding is currently provided by a range of sectors and is frequently short-term and disparate. Advocacy drives and meetings in this sector should discuss alignment of existing systems and resources for more sustainable funding and identify possible further funds. The current funding situation reflects the interdisciplinary nature of the arts and health field, as well as lack of awareness, advocacy and support for the field. Financial sustainability is important for arts and health interventions, which are often community-based, involve building relationships and take place over the medium to the long term. Size and scale must, however, be balanced, and wider, more sustainable funding should still allow prioritization of local activities. One of the results of a dedicated community of practice might be greater connectivity among the various fields involved in funding projects. This could also result in identification of creative solutions and opportunities with existing pools of funding. Existing systems and resources could be pursued, although they should be consolidated and realigned. WHO expert meeting on prevention and control of noncommunicable diseases: learning from the arts 19 Conclusion Building on WHO’s increasing work on arts and health (3,11), the meeting was the first reflection on what the arts can contribute to NCD prevention and control. The outcomes will be the beginning of an inquiry, which will eventually result in specific priorities and actions. Since the meeting, there have been a number of important developments in the field of arts and health. First, the Jameel Arts & Health Lab (42) was launched as is a collaboration between the WHO Regional Office for Europe, the Steinhardt School at New York University (USA), Community Jameel and CULTURUNNERS. The lab addresses overlooked, underserved communities and will coordinate and amplify academic research on the effectiveness of the arts in improving health and well-being to drive policy implementation in WHO’s 194 Member States. Secondly, the European Commission has published a communication on a comprehensive approach to mental health (43), which notes that social prescribing is an innovative approach for improving well-being and health, including mental health. In addition, the Commission will launch voluntary collaboration with Member States (through the Open Method of Coordination) to strengthen links between culture and mental health. 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WHO expert meeting on prevention and control of noncommunicable diseases: Learning from the arts 22 Biró, Krisztina, Ministry of the Interior, State Secretariat for Health, Budapest, Hungary Bogos, Krisztina, National Korányi Institute for Pulmonology, Budapest, Hungary Chițac, Maria Racu, National Surveillance Centre of Noncommunicable Diseases, National Institute of Public Health, Bucharest, Romania Gonçalves, Mafalda, Co-Create Youth Task Force, Brussels, Belgium Goodwin, Frazer, European Public Health Alliance, Brussels, Belgium Grigg, Jonathan, Paediatric Respiratory and Environmental Medicine, Queen Mary University of London, London, United Kingdom Horváth, Ildikó, Hungarian Respiratory Society, and Director of Research and Education, National Korányi Institute for Pulmonology, Budapest, Hungary Jensen, Anita, Arts and Health, Lund University, Lund, Sweden Kiss, Kornelia, Projects and Operations, Culture Action Europe, Brussels, Belgium Konsevaya, Anna, Science and Analytics, National Medical Research Centre for Therapy and Preventive Medicine, Moscow, Russian Federation Lega, Ilaria, Istituto Superiore di Sanità, Rome, Italy MacDonald, Raymond, Music Psychology and Improvisation, Edinburgh University, Edinburgh, United Kingdom (Scotland) Magsamen, Susan, International Arts + Mind Lab, Center for Applied Neuroaesthetics, Pedersen Brain Science Institute, Johns Hopkins University School of Medicine, Baltimore (MD), USA Marosi, Eszter, Public Health Department, State Secretariat for Health, Ministry of the Interir, Budapest, Hungary Papartyte, Lina, EuroHealthNet, European Partnership for Health, Equity and Wellbeing, Brussels, Belgium Philipp, György, Alternative Secondary High School, Budapest, Hungary Pratt, Michael, Institute for Public Health and Masters in Public Health Program, University of California San Diego, San Diego (CA), USA Racu, Maria-Victoria, Nutritional and Children’s Health Department, National Agency for Public Health, Chişinău, Republic of Moldova Sonke Jill K, Center for Arts in Medicine, University of Florida, Gaineseville (FL), USA Sturua, Lela, Noncommunicable Disease Department, National Centre of Disease Control and Public Health, Tbilisi, Georgia Torbeyns, Bart, European Diabetes