Keywords

1 Introduction

Art-making and creative expression are powerful tools for personal and social learning, growth, and transformation. This rationale is at the essence of the practice of community arts (CA). CA have been defined as artistic activity based in a community setting and characterized by dialogue and co-creation with the community (Novak 2012). CA programs cite goals ranging from improving the social and emotional well-being of participants (Carson et al. 2007; Hampshire and Matthijsse 2010) to promoting civic dialogue and community building (Kelaher et al. 2014; Rhodes and Schechter 2012). CA initiatives are increasingly being understood as “whole person” approaches for improving health at individual and community levels, drawing on holistic conceptualizations of health that are not just physical or disease-specific, but rather emphasize broader concepts of mental and social well-being (Macnaughton et al. 2005) and thus aim to promote synergy within health promotion initiatives (for further theoretical background of synergy in health promotion, see Chap. 21, this volume).

The use of the arts within diverse health-related endeavors has been identified as an emerging field of “arts and health.” This comprises arts-infused practice within a range of settings and approaches, including in therapeutic initiatives and health care practices, as a method for conducting and/or disseminating health research, or as an intervention strategy for community development and health promotion (Cox et al. 2010). This chapter seeks to investigate the latter—to unpack the current state of knowledge on the health-promoting impacts of CA. Health promotion refers to the conceptualization and specialized field of public health practice grounded in a social model of health that recognizes the wider social, economic, and environmental determinants of health (Rootman and O’Neill 2017; Chap. 1, this volume). The structural determinants and conditions of daily life, marked by the unequal distribution of power, income, goods, and services, constitute the social determinants of health and are responsible for a major part of health inequities (CSDH 2008; Marmot 2015; Raphael 2016).

A growing body of literature seeks to substantiate the impacts of arts and health initiatives. There is no shortage of individual initiative evaluations. As the evidence base grows, there are now academic and lay synthesis publications detailing various forms of reviews (APPGAHW 2017; Bungay and Vella-Burrows 2013; Daykin et al. 2008; Zarobe and Bungay 2017). This work, however, has been hampered by complexities of practice and by contention regarding what constitutes the best or most valid forms of evidence (Clift 2012; Putland 2008; Raw et al. 2012). This chapter explores the discourse on the health-promoting impacts of CA, seeking to map current knowledge and debate in relation to CA and impacts on social determinants of health, in the English language literature.

2 Methods

A search was undertaken between April and August of 2018 to identify and synthesize peer-reviewed and grey literature on community arts and health promotion. Literature was identified through English language database searches (using the keywords “community arts” AND “health” OR “social impact”), reference lists of key articles, key informants, conferences, and workshops. For the purposes of mapping, emphasis was placed on articles identifying and summarizing outcomes of CA interventions, and on articles directly discussing or theorizing CA impacts. The goal here was not an exhaustive review, but rather a mapping of the central arguments and key tensions across the discourse on CA and health promotion in the English language literature.

One hundred and fifteen articles were initially identified, and 39 were found to meet the inclusion criteria (i.e., a focus on CA and impacts related to the social determinants/social model of health). CA was conceptualized as the participatory practice of art-making in groups within community settings. Articles were excluded if their primary focus was individually oriented and/or not community-based, such as therapeutic initiatives (e.g., arts-therapy, hospital/clinic-based interventions or supports), school-based arts education (arts engagement in formal curricula), and more general engagement in arts and culture (e.g., museum attendance, audience participation in music or performing arts, personal art-making or instruction). Articles were also excluded if their main focus was arts-based research (ABR), such as arts-based methods employed primarily in the context of a research project. ABR and CA are similar and related; the key differentiation lies in the overarching approach. While much ABR is participatory and socially motivated, arts-based activities/methods in ABR are undertaken primarily in the service of a pre-defined research question/program (Boydell et al. 2012). (For a detailed discussion of ABR, please see Chap. 11 (Madsen et al. 2021) in this volume). CA are community-based arts programs/interventions that seek to engage participants broadly in creative expression for the purpose of plural knowledge and cultural production (Novak 2012). Though generally not the expressed focus, CA approaches can be understood and leveraged as a form of research. Leading CA practitioner and theorist Deborah Barndt (2004) identifies processes of CA broadly as collaborative and participatory research, explaining: “When people are given the opportunity to tell their own stories, they bring their bodies, minds, and spirits into a process of communicating and sharing their experiences; they affirm their lives as sources of knowledge, and they stimulate each other in a synergistic process of collective knowledge production” (p. 354). While ABR methods are becoming increasingly recognized and integrated into research paradigms, less attention has been paid to more emergent CA approaches, hence the emphasis of this chapter.

