Two perspectives on arts and public health

Andrew Fletcher, PhD researcher, Faculty of Health & Life Sciences, Northumbria University

Engagement with the arts and/or creative practice benefits wellbeing in multiple ways. I am a musician and relatively new to public health. This post argues that arts and culture should have greater prominence in health and social care.

Courtesy uk.pinterest.com

So what of arts-based therapies? Compared to Cognitive Behavioral Therapy (CBT) for example, such programmes are not heavily promoted. Perhaps this is right; CBT is cheap and effective, whereas things like music therapy are often reserved for individuals with more complex needs. But this hierarchy contributes to the idea that arts-based therapies are ‘alternative’ – potentially placing them in the same category as, say, homeopathy. This is not a helpful perception, but anyone who’s tried to advocate for creative therapies will know it exists.

Then there’s ‘evidence-based medicine’, which is of critical importance, but whose dominance has been challenged.2,3  This is particularly relevant to approaches to health and wellbeing that are seen as ‘alternative’, which still seem to remain the preserve of those who can afford to try more ‘esoteric’ interventions – thereby reinforcing inequality. So what’s the response? Promote holism*; make arts therapies mainstream; emphasise their part in everyday life; make creativity and cultural engagement as vital as exercise, healthy eating or social interaction. The idea that creativity is intrinsic to wellbeing needs to be established in the early years and beyond, and to neglect this idea is missing a trick.

Courtesy tinybuddha.com

Why do people do art? Usually to express a political statement, to communicate a specific feeling or sentiment, or to satisfy some intangible ‘urge’. Making a painting to hang on your bedroom wall cultivates a more pleasurable living environment; putting your kid’s collage on the fridge boosts self-esteem; and who never listens to music? Creative practice, in one way or another, feeds into numerous wellbeing outcomes. Artists know this instinctively, yet policy around art and culture focuses on tourism and/or entertainment income, and a vague ‘intrinsic’ social value. Lip service is paid to health, but as Tiffany Jenkins says: “If you’re competing with hospitals, you’ll lose”.4

But art and wellbeing are significant components of the lived experience. They make us human. They sit at the apex of Maslow’s hierarchy** and most people understand the inherent value of culture to either social or personal wellbeing. If prevention really is better than cure, we must pay attention to the cultural-wellbeing landscape and the atmosphere these concepts exist in. Perceptions are changed through innovative and creative information delivery – so creativity not only has its own wellbeing outcomes, it’s also the key to shifting arts and culture towards being a major pillar in overall wellbeing.

I can’t help but wonder what the world would be like if the perceptions of arts therapies were different. Stickley (2014)5 outlines one potential scenario as follows:

The year is 2080. A new textbook has been published. The book is called ‘A Century of Healthcare’ and I would like to quote from this book:

"For most of the last century it was unusual for people to be treated holistically. Incredible as it sounds today, healthcare systems separated physical interventions from anything they referred to as "mental". Thus a dualism existed and people were treated as divided objects. At the time, there were many attempts at holism, especially by those who practised alternative or complimentary therapies. However, anything that remotely threatened the domination of the medical model was largely side-lined and researchers gave little credence to anything that was not considered scientific.

We should however give a great deal of credit to those who foresaw the potential contribution that the arts and humanities could make to healthcare and wellness but they operated in a narrow scientific paradigm that gave little acceptance to holism…”

The contexts in which creative practice occurs are complex, but the benefits are multiple and well-known. The key here is changing perceptions. This takes time, but perhaps Stickley’s vision will bear out. I hope so.


Footnotes:

* The idea that the human experience of wellbeing is social, cultural and complex, and extends far beyond medical definitions of health.
** 'Self actualisation' appears at the apex of psychologist Abraham Maslow's 'hierarchy of needs' model and includes in its definition (among other things): "expressing one's creativity".

References:

1. Various demographic data available from www.theaudienceagency.org
2. Greenhalgh, T., Howick, J. & Maskrey, N. (2014). Evidence based medicine: a movement in crisis? BMJ g3725.
3. Stickley, T. (2015). A little rant about evidence, available from: https://ayrshirehealthandarts.wordpress.com/2015/03/31/dr-theo-stickley-a-little-rant-about-evidence/
4. Jenkins, T. (2015). Front Row debate (23rd Feb, 2015). Are artists owed a living? Online: BBC.
5. Monologue delivered at ESRC funded Seminar Series on Arts, Health & Wellbeing, 15th September 2014.