Forum, Brussels, Belgium Turpeinen, Isto, Arts Promotion Centre (Taike), Helsinki, Finland Valdes, Noemí Ávila, Department of Language, Arts and Physical Education, Faculty of Education, Computense University, Madrid, Spain Várdi-Visy, Katalin, Breath for Soul Choir, Farkasgyepü, Hungary Ware, Vicki-Ann, International and Community Development, Deakin University, Melbourne (VIC), Australia Warren, Katey, WHO Collaborating Centre for Arts and Health, University College London, London, United Kingdom Weitz Jakob, Department of Health Promotion and Disease Prevention, Federal Ministry of Social Affairs, Health, Care and Consumer Protection, Vienna, Austria Zbranca, Rarita, AltArt Foundation and Cluj Culural Centre, Cluj, Romania Further contributions Bihari, Adél, Brain Imaging Unit, Centre for Natural Sciences, Budapest, Hungary Delbó, Balázs, DelbeauFilm, Budapest, Hungary Fekete, Zsófia, National Institute of Medical Rehabilitation, choir conductor, Hungarian Aphasia Association, founder, Hangadó Vocal Ensemble, Budapest, Hungary Fool Moon acapella band, Budapest, Hungary Kelemen, László, Tango Flow Dance School, Budapest, Hungary Krizsán, Emma, Tango Flow Dance School, Budapest, Hungary Lehockzy, Hajnalka, National Choir, Müpa, Budapest, Hungary Pazzagli, Ágnes Rita, Tango Flow Dance School, Budapest, Hungary Annex 1. List of participants WHO expert meeting on prevention and control of noncommunicable diseases: Learning from the arts 23 WHO Bailey, Christopher Tomlin, Arts and Health Lead, WHO headquarters Chaturvedi (Mezentseva), Anna, WHO European Office for the Prevention and Control of Noncommunicable Diseases Fietje, Nils, Behavioural and Cultural Insights Unit, WHO Regional Office for Europe, Copenhagen, Denmark Hajrulahovic, Haris, WHO Country Office for Hungary, Budapest, Hungary Szigeti, Szabolcs, WHO Country Office for Hungary, Budapest, Hungary Wickramasinghe, Kremlin, WHO European Office for the Prevention and Control of Noncommunicable Diseases Zhiteneva, Olga, WHO European Office for the Prevention and Control of Noncommunicable Diseases Consultants, WHO European Office for the Prevention and Control of Noncommunicable Diseases Andreeva, Olga D’Souza, Luis Hetz, Kathrin Kovacs, Viktoria Pinedo, Adriana Shaheed, Ameer, rapporteur WHO expert meeting on prevention and control of noncommunicable diseases: learning from the arts 24 Session 1 Situating NCDs Control and Prevention in the Arts Time (CET) Session 08.30–9.00 Registration 09.00–09.20 Welcome Moderator: Kremlin Wickramasinghe, a.i. Head, WHO European Office for Prevention and Control of NCDs, WHO Regional Office for Europe Haris Hajrulahovic, Head of Country Office in Hungary Hans Kluge, WHO Regional Director of Europe 09.20–09.30 How Arts can contribute to NCDs Prevention? Kremlin Wickramasinghe 09.30–09.40 The Arts and Health programme at WHO: situating the work to date Nils Fietje, Technical Officer, Behavioural and Cultural Insights Session 2 Setting the Scene: Situating Arts in Health Moderator: Kremlin Wickramasinghe 09.40–10.00 Carry that Weight: obesity, perception and well-being Christopher Bailey, Arts and Health Lead, WHO HQ 10.00–10.15 A brief history of Arts in Health and how to integrate arts into the wider health system Jill K Sonke, University of Florida, College of the Arts, Center for Arts in Medicine 10.15–10.30 Exploring the research landscape in arts and health Katey Warren, WHO Collaborating Centre for Arts & Health, UCL Pre-recorded presentation 10.30–10.45 Is art a privilege? How different community groups can benefit from the arts Vicki-Ann Ware, Deakin University 10.45-11.00 Art intervention Adél Bihari, Hajnal Lehóczky, Marianna Vékey Moderator Szabolcs Szigeti, WHO Country Office for Hungary 11.00–11.20 Coffee break 11.20–11.30 The intersection of brain sciences and the arts: the NeuroArts Blueprint Susan Magsamen, Johns Hopkins University School of Medicine Pre-recorded video presentation Annex 2. Agenda Day 1 WHO expert meeting on prevention and control of noncommunicable diseases: learning from the arts 25 Time (CET) Session 11.30–11.40 Art, health and prevention: an intersectoral approach Noemi Avila Valdes, School of Education of Complutense University 11.40–11.50 Physical activity as a bridge between the arts and NCDs Michael Pratt, University of California San Diego 11.50–12.40 Panel discussion, questions and answers Chair: Nils Fietje, Technical Officer, Behavioural and Cultural Insights Jill K Sonke, University of Florida Vicki-Ann Ware, Deakin University Noemi Avila Valdes, School of Education of Complutense University Michael Pratt, University of California 12.40-13.30 Lunch Session 3 How to integrate research evidence in arts and health into policy and practice: country cases Moderators: Kremlin Wickramasinghe and Nils Fietje 13.30-13.45 Art intervention Aphasia choir: Zsófia Fekete Moderator: Szabolcs Szigeti, WHO Country Office for Hungary 13.45–13.55 The whole person, the whole life: Region Skåne’s Strategy for Arts and Health 2022–2030. Anita Jensen, Sweden 13.55–14.05 A dance with the world – from grass-roots activities to national policies of arts and health in Finland Isto Turpeinen, Finland 14.05–14.15 The relationship between music, health and wellbeing Raymond MacDonald, United Kingdom (Scotland) 14.15–14.25 Culture For Health: arts and health in the European Union Kornelia Kiss, Culture Action Europe 14.25 –14.35 Music and motherhood: implementing an arts and health intervention in Romania Rarita Zbranca, Romania 14.35–14.45 The result of pulmonary and social rehabilitation with choir singing using SingLung method amongst chronic respiratory patients Katalin Várdi and György Philipp, Hungary 14.45–14.50 Fairy tales as a tool for the formation of motivation to healthy lifestyle among primary school children Anna Kontsevaya, Deputy Director, Science and Analytics (pre-recorded) WHO expert meeting on prevention and control of noncommunicable diseases: learning from the arts 26 Time (CET) Session 14.50–15.35 Panel discussion and questions and answers Chair Nils Fietje Isto Turpeinen, Finland Anita Jensen, Sweden Raymond MacDonald, United Kingdom (Scotland) Rarita Zbranca, Romania Kornelia Kiss, Culture Action Europe Katalin Várdi, Hungary György Philipp, Hungary 15.35–15.50 Art intervention Argentine tango: László Kelemen, Emma Krizsán, Hajnal Lehóczky, Ágnes Pazzagli, Marianna Vékey Moderator: Szabolcs Szigeti, WHO Country Office for Hungary 15.50-16.10 Coffee break Session 4 Open and group discussions 16.10–16.50 The purpose of this session is to further discuss experiences with arts and health among participants and to unpack the impressions from the presentations so far Guiding questions: 1. What is your personal and/or professional experience with arts and health? 2. What do you take away from today’s presentations and comments? 16.50–17.00 Wrap up and closing Kremlin Wickramasinghe & Nils Fietje Day 2 Session 1 The role of arts in policy and health design, implementation and funding Time (CET) Session 09.00–09.10 Recap and overview of Day 1 Kremlin Wickramasinghe 9.10–10.10 Stage 4: Cancer and the imagination Christopher Bailey, Arts and Health Lead, WHO HQ 10.10–10.30 Coffee break Session 2 Usefulness and feasibility of the arts and health approach in their own areas of work - group work I 10.30–11.15 Moderators: Luis D’Souza & Olga Zhiteneva, WHO European Office for Prevention and Control of Noncommunicable Diseases Brief introductions from group members • What opportunities do you see in your country to develop arts and health interventions in relation to NCDs? • What challenges do you think still need to be overcome before arts and health can flourish in your country? WHO expert meeting on prevention and control of noncommunicable diseases: learning from the arts 27 Time (CET) Session 11:15–11:30 Open group discussion Moderators: Kremlin Wickramasinghe and Nils Fietje 11:30–11:50 Art intervention Moderator: Viktoria Anna Kovacs, Consultant, WHO NCD Office Fool Moon acapella band Session 3 From discussions to action – how can we facilitate the uptake of knowledge by policy and health care systems – group work II 11:50–12:45 World café session Moderators: Jill K Sonke, University of Florida & Vicki-Ann Ware, Deakin University 1. How can the growing evidence base for the role of the arts in improving health and well-being be shared effectively on country levels and among stakeholders? 2. How could collaboration be facilitated among health, social and creativity sectors to bridge the implementation gap of art benefits for health, policy and practice? 3. How can the WHO NCD Office support countries and stakeholders to implement art activities to prevent and manage NCDs? 4. Who (what stakeholder) is/are needed to solve identified challenges and improve uptake? 5. How can we effectively raise awareness of arts interventions on the national level? Million dollar question... If you had the funds... What art activities would you invest in to address NCDs? 12:45–13:00 Closing Kremlin Wickramasinghe & Nils Fietje 13:00–14:00 Lunch 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 (Kingdom of the) North Macedonia Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan Türkiye Turkmenistan Ukraine United Kingdom Uzbekistan World Health Organization Regional Office for Europe UN City Marmorvej 51 DK-2100 Copenhagen Ø Denmark Email: eurocontact@who.int Website: www.who.int/europeDocument number: WHO/EURO:2023-8280-48052-71230