The world's population is ageing at an unprecedented rate (United Nations, 2017) and particularly so in Europe, where the median age is the highest in the world. While the increased older population is a cause for celebration, confirming improved living standards and healthcare interventions, it creates the need to add ‘quality’ to extending lives, because a long life is not necessarily a good life. The importance of living life beyond simply existing has been reflected in the development of policies relating to the arts, culture and health across different European countries, for example, in Finland, Iceland, Norway, Sweden and the UK (Liikanen, 2010; Camic and Clift, 2015; Department for Culture, Media and Sport, 2016; All Parliamentary Group on Arts, Health and Wellbeing, 2017).
Quality of life is a multidimensional concept relating to a person's perceptions of various aspects of their life across the physical, psychological, social and spiritual dimensions. It reflects a dynamic between the external environment and associated conditions in which a life is lived and the perception of that experience. The World Health Organization (WHO) (1997:2) defined quality of life as:
‘an individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns.’
There is increasing evidence that the arts and gardens contribute to health and wellbeing, and thereby quality of life, although the mechanism by which this is achieved is not entirely clear.
The arts
Fancourt and Finn (2019) conducted a scoping review for the WHO of the global evidence of the effects of the arts on health and wellbeing. Their definition of the arts included performing arts such as music, film and theatre; visual arts, design and craft; literature; culture, including going to museums and events; and online, digital and electronic arts, including animations and graphics (Table 1). They used the WHO definition of health with its emphasis on physical, mental and social wellbeing within the societal and cultural context of the individual. They also recognised that the presence of an ongoing health problem might mean that complete health and wellbeing is not realisable, but, rather, the question is whether the health problem can be managed adequately so that the person can cope and have some independence and participation socially.
| Performing arts |
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| Visual arts, design and craft |
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| Literature |
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| Culture |
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| Online, digital and electronic arts |
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Source: Fancourt and Finn, 2019
The literature review reflected an underlying logic model linking arts with health, with ‘components’ such as cognitive stimulation or social interaction, stimulating responses that might be psychological, physiological, social or behavioural (Table 2). These responses, in turn, resulted in outcomes relating to health, such as promotion, prevention, treatment or management. The literature search included databases such as the Cochrane Library and PubMed, as well as relevant journals. The thematic analysis to synthesise the literature was informed by the logic model and attempted to understand how the arts affected, enabled, encouraged, assisted or supported the four health outcomes.
| Mechanism of the arts |
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| Responses to the arts |
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| Outcomes in response to the arts |
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Five themes emerged relating to prevention and promotion, namely, social determinants of health, child development, caregiving, prevention of ill health and health-promoting behaviours. Similarly, five themes also emerged relating to management and treatment, namely, mental illness, acute conditions, neurodevelopmental and neurological disorders (including dementia), non-communicable diseases and endof-life care.
Prevention and promotion
Engagement with the arts appears to enhance social bonding in various ways and, in so doing, fosters greater social inclusion to build social and community capital while addressing both social inequalities and inequities within societies. While much of the evidence relates to children and especially those who are marginalised, there is evidence that group participation activities, such as singing, art classes, dramatics/theatre, dance and volunteering, promote social inclusion while also reducing social isolation and loneliness among adults, including carers. The report outlines the range of evidence on the arts supporting child development, with improved mother-infant bonding, language development and educational attainment being particularly behavioural benefits. But of greater relevance to this article is the evidence of how the arts encourage health-promoting behaviours, such as healthy eating and remaining physically active, coupled with higher levels of self-perceived health and wellbeing as well as healthy weight (Fancourt and Finn, 2019). Importantly, the arts enhance health communications through greater engagement with various populations especially in relation to sensitive topics, such as sexual and other health behaviours. The arts appear to mediate between health professionals and the public and, because they are community based, they are able to build on existing social networks and social capital and increase engagement with health services, especially reaching out to those with unmet health needs. Some arts projects have also been associated with improved self-care adherence.
A particular strength of the arts is their ability to reduce stigma associated with certain health conditions by promoting positive attitudes towards them. The arts have destigmatised HIV, mental illness, dementia and ageing. Additionally, the arts appear to be effective in reducing barriers to engagement with healthcare, especially among marginalised groups, with the community base of the arts supporting empowerment around health (Fancourt and Finn, 2019).