How big food and drink are using sport

Guest post by Robin Ireland, Director of Research, Food Active and Healthy Stadia

You don't have to do much travelling to realise that the unhealthy alliance between sport and the Food and Drink Industry isn't only an issue in the UK.

I am lucky enough to be visiting New Zealand and Australia at the moment and it's easy to see all the same signs - and very similar marketing campaigns and messaging. Whether it's the All Blacks rugby team being pictured with the product of their "Official Hydration Partner", Gatorade, or the recent Australian Tennis Open full of alcohol advertisements (and I haven't even mentioned cricket), it's clear that the Food and Drink Industry have an international agenda.


Advertising featuring the All Blacks rugby team photographed in New Zealand

In January, the British Medical Journal published an editorial (Ireland and Ashton 2017)1 that I wrote (with Professor John Ashton CBE) about how Coca-Cola's publicity machine was subverting the Christmas message.

If anything, it's even more blatant in sport and we have been aware of it for some time from London's "Obesity Games" (Garde and Rigby 2012)2 to Rio's promotion of ultra-processed foods (Loughborough University)3. Even when spectators want healthier food, this choice is rarely made available to them.

George Monbiot recently referred to "Dark Money" (Monbiot 2017)4 which describes the funding of organisations involved in political advocacy that are not obliged to disclose where the money comes from. In public health terms, we may describe this as Commercial Determinants of Health where industry interests impact on our health. It is often linked to the increasingly sophisticated Corporate Social Responsibility policies being adopted by big corporations.

The latest of these is of course the deal just announced by the English Premier League and Cadburys criticised by the Obesity Health Alliance in a letter to The Times (Obesity Health Alliance 2017)5. Cadburys no doubt will argue that they are taking an ethical position to help educate people. But can we really take a chocolate company seriously that wishes to advise schoolchildren on nutrition, healthy eating and exercise?



FC Bayern München's branded energy drink

It is no coincidence that the mantra parroted by food and drink sponsors is that our diets are down to individual choice and that if we simply took more exercise we wouldn't be having the obesity epidemic now prevalent worldwide. This is rubbish. So called energy and sports drinks should have no part to play in the diet of the average member of the public. Kids do not need more sugar (or more protein for that matter) if they are eating a balanced diet with lots of fruit and veg. But of course the food and drink industry do not make their enormous profits in this way.

It is these concerns - amongst many others - that encouraged myself and colleagues to establish Healthy Stadia in 2005, of which I am a Director. Healthy Stadia takes a holistic and integrated approach to developing sports stadia and clubs as "health promoting settings":

"Healthy Stadia are those which promote the health of visitors, fans, players, employees and the surrounding community" (from Healthy Stadia website)6.

Healthy Stadia's Conference which will be held at the Emirates Stadium, London, in April will be discussing food and drink sponsorship in professional sport among other issues. I anticipate that these topics will come under increasing public scrutiny in years to come, as we develop more awareness of the impact that marketing has on our food and drink choices. (Cairns et al., 2013)7.

Sports fans and public health professionals alike should be questioning how 'Our Beautiful Games' are being manipulated by the Food and Drink Industry to promote ultra-processed food and drink - including alcohol - to audiences, often well populated by impressionable youngsters. Let's see if we can link up the campaigns in different countries to make a louder voice demanding change from the governing bodies of sport.

References:

1. Ireland R and Ashton John R. (2017). Happy corporate holidays from Coca-Cola. BMJ 2017;356:i6833. http://www.bmj.com/content/356/bmj.i6833. 10 January 2017.
2. Garde A and Rigby N. (2012). Going for gold – should responsible governments raise the bar on sponsorship of the Olympic games and other sporting events by food and beverage companies? Commun Law. 2012:356:42-9.
3. Loughborough University Press Release (2016). Loughborough research calls for change in spectator food and drink provision at sports mega events such as Rio 2016. PR/16/158. http://www.lboro.ac.uk/media-centre/press-releases/2016/december/loughborough-research-calls-for-change-in-spectator-food-and-drink-provision-at-.html. 05 December 2016.
4. Monbiot G. How corporate dark money is taking power on both sides of the Atlantic. The Guardian. https://www.theguardian.com/commentisfree/2017/feb/02/corporate-dark-money-power-atlantic-lobbyists-brexit. 02 February 2017.
5. Obesity Health Alliance (2017). Letter to The Times – Cadbury and Premier League Sponsorship. Accessed online at: http://obesityhealthalliance.org.uk/2017/02/06/letter-times-cadbury-premier-league-sponsorship/?utm_campaign=Cadbury%20letter. 06 February 2017.
6. European Healthy Stadia Network. http://www.healthystadia.eu/about.html
7. Cairns G, Angus K, Hastings, G and Caraher M (2013). Systematic reviews of the evidence on the nature, extent and effects of food marketing to children. A retrospective summary. Appetite 2013: 356:209-15. http://www.sciencedirect.com/science/article/pii/S0195666312001511. 03 March 2013.

All views expressed are exclusively those of the author.

The importance of partnership working to improve priority-setting in public health decision-making

Guest post by Sarah Hill, Fuse PhD student, Newcastle University

Last month I attended a workshop in London that explored how local authorities could be supported in setting priorities to improve people’s health and wellbeing. The workshop provided a platform to report the findings of a follow-on study to the Fuse led "Shifting the Gravity of Spending?" project and to explore methods for supporting local authorities in priority-setting.  Watch the video below to find out more about the study.

As a health economics PhD student looking into methods of evaluating public health interventions, the workshop was of interest to me since the prioritisation tools focused on at the workshop are a part of the evaluative toolkit I am examining. Additionally, as a health economist by trade - who was thrown-in at the deep-end of public health just over a year ago when I started my PhD research - any opportunity to meet those working in the public health field is one that I seize in order to broaden my knowledge and appreciation of the public health context.  Particularly public health officers and those working outside of the academic realm.

A full report of the workshop can be found here for those who are interested in the outcomes of the event; I will focus here on a few of the key points from the event.

Small group discussions centred around partnership working

At the close of the workshop, following small group discussions, each group of delegates was asked to feedback one key point that came out of their discussion regarding how to aid the use of prioritisation tools for public health spending decisions. Interestingly, a number of the points fed back from each group were related to partnership working to make decisions; such as:

•  “gathering together” with NHS partners to ensure funding for effective interventions is secured when benefits may fall outside of public health’s remit and more under the NHS umbrella; 
• considering a “place based” approach to seek good outcomes within a place rather than within separate organisations and;
• working with local politicians to move decisions forward by understanding their objectives.

The take-home message I got from these points was that for priority-setting to be most successful in public health, a wider viewpoint needs to be considered given the number of stakeholders outside of public health teams that are involved in funding decisions and interventions being successfully implemented. This point echoes a sentiment voiced by Professor Peter Kelly at the recent Fuse meeting on inequalities (see Professor Paul Johnstone’s blog on the meeting here) who emphasised the huge reduction in both alcohol-related hospital admissions and smoking rates in the North-East since a regional approach has been taken to tackling tobacco and alcohol through pooling local resources to invest in initiatives like Fresh and Balance.

The impetus placed on collaborative working coming out of the workshop has given me something to think about for my PhD research since it appears that being able to evaluate interventions in such a way that incorporates and reflects that way of working is valuable. In fact, this is not necessarily a new thought; incorporating intersectoral costs and consequences has been established as a challenge to be addressed when evaluating public health interventions by health economists previously. A review I recently conducted on existing economic evaluations of public health interventions indicates that there is still a lot of room for improvement when it comes to overcoming this challenge and actually incorporating intersectoral costs and consequences. Often evaluations are conducted from either a health care or provider perspective, thus only considering the costs to those sectors exclusively. Also, of the evaluations I reviewed and those previously identified in the literature, the incorporation of consequences (i.e. benefits or disbenefits) to sectors other than the intervention provider is practically non-existent.

Perhaps if more evaluations were able to reflect who benefits from an intervention and to what extent this may enable more collaborative working between different partners and sectors in either funding and/or aiding with the implementation of interventions. Of course the availability of appropriate data is a real barrier since an evaluation is only as good as its data, thus a drive needs to be made within public health departments to stipulate the collection of appropriate outcomes data from the very beginning of an intervention being commissioned to build up the database for effective evaluations.