Sixteen primary studies, eight review articles, and 15 practice commentaries were included and analyzed. Primary studies and review articles were so classified as they describe clear data collection and analysis methods. Practice commentaries, as opposed to reporting or synthesizing research, focus instead on discussing practice-based issues related to impact and evaluation, exploring practitioner perspectives on particular challenges, or reviewing and discussing epistemological tensions. The majority of the literature stems from Western contexts—notably the United Kingdom, Australia, and Canada—where policy agendas explicitly seeking to leverage CA approaches for health and/or community development have recently proliferated (Badham 2010; Clift et al. 2009; Cox et al. 2010). Table 13.1 provides a short description of each article.

Table 13.1 Summary of articles included
Full size table

The identified literature was further organized using an ecological mapping of micro-, meso-, and macro-level findings. Ecological analysis and mapping is a way of approaching issues that accounts for interrelationships between persons and settings, with the goal of exploring and unpacking dynamic interactions between individuals and their environment (Kingry-Westergaard and Kelly 1990). Increasingly utilized in public health and health promotion, such models explore health issues through multiple, interdependent levels of influence, from individual (micro), to interpersonal/communal (meso), to broader social (macro) levels (Richard et al. 2011).

3 Ecological Analysis of CA Health-Promoting Impacts

The following ecological analysis seeks to map and discuss health-promoting impacts of CA within a dynamic social context that should be read as complex and interrelated (Sallis et al. 2015). While locating issues or outcomes with a key ecological level, the whole system is understood as fluid and reciprocal. See Fig. 13.1 for a graphic depiction of this ecological mapping.

Fig. 13.1
figure 1

Health-promoting impacts of community arts: an ecological model. (Reproduced with permission from author. Copyright © 2021 Charlotte Lombardo. All rights reserved)

Full size image

3.1 Micro-level Impacts

At the micro level, CA impacts map to individually oriented constructs of health-related knowledge, attitudes, and personal actions (Angus 2004; Bungay and Vella-Burrows 2013) and to aspects of self-concept, i.e., beliefs about oneself (Baumeister 1999). Several initiatives report improved mental/psychological health (Cuypers et al. 2011; Hacking et al. 2008; Secker et al. 2011; White 2006). CA programs have reported life course effects from childhood through to end of life (APPGAHW 2017). In youth, CA programs have been found to promote intrinsic resilience in the form of a sense of belonging, identify formation, confidence, and self-esteem (Zarobe and Bungay 2017), and to have positive effects on social skills, awareness raising, and behavior change in relation to health issues such as HIV/AIDS and drug use (Daykin et al. 2008). In older adults, participation in CA has produced evidence of improvements in physical well-being and morale, as well as reductions in loneliness, doctor visits, falls, and medication use (Cohen 2009).

3.2 Meso-level Impacts

At the meso level, interpersonal and community-related impacts are explored through “upstream” health determinants, e.g., psychosocial mechanisms such as social support and social engagement (Berkman and Glass 2000). CA initiatives have reported increased community connection, creativity, social support, and civic dialogue and have been highlighted as asset-based spaces for communal reflection, value exploration, and community development (Cameron et al. 2013; Carson et al. 2007; Kelaher et al. 2014; Purcell 2007; Rhodes and Schechter 2012). Supporting ecological concepts of reciprocity, CA evaluations have found interrelated individual and community empowerment outcomes related to imagination and vision, positive risk taking, and strengthened sense of place (Hacking et al. 2008; Matarasso 1997). Micro-level impacts of personal transformation have been found to be reinforced by meso-level impacts of collective creative expression and cathartic experience (Spiegel and Parent 2017).

3.3 Macro-level Impacts

At the macro level, CA impact analyses explore societal structures and systems, understood to be dynamic and operating within and across levels, with individual and interpersonal constructs dependent upon—and interacting with—broader social and economic processes (Johnson and Stanley 2007; Newman et al. 2003; Spiegel and Parent 2017). Here conceptualizations of social capital in particular are employed, building on foundational theorists Bourdieu (1997) and Putnam (2000) and exploring bonding (within community) and bridging (between community) forms of capital such as social networks and norms/processes of cohesion or exclusion (Hampshire and Matthijsse 2010; Khan 2013; Macnaughton et al. 2005).