Fancourt and Finn's (2019) review outlined the extensive evidence implying that the arts are associated with higher quality of life by enhancing subjective wellbeing, which includes emotions, life satisfaction and sense of purpose. These benefits have been found for both volunteers who participate and for those referred to activities through social prescribing (Polley and Pilkington, 2017). There is also growing evidence that arts engagement has preventive benefits in relation to mental health and wellbeing and helps in the development of cognitive resilience as people age.
There is some evidence that the arts can reduce the risk of becoming frail with age. In particular, dance has many physical benefits that help prevent age-related functional decline and may also help prevent falls and the fear of falls. Studies focusing on leisure activities including hobbies and arts participation or cultural engagement have found protective associations with premature mortality, with some of the effect being partly explained by lower sedentary behaviours and socio-economic factors.
The explanatory power of the arts helps understanding of health and illness both among those who have a health condition and their carers, and can also enhance understanding of the illness experience among health professionals. An increasing number of personal experience accounts are being published as books alongside novels drawing on personal experience, plays and films (see Table 3 for some narratives available online). Art classes and activities involving music including joint carer–care recipient activities have also been associated with wellbeing benefits for carers, such as reduced levels of perceived burden, anxiety and stress and improved relaxation and self-efficacy (Fancourt and Finn, 2019).
| Healthtalk | https://healthtalk.org/ |
| Patient Voices | https://www.patientvoices.org.uk/stories-htm |
| Patient Stories | https://www.patientstories.org.uk/ |
| Diabetes UK | https://www.diabetes.org.uk/your-stories |
| Parkinson's UK | https://www.parkinsons.org.uk/information-and-support/your-magazine/stories |
| Multiple Sclerosis Trust | https://www.mstrust.org.uk/life-ms/your-stories/life-ms-stories |
| National Multiple Sclerosis Society | https://www.nationalmssociety.org/Get-Involved/Personal-Stories |
| Macmillan Cancer Support | https://www.macmillan.org.uk/about-us/what-we-do/our-ambition/life-with-cancer-stories.html |
| Dementia UK | https://www.dementiauk.org/get-support/children-young-people-and-adults/their-stories/ |
| Carers Trust | https://carers.org/carer-stories |
| Carers UK | https://www.carersuk.org/help-and-advice/technology-and-equipment/carers-stories |
Management and treatment
Arts engagement including music has been associated with mental health benefits as it reduces mental distress, depression and anxiety across the lifespan, including among older people. Music has also been found to improve sleep quality and time to sleep onset (Buck, 2016).
Arts activities and environmental design including decoration have been found to reduce anxiety and pain within hospital settings and are associated with higher patient satisfaction ratings. Listening to music and music-making have also been found to help stroke recovery (mood, memory, motor rehabilitation and speech recovery). Music-associated activities have similar benefits for those with an acquired brain injury (Buck, 2016). Additionally, dance has been found to bring about motor score improvements in people with Parkinson's disease and is superior to exercise interventions, while both music and dance have been found to improve the mobility skills of people living with multiple sclerosis. There are also benefits for those who have dementia, particularly from listening to and making music (Buck, 2016).
Participation in the arts has benefits both during cancer treatment and outside treatment sessions, including reduced side-effects of treatment, such as fatigue, anxiety and distress, and improved subjective quality of life and coping. With its breath control, singing has some similarity to chest physiotherapy and, not surprisingly, it improves breathlessness and airway clearance in those with respiratory disease, as well as offering psychological benefits, including improved wellbeing (Buck, 2016). Listening to music also appears to increase the exercise capacity of people with chronic obstructive pulmonary disorder (COPD), and, along with dance, it has been found to have clinical and emotional benefits for those with diabetes and cardiovascular disease (Buck, 2016).
There is increasing evidence of the benefits of the arts as part of palliative or end-of-life care. There is some evidence that the arts are associated with psychological and physical benefits (Buck, 2016). They provide opportunities for communication and emotional expression, which assist cognitive reframing and readiness for end of life alongside improving social interaction and connectivity. Physical benefits include greater relaxation, fewer physical symptoms, including lower pain scores and less fatigue, and marginally less trouble breathing (Buck, 2016).
Bereavement support through use of the arts is well established both at the community and individual levels. Funerals frequently incorporate singing and images or photographs, with gravestones and other memorials aiding coping after the death of a loved one (Buck, 2016).