Shifting the Gravity of Spending? Workshop to explore methods in public health priority-setting was held on the 17 January 2017, and funded by the NIHR School of Public Health Research and supported by the Local Government Association and Public Health England.  The “Shifting the Gravity of Spending?” project is led by Fuse Deputy Director Professor David Hunter at Durham University.

Mannequin challenge: preparing cancer nurses through simulating emergency situations

Guest post by Gillian Walton, Director of Learning and Teaching, Northumbria University 

Tomorrow (4 February) is World Cancer Day, a day where millions of people across the world unite to raise awareness of cancer. One in two people will be diagnosed with cancer at some point in their lives (cancer research UK), an alarming statistic. Currently, 8.2 million people die from cancer worldwide every year, out of which, 4 million people aged 30 to 69 years die prematurely.

Of the millions of people diagnosed, a high percentage will receive systemic chemotherapy (anti-cancer drugs that are injected into a vein or given by mouth) as a primary, secondary or palliative form of treatment.

Students role play chemotherapy induced emergency situations

As a previous oncology nurse I’m acutely aware that managing chemotherapy and the potential life threatening side effects can be demanding and highly stressful. Management of acute side effects is usually a nursing responsibility which adds extra pressure not only on resources but the knowledge required of the many drugs available to treat over 200 different cancers. Chemotherapy drugs are highly toxic and can have life threatening side effects, so managing severe reactions is essential. This can therefore be a scary environment for both the nurse and the patient!

Mannequins mimic the symptoms of a deteriorating patient 

At Northumbria University I run a chemotherapy module and have designed a simulation based interactive educational (SBE) activity to encourage students to engage in scenarios to simulate chemotherapy induced emergency situations. Simulated practice has been described as the "activities that mimic the reality of a clinical environment and are designed to demonstrate procedure, decision making and critical thinking through techniques such as role playing and the use of devices such as interactive manikins” (Jefferies 2005)1. Ongoing qualitative research by my colleague Alan Platt who collaborates with me on this project has shown that the use of simulation informs and improves student performance. His knowledge and findings have facilitated translating the theory into practice. We use high fidelity mannequins, which can mimic the symptoms of a deteriorating patient so the student can role play chemotherapy induced emergency situations in a safe simulated clinical environment. Students are briefed prior to the encounter about the clinical scenario and their role as a nurse caring for a patient in a chemotherapy day unit. They are asked to be themselves and to act as they would if they were at work in the clinical area. A clinical expert assists the learning experience by providing prompts for the nurses to manage the emergency situation. Covert cameras record the scenario in real time and allow the students to review and reflect “on action” and evaluate their performance following the scenario. I then debrief the group which is widely recognised as a critical element of simulation-based education. Debriefing following the scenario allows the students to engage in reflective learning(Fanning and Gaba 2007)2,3 as well as consider decision making, risk management, patient safety and communication amongst the team. Although the students initially find it a bit daunting being filmed and working with dummies that can actually speak, breath and blink their eyes, they also have said that it’s a fun and great way to learn.

All students complete a questionnaire after the SBE relating to the learning experience. To date, 100% of the students reported that the use of simulation enhanced their learning and that the learning was stimulating and exciting. The majority of the students said that they would recommend the learning experience to a colleague. Comments suggest that they learnt how to react if they experienced the situation again in practice which increased their overall confidence; the main objective of the exercise.

The use of simulation means students feel much better prepared to manage chemotherapy emergencies. Overall they valued the learning experience and the opportunity to reflect on their practice in a safe environment. This in turn translates to greater safety for students and patients.

Evaluation and research findings provide support that simulation is an effective learning technique which prepares students to manage the situation should it arise in clinical practice.

References:

1. Jeffries, P. (2005) A framework for designing, implementing and evaluation simulation used as teaching strategies in nursing. Nurse Education Perspective; 26: 2, pp96-103
2. Fanning RM, Gaba DM. (2007) The role of debriefing in simulation-based learning. Simul healthc;2:115Y125.
3. Gaba DM. (2004) The future vision of simulation in health care. Qual Saf Health Care;13(suppl 1):i2Yi10.