1.1.1. Defining the arts

While the arts have always been conceptually difficult to define, there are a number of cross-cultural characteristics recognized as fundamental to art. These include the art object (whether physical or experiential) being valued in its own right rather than merely as a utility; providing imaginative experiences for both the producer and audience; and comprising or provoking an emotional response. In addition, the production of art is characterized by requiring novelty, creativity or originality; requiring specialized skills; and relating to the rules of form, composition or expression (either conforming or diverging) (1–3).

These criteria provide the boundaries for deciding what constitutes art, but the specific types of art within these boundaries are diverse and fluid. In relation to health research, engagement with the arts has been proposed as consisting of five broad categories (4):

• performing arts (e.g. activities in the genre of music, dance, theatre, singing and film);
• visual arts, design and craft (e.g. crafts, design, painting, photography, sculpture and textiles);
• literature (e.g. writing, reading and attending literary festivals);
• culture (e.g. going to museums, galleries, art exhibitions, concerts, the theatre, community events, cultural festivals and fairs); and
• online, digital and electronic arts (e.g. animations, film-making and computer graphics).

These categories combine both active and receptive engagement and, importantly, also transcend cultural boundaries and contain flexibility to allow new art forms to develop (as evidenced in the development of online, digital and electronic arts over recent years). For the purposes of this review, this conceptual definition of art (combining common attributes but allowing fluidity in categorization) is followed. While there are other activities that fulfil many of the categories listed above (e.g. gardening, cooking and volunteering), consensus research has suggested these may be seen as creative but are not generally considered as arts, particularly when cross-referenced with definitions from national arts councils (5–7); consequently, these were not included in the review (4). Similarly, this review did not focus on architecture or the design of buildings. However, some secondary references to the use of visual art in health settings are made.

1.1.2. Defining health

WHO defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (8), thus rooting health firmly within society and culture. It emphasizes the importance of illness prevention and, consequently, the determinants of health: how health is shaped by the cultural constructs within which it is situated and how it can be promoted at both an individual and a society level (9–11). The definition also focuses on being well, from an individual perspective (12–14) and socially (15). The latter can include multiple aspects such as integration within society, contribution to society, acceptance and trust within society, individual understanding of society and belief in the potential of society (15).

In the decades since 1948 when this definition of health was published, the concept of health has expanded further (16). Complete health and well-being may not be everyone's goal. For example, the presence of a chronic mental or physical illness is not necessarily a sign of being ill but may be something that can be managed (17). Management is shaped in part by resilience and whether individuals can adapt with their health: whether they can restore their physiological homeostasis (balance) and feel they have the capacity to cope and fulfil their potential with a degree of independence and opportunity to participate socially (18–20). Health is, therefore, a dynamic process that, at its core, is about having the capacity to self-manage.

1.1.3. Linking the arts with health

Arts activities can be considered as complex or multimodal interventions in that they combine multiple different components that are all known to be health promoting (21). Arts activities can involve aesthetic engagement, involvement of the imagination, sensory activation, evocation of emotion and cognitive stimulation. Depending on its nature, an art activity may also involve social interaction, physical activity, engagement with themes of health and interaction with health-care settings (Fig. 1) (22).

Fig. 1.

A logic model linking the arts with health.

Each of the component parts of arts activities can trigger psychological, physiological, social and behavioural responses that are themselves causally linked with health outcomes. For example, the aesthetic and emotional components of arts activities can provide opportunities for emotional expression, emotion regulation and stress reduction (23). Emotion regulation is intrinsic to how we manage our mental health (24,25), while stress is a well-known risk factor for the onset and/or progression of a range of health conditions including cardiovascular diseases (CVD) (26) and cancers (27). Cognitive stimulation when engaging in the arts can provide opportunities for learning and skills development, and it is not only associated with a lower risk of developing dementias but also interrelated with mental illness such as depression (28). Social interaction while participating in the arts can reduce loneliness and lack of social support, which are both linked with adverse physiological responses, cognitive decline, functional and motor decline, mental illness and premature mortality (29,30). Social interaction that brings together different groups of people can improve social capital and reduce discrimination, the latter being linked with mental illness and a range of other health conditions including CVD, respiratory conditions and indicators of illness such as pain and headaches (31). Physical activity through participating in the arts can reduce sedentary behaviours, which are associated with conditions such as chronic pain, depression and dementia (32). Engagement with discussions of health or with health-care settings through arts activities can also help to encourage health-promoting behaviours such as having a healthy diet and not smoking or drinking too much, which are all linked with a lower risk of mortality from CVD and cancer (33). Further, such discussions can encourage engagement with health services, such as visiting the doctor for check-ups or screening, which is associated with better control of pre-existing health conditions and a lower risk of mortality (34).