Gardens
Buck and Gregory (2013) previously reported strong evidence of the association between exposure to green spaces and wide health benefits, including physical and mental health outcomes, such as longer lives, reduced obesity levels, high self-rated physical and mental health and less income-related inequality. More recently, the Parliamentary Office of Science and Technology (2016) added to the evidence of the benefits of green spaces.
Buck (2016) adopted a broad definition of ‘garden’ to include a piece of ground adjoining a dwelling, that is, a private space, as well as larger private or formal gardens open to the public and gardens around hospitals, hospices and care homes. Of course, gardens are also spaces for relaxation, social interaction, exercise and play. The literature review reflected key questions relating to gardens and gardening (Table 4) and their potential effects upon health (Buck, 2016). The author conducted the scoping review of published evidence (2000–2015) using the resources of the King's Fund library together with those at the Department for Environment, Food and Rural Affairs (Defra) and the Parliamentary Office of Science and Technology. The National Gardens Scheme (NGS) provided case studies (Buck, 2016).
| Evidence of association | Indicators such as health measures and healthcare usage |
| Evidence of causation | Causal versus related to wider issues (including socioeconomic factors) |
| Evidence of impact | Extent of health change due to direct or indirect access to gardens/gardening |
Controlled studies have provided particularly strong evidence that allotment gardeners have better physical and mental health outcomes, although the sample of allotment gardeners is likely biased by self-selection (Buck, 2016). Nonetheless, there is no doubt that having an allotment garden promotes an active lifestyle and contributes to healthy ageing. While there are no controlled studies involving those with diagnosed mental health problems, the evidence of association suggests that gardening facilitates recovery and social inclusion (Buck, 2016).
While gardening is not restricted to later in the lifespan, it appears to become more important to older people because of its psychological weight as a provider of a reason for existence (Wright and Wadsworth, 2014). Wang and Glicksman (2013) listed the following self-reported benefits of gardening: mental health, growing fruit and vegetables, continuation of a past life, a source of responsibility, beauty, connection with others, learning something new and helping each other out. There is surprisingly little evidence relating to physical activity and gardening among older people, although a US national longitudinal study reported better balance and gait and fewer falls among gardeners, with multiple regression analysis showing that gardeners were healthier even when controlling for age, gender, education and functional limitations (Chen and Janke, 2012). However, other studies have found that gardeners often have lower back pain and, for some, a garden can become a worry if its care becomes a practical burden (Buck, 2016).
Gardening has become popular within social prescribing, and anecdotal evidence suggests that individuals benefit. However, there is little strong evidence due to a lack of study rigour and poor records of what patients actually do as part of the gardening intervention. Bromley-by-Bow Centre and Lambeth GP Food Co-op, where gardening is offered, report psychological, physical and social benefits for their patients and healthcare staff (Buck, 2016).
Horatio gardens are now an adjunct to spinal injury recovery at the spinal injury units at Salisbury, Glasgow and Stoke Mandeville, with the gardens offering a therapeutic outside space to promote wellbeing during in-patient stays. Those with spinal injuries have reported how the garden has improved their happiness and health (Buck, 2016).
There have been no studies exploring the impact of gardens on stroke survivors or those with neurological disorders. However, gardens and gardening are also emerging as an adjunct to dementia care. While the studies are of variable quality, Whear et al (2014) concluded that gardens reduced agitation and other negative behaviours, and staff and family members reported how those with dementia enjoyed gardening and being outside. Additionally, while it is known that people want to die at home and that home-like environments are important, as yet there has been no research regarding the importance of outside spaces or gardens for those at the end of life, although, it appears that having sight of a garden would be highly valued.
Conclusion
Within the constraints of the literature reviews cited in this article, which did not conduct systematic searches nor meta-syntheses, there is a growing body of research supporting the health benefits of the arts and gardens in terms of both efficacy and cost-effectiveness, although the benefits have yet to be quantified (Buck, 2016; Fancourt and Finn, 2019). Further, there is more evidence for certain types of arts activities and, like gardens, the evidence is focused on certain health conditions, leaving a gap in knowledge regarding whether they offer benefits to other areas of health (Buck, 2016). Nonetheless, district nursing teams may wish to consider how they can enable their clients and/or their carers to access appropriate arts-based and garden-related (or gardening) opportunities to improve wellbeing.