4 Goals and Epistemologies of CA Impact Analyses

Across the evolving discussion of CA outcomes are epistemological, methodological, and theoretical considerations and debates with regards to what constitutes valid evidence of impact. With growing interest in arts-based approaches, as well as the need to justify return on investment, CA initiatives are increasingly feeling pressure to evaluate and substantiate their work using empirical methods (Clift 2012; Hamilton et al. 2003). However, alongside broad calls for “better evidence” are questions and tensions related to the feasibility and fit of positivist approaches (Daykin et al. 2017). With an inherent emphasis on artistic and community-driven process, many CA investigators and practitioners locate themselves within more constructivist and qualitative-oriented perspectives (Goulding 2014; Putland 2008). A lack of theory-driven and theory-based evaluations and frameworks has also been frequently noted (Galloway 2009; Sonn and Baker 2016). This section discusses three distinct themes uncovered in the literature related to the goals and epistemologies of CA impact analyses: (1) making the case/scaling up, (2) articulating and uncovering process, and (3) mapping mechanisms and building testable theories.

4.1 Making the Case/Scaling Up

The increasing interest in and uptake of arts-based interventions has generated efforts and calls for more attention to the evidence base for this work. This perspective is often rooted within hierarchies of evidence-based practice, ascribing some value to case studies, qualitative research, and participant testimonies while calling for controlled studies quantitatively substantiating health outcomes, in order to scale up CA interventions to population-level impacts (Clift 2012). To this end, methodologies often center on the use of surveys or standardized scales to test individuals before and after exposure to a CA experience, ideally in comparison to some control group.

Arts therapy and clinical initiatives have been successfully measured using “gold standards” of evidence-based medicine, such as randomized controlled trials and meta-analyses, but this approach has been more challenging for CA initiatives, which often consist of small sample sizes with no obvious control group (APPGAHW 2017). Though there is some agreement regarding “encouraging” findings, systematized reviews of the CA evidence base consistently report issues with methodological rigor, citing concerns such as lack of validated outcome measures, issues with response rates and attrition, and lack of statistical power (Bungay and Vella-Burrows 2013; Clift 2012; Merli 2002; Zarobe and Bungay 2017). Consequently, there is an overall appraisal of the evidence as lacking robustness and multiple calls for higher-quality studies, which Hamilton et al. (2003) characterize as “still searching for the holy grail.” In contrast, some question whether positivist approaches are appropriate for CA initiatives, with their focus on participatory and creative process (Daykin et al. 2017). Raw et al. (2012) caution that attempts to gain visibility alongside dominant healthcare research can lead to a problematic “conflation of professionalized, clinically based arts and health practice and non-professionalized, participatory, community-based practice” (p. 100). These discussions emphasize the complex nature of CA interventions, rooted in the “open systems of the real world,” as well as related challenges in areas such as data collection, selection of appropriate outcome measures, and ability to synthesize findings (Daykin et al. 2008).

4.2 Articulating and Uncovering Process

Reflecting the tensions described above, many CA analyses emphasize qualitative investigations that focus on intervention and change processes, as opposed to empirical substantiation of outcomes (Clift 2012, p. 123). There is a significant body of peer-reviewed qualitative research on CA impacts, which highlights the role of such methods—including focus groups, interviews, and participant observation—in uncovering deeply contextual and relational effects and processes (Staricoff 2006). Macnaughton et al. (2005) suggest this is of particular importance in the evaluation of social capital goals of CA, framing evaluation in such cases as a “process of discovery, not proof” (p. 336). Of note is the recent proliferation of “mixed methods” designs, utilizing quantitative methods to explore specific impacts alongside qualitative methods to deepen the analysis and critically interpret findings (Spiegel and Parent 2017). Many CA initiatives rely on testimonials and case reports, often published in the form of grey literature reports by programs, funders, or policy makers (Galloway 2009; Putland 2008). Such publications can be influential, while also critiqued for lack of formal or rigorous evaluation measures (Hamilton et al. 2003). One of the first large-scale CA evaluations, Use or Ornament, utilized case studies to investigate CA initiatives across Britain (Matarasso 1997). The report details a host of individual and social outcomes and was a key element in an ongoing health policy agenda employing CA approaches in the UK. However, it has come under criticism for lack of internal and external validity, as well as its overall inability to prove causation in relation to the reported effects (Belfiore 2006; Merli 2002).

