“Nobody can fail at it, everybody succeeds”: Perceived processes of change following attendance at an arts on prescription programme

Holt, Nicola; Elliot, Caroline; Jenkinson, Elizabeth

Abstract

Introduction
As the delivery of social prescribing schemes is increasing nationally (NHS England, 2019; Fixsen & Polley, 2019), evaluation of their impact and efficacy is pressing: quantitative, qualitative and econometric (Public Health England, 2016). The current research constitutes a qualitative analysis of semi-structured interviews with nine participants who participated in arts on prescription workshops (delivered through Bristol Arts on Referral Alliance). A quantitative analysis from the same cohort indicated that wellbeing (measured with the Warwick-Edinburgh Mental Wellbeing Scale, WEMWBS) significantly increased across a twelve-week programme, and that this wellbeing change was predicted by reduced anxiety immediately after the art workshops (Holt, 2020). The current study focused on further exploring the perceived benefits of participating in these workshops to gain a fuller understanding of potential mechanisms for change. Previous qualitative research on arts on prescription has supported the role of social bonding as an important factor, impacting on confidence and self-esteem, and the creation of a safe space that enables this (Stickley & Hui, 2012). Further work has highlighted psychological features of this space, including being able to relax and forget about worries and symptoms of poor health (Hughes et al., 2019; Redmond et al., 2019). However, previous qualitative research has either used a particular lens, focusing on social factors through narrative enquiry (Stickley & Hui, 2012) or has used brief responses written on end of programme evaluation forms (Hughes et al., 2019; Redmond et al., 2019), limiting the richness and depth of descriptions and reflective exploration. The current study sought to redress this by conducting in-depth interviews with nine participants, specifically focusing on the ways in which participants felt that arts on prescription had impacted their wellbeing.

Methodology
A qualitative design was employed utilising semi-structured interviews and inductive reflexive thematic analysis (Braun & Clarke, 2020). Attendees at three art on prescription programmes were invited to participate in both the quantitative and qualitative components of the evaluation. Nine participants took part in semi-structured interviews in the final weeks of a twelve-week-long programme (5 females and 4 males, with a mean age of 49 [range = 35 to 70]). Participants had a range of outcomes on the quantitative analysis. Two reported a ‘meaningful’ increase in wellbeing scores (more than 3 points on the WEMWBS), three a small increase (3 points or below), one participant reported no change, and two participants reported decreased wellbeing scores. Semi-structured interviews took place in a quiet room in the participants’ usual setting, during or at the end of art workshops, between March and June, 2018. Participants were given an information sheet about the study in advance, which included the interview schedule, so that they could give informed consent if they wished to take part and agreed for the conversation to be recorded. One participant was uncomfortable about the interview being recorded and submitted their responses in written form. Interviews were transcribed, coded and analysed using thematic analysis methods. Coding and themes were agreed upon by all authors in a reflexive process. The study received ethical approval from UWEs ethics committee.

Findings and Discussion
Three main themes were: ‘the embrace’ (focusing on the support provided by the artist facilitator and workshop); ‘the journey’ (focusing on perceptions of change) and ‘the ripple effect’ (focusing on the broader impact of attending the workshops). ‘The embrace’ was the core theme and emphasised the role of the artist facilitator as a therapeutic agent in the art workshops. ‘The embrace’ included two sub-themes: ’responsive facilitation’ (reflecting the care, reassurance and non-judgemental understanding shown by the artist facilitator); and ‘the escape room’ (illustrating the experiential consequences of ‘the embrace’: the positive experiences during art workshops, such as the opportunity to talk, freedom from external pressures, relaxation and absorption). The sub-theme of the ‘escape room’ builds on previous research that has recognised the importance of a ‘safe space’ in arts on prescription workshops, and the role of social bonding and relaxation during the art sessions (e.g. Hughes et al., 2019), However, this more in-depth analysis provides further details about the components of this space and emphasises the importance of the artist facilitator in this process, the care and support they provided, for example, being: “very attentive to how everyone in the group is doing … she’s very good for building up people’s confidence … and seeing what’s … happening in the room and responding to it”. The theme of ‘the journey’ emphasised participants’ reflections on change across the programme. For example, participants discussed a reduction in symptoms (such as anxiety), feeling pride in creative achievements and enjoying developing artistic skills, with an ensuing change in identity (akin to Stickley & Hui, 2012). This led into the final theme, which illustrated the broader impact of this in everyday life: ‘the ripple effect’. For example, participants described how others, at work or home, noticed changes in their behaviour (e.g., being calmer or more sociable), positively reinforcing change. In addition, they discussed sharing new skills with others and using art at home, for enjoyment and emotional regulation. This suggests that the workshops go beyond building social bonding (Daykin, 2020), but also may promote resilience, self-care and regulation.