Overall, each of the arts categories outlined in section 1.1.1 involves different combinations of these health-promoting components, whether undertaken in everyday life (not for a health purpose but having a secondary benefit for health) or within bespoke arts programmes designed with targeted health or well-being goals, or therapeutic arts programmes delivered by trained arts therapists (22). For certain populations, or when aiming to influence certain health conditions, particular types of arts activities (whether everyday, bespoke or therapy) and particular art forms may be more suitable than others as they may combine specific relevant components (e.g. dance is particularly relevant for rehabilitation as it is a physical activity). For other populations or health conditions, the deciding factor as to which type of programme or art form is most appropriate may be driven largely by personal taste and cultural influence. Indeed, this is proposed as a strength of arts projects within health: while other activities can also contain different health-promoting components (e.g. exercise activities), the arts combine many health-promoting factors with an inner aesthetic beauty and creative expression that provide an intrinsic motivation for engaging beyond a particular regard for good health (22). A further strength is that the multimodal nature of arts interventions means that engagement can be associated with a number of different effects on health.

Consequently, this report explores the wide-ranging effects of multiple different types of arts activity and will distinguish between the following broad types of effect:

• where research suggests that multiple types of arts activity could achieve similar outcomes, activities will be referred to as arts engagement or engaging in the arts;
• where evidence suggests that specifically participation is important (to differentiate from visiting cultural venues or attending events), activities will be referred to as participating in the arts or arts participation; and
• where evidence suggests that one particular type of activity may be particularly effective (e.g. listening to music or dance), this will be specified.

1.1.4. Objectives of this report

There have been many policy developments across the WHO European Region relating to arts and health since the early 2000s. For example, in England (United Kingdom), joint publications between Arts Council England and the National Health Service have been produced since 2007 (35,36); the Department of Culture, Media and Sport has included health within the new Culture White Paper (37); and an All-Party Parliamentary Group report Creative Health has made a series of political recommendations to the United Kingdom Government and other bodies (38). In Finland, the Government adopted a policy programme for health promotion in 2007 that focused on enhancing the contribution of art and culture to health and well-being (39). In Ireland, Arts Council Ireland and the Health Service Executive have been collaborating since the late 1990s, producing policy and strategy documents on the potential for collaboration between the arts and health sectors (40). In Norway, the Government has instituted a public health law and a cultural law, with both emphasizing the importance of arts in health promotion and care (41). In Sweden, the Swedish Parliament has started a Society for Culture and Health and a Cultural Politics Commission (42). Further political developments are discussed elsewhere (22,43).

However, developments in this field have largely had a national focus, aiming to influence policy and practice in individual countries, with only limited examples of cross-country influence (44). This means that there has been little consistency in policy development or even in sharing good practice, and many efforts of individual countries have remained short term rather than being long lasting. This report, therefore, seeks to map the growing evidence base on the arts and health that has arisen since the start of 2000 and proposes a set of policy considerations that will promote the cohesion and longevity of policy development in this field.

For WHO, the increasing interest from arts sectors in health is particularly timely and dovetails with a number of important developments in the global health policy arena. Building on the Health in All Policies approach articulated in the early 2000s, Health 2020, the European health policy framework, highlights the importance of multisectoral collaboration for catalysing action (45). This strategic shift has been further underlined by the recently published WHO Thirteenth General Programme of Work 2019–2023 (46), which also promotes a greater focus on both well-being and increasing human capital throughout the life-course. Furthermore, the 2030 Agenda for Sustainable Development (47) includes supporting good health and well-being, providing quality education, building sustainable cities and communities, encouraging decent work and economic growth, and working in partnership. All of these goals, priorities and approaches are integral parts of engaging with the arts, increasing the cultural capital within societies and potentially helping to promote resilience, equity, health and well-being across the life-course. Finally, because they operate simultaneously on the individual and social, as well as physical and mental, levels, arts-based health interventions are uniquely placed to address the full complexity of the challenges that being healthy and well are increasingly recognized to present.