4.3 Mapping Mechanisms and Building Testable Theories

In an effort to recognize , but not necessarily reconcile, epistemological challenges related to evaluation and impact, some practitioners are calling for more efforts toward theorizing CA practice. Such perspectives argue that attention is needed toward theorizing the mechanisms by which CA interventions achieve impact, both as a basis for understanding and actualizing the findings of impact studies, and for moving beyond repeated debates on the quality of the evidence base (Raw et al. 2012, p. 105). Some believe that as long as the mechanisms of impact remain a mystery, evidence will fail to contribute to the field gaining the status desired (Cohen 2009; Sonn and Baker 2016). A small body of work is rooted in critical social science perspectives. Exploring the use of circus arts with equity-seeking communities, Spiegel and Parent (2017) take up the work of social theorist Guattari (1995) on “aesthetic paradigm”—art as a means of altering ways of seeing and engaging with the world, and experimenting with different kinds of social configurations. Spiegel and Parent (2017) draw on Guattari’s ideas to explore concepts of “social subjectivities and collectivities” (p. 2) in circus arts’ participants. Theory-based evaluation on the social effects of the arts seeks to counter the critique of the evidence base rooted in a “dominant rationalist-modernist paradigm” that emphasizes methodology rather than theory as the basis of “good evaluation” (Galloway 2009). Growing in popularity, “Theory of Change” approaches (Mayne 2015) seek to provide rigorous models of causality rooted in an embrace of complexity rather than experimental design (Galloway 2009). Though relying heavily on qualitative and first-person accounts, theory-based evaluation approaches seek to counter the view of self-report data as anecdotal by utilizing participant testimony as way of confirming, refining, or falsifying theory, and by providing an explicit methodological framework for data analysis.

5 Key Themes and Tensions

Given the dominant discourse on the need for more “robust and credible” evidence, there are growing attempts to support research and evaluation on CA practice through a proliferation of toolkits and frameworks. Such resources seek to provide enough detail on a range of methodological options to allow practitioners to employ them effectively. Some, however, critique what they refer to as over-reliance on a toolkit mentality, problematizing the oversimplification inherent in seeking to identify a method of impact evaluation that is easily replicable across contexts and equally applicable to diverse art forms and audiences (Belfiore and Bennett 2010, p. 122). Also questioned are the perceived benefits of generating more and “better” evidence; despite the goals of evidence-informed policy making, evidence is infrequently the main driver of policy action (Goulding 2014). Rather, well-focused theory and advocacy may be more effective than resource-intensive attempts to generate more evidence.

A key tension is emerging between the more instrumentalist approach, which positions the arts activity as a tool to fulfill policy objectives (Belfiore 2002), and a creative or transformational approach “that trusts in the arts process itself to deliver outcomes” (Macnaughton et al. 2005, p. 336). Artists often report feeling marginalized by research and evaluation discourse, which can be perceived to have a reductive focus on outputs and products, as opposed to artistic process (Daykin et al. 2017). As Badham (2010) contends, “Socially engaged arts are inherently transformational because they are collaborative and engaging, especially when lead artists are determined to uphold the artistic integrity of the work. It is the art more than the social policy outcome that results in transformation, yet there has been limited discussion in the literature on these kinds of artistic processes” (p. 91).

Reductionism can impact not only how community arts projects are valued and evaluated, but also project design and implementation. Consider the shift in emphasis from a discovery-oriented artistic process to “social policy” outcomes such as improved self-esteem or decreased social isolation; how might such changes impact the way an intervention is conceptualized or delivered? Might the more intentional, instrumental approach even diminish the potential for self-esteem to emerge as a more natural product of the collective process? Some fear this emphasis may be “throwing arts projects off track,” in particular through a shift in emphasis toward outcome evaluation “with a consequent devaluing of other forms, such as process evaluation and reflective practice” (Daykin et al. 2017, p. 133).