Strengths and Limitations of the Study
A key strength of this study was conducting in-depth interviews with people who had participated in arts on prescription workshops, with a specific focus on mechanisms of change from their perspective, which drew out further nuances on perceived processes. The novel findings in this evaluation were the importance of the skill set of artist and recognition of the wider-reaching impact of the art workshops in the everyday lives of participants. As is common in this type of research there is the possibility of self-selection biases, where people who most enjoyed the sessions were more willing to be interviewed. Nevertheless, this gives insight into the positive impact that the arts can have on wellbeing and has implications for best practice.

Conclusions and Recommendations for Further Research
This qualitative study supports previous work that arts on prescription is a meaningful intervention that can be perceived as deeply beneficial and life-changing by participants. Participants identified strongly with the artist facilitator, suggesting that further research on the skillset of this role be explored in order to facilitate best practice more widely.

References
Braun, V., & Clarke, V. (2020). One size fits all? What counts as quality practice in (reflexive) thematic analysis? Qualitative research in psychology, 1-25.

Daykin, N., Mansfield, L., Meads, C., Gray, K., Golding, A., Tomlinson, A., & Victor, C. (2020). The role of social capital in participatory arts for wellbeing: findings from a qualitative systematic review. Arts & Health, 1-24. doi: 10.1080/17533015.2020.1802605

Fixsen, A., & Polley, M. (2020). Social prescribing for stress related disorders and brain health. Stress and Brain Health: In Clinical Conditions, 152, 237-257.

Holt, N. J. (2020). Tracking momentary experience in the evaluation of arts-on-prescription services: using mood changes during art workshops to predict global wellbeing change. Perspectives in Public Health, 140(5), 270-276.

Hughes, S., Crone, D. M., Sumner, R.C. & Redmond, M. (2019). Understanding well-being outcomes in primary care arts on referral interventions: a mixed method study. European Journal for Person Centered Healthcare, 7(3), 1768. doi:10.5750/ejpch.v7i3.1768

NHS England. (2019). Social prescribing and community-based support: Summary guide. Retrieved from https://www.england.nhs.uk/wpcontent/uploads/2019/01/social-prescribing-communitybased-support-summary-guide.pdf

Public Health England. (2016). Arts for health and wellbeing: An evaluation framework. London: Public Health England.

Redmond, M., Sumner, R. C., Crone, D. M., & Hughes, S. (2019). ‘Light in dark places’: exploring qualitative data from a longitudinal study using creative arts as a form of social prescribing. Arts & Health, 11(3), 232-245.

Stickley, T., & Hui, A. (2012). Social prescribing through arts on prescription in a UK city: Participants' perspectives (Part 1). Public health, 126(7), 574-579.

• Presentation Conference Type: Conference Paper (published)
• Conference Name: Culture, Health and Wellbeing Alliance International Conference
• Start Date: Jun 21, 2021
• End Date: Jun 23, 2021
• Acceptance Date: Feb 2, 2021
• Online Publication Date: Jun 8, 2021
• Publication Date: Jun 8, 2021
• Deposit Date: Mar 30, 2021
• Publicly Available Date: Mar 31, 2021
• Pages: 66-68
• Book Title: Culture, Health and Wellbeing International Conference 2021 CHW21 Research Proceedings
• Keywords: Art on prescription, social prescribing, wellbeing
• Public URL: https://uwe-repository.worktribe.com/output/7240845
• Publisher URL: https://www.ahsw.org.uk/wp-content/uploads/2021/07/CHW21-Conference-Research-Proceedings-June-2021-PDF.pdf