Returning to the ecological perspective, a change in discourse has been noted from an emphasis on the direct economic contributions of cultural industries, such as increased tourism and job creation, to more indirect economic benefits, such as creativity and innovation, employability, social inclusion, and community cohesion (Böhm and Land 2009). This may be due to a view of the product of artistic and cultural activity as capital—human, social, and cultural—within “the simultaneous recognition of the value of culture and the difficulty of measuring that value” (Böhm and Land 2009, p. 77). Some question whether “it may seem like positivism gone mad to expect the arts to justify their existence on scientific grounds” (Hamilton et al. 2003, p. 402). Further problematizing notions of impact, Gaztambide-Fernández (2013) challenges the construction of the arts as a definable naturalistic phenomenon that is available to be observed and measured, arguing that diverse art forms and practices are “processes of cultural production…evolving within both symbolic and material conditions that constrain but do not predefine how individuals engage each other. In other words, rather than thinking about the arts as doing something to people, we should think about artistic forms as something people do” (p. 225–226). Further research on, with, and through CA—which embraces explorations of artistic and social processes, as opposed to more individually oriented notions of output and impact—would be well positioned to engage and deepen this dialogue.

6 Potential Ways Forward

How to reconcile these diverse perspectives and approaches? Perhaps the key—for funders, researchers, and practitioners alike—is in not seeking to do so, in resisting the urge to espouse one particular standard for all CA practice and to live instead in the tensions and complexities. Such thinking can be found in the rising popularity of “whole system” approaches to impact and evaluation that embrace complexity theory and explore impacts at more macro levels and/or across multiple initiatives (APPGAHW 2017). Collective Impact (CI), for example, has gained traction as an approach to social impact analysis based on an embrace of complexity principles. CI seeks to move beyond standard evaluations of individual initiatives (termed “isolated impact”) toward a focus on relationships between organizations and progress toward shared objectives (Kania and Kramer 2011). CI takes a complexity, systems-oriented perspective rooted in the belief that the process and results of social innovation are emergent rather than predetermined, and that adoption often happens simultaneously across many different organizations (Kania and Kramer 2013). CI-oriented research on CA would provide an interesting opportunity to further illuminate both approaches, as well as systems and complexity thinking in general.

A way forward that also embraces plurality of thought and approach lies in the call for more attention to theory development, building on the recent attention paid to theory-based evaluation and Theory of Change approaches (Galloway 2009; Mayne 2015). Deeper attention to theorizing practice can build on foundational artists and cultural theorists such as Augusto Boal, Paulo Freire, and Jan Cohen-Cruz and can draw on interdisciplinary perspectives, incorporating disciplines such as geography, anthropology, and psychology (Raw et al. 2012). Within such directions are discussions on the need for more explicit attention to issues of equity and cultural production. A shift in discourse has been noted from “a ‘top-down’ welfare-like approach of helping disadvantaged communities, to the embracing of cultural democracy: the recognition of unique, valuable and plural communities’ right to control the creation and trajectory of their own culture” (Badham 2010, p. 86). Such narratives suggest an important role for harnessing and actualizing theoretical frames that can help operationalize values and principles like participatory practice, anti-oppression, and Indigenous ways of knowing.

More research in general is needed that seeks to view and build upon CA as an intrinsic form of knowledge production, for example through the use of artistic outputs of CA initiatives to theorize and/or evaluate programs and to explore impacts on both direct participants and broader communities. CA approaches may also provide a unique space to explore the growing interest in implementation research, an emerging discipline that seeks to link research and practice to adopt and integrate evidence-based health interventions within specific settings (Theobald et al. 2018). Implementation research investigates what, why, and how interventions work in “real world settings,” working within these conditions rather than trying to control or remove their influence as causal effects (Peters et al. 2013). Principals of implementation research include a critical reflection on contextual and power dynamics, equitable knowledge production, and engagement of marginalized communities (Wallerstein and Duran 2010)—all of which are key elements of the CA discourse. Finally, potential synergies may be found in strengthening linkages between CA and ABR. Similar needs and tensions exist in ABR in relation to problematization of impact as fluid, emergent, non-linear, and highly complex (Parsons et al. 2017), which could be co-explored for shared meaning making.

7 Conclusions and Limitations

This chapter describes increasing attention in both academic and community settings to the role of CA in promoting health and well-being at multiple levels, from the personal to the social. Within the widening discourse on CA approaches, disagreements exist in relation to state of the evidence base and on what is most needed to move this work forward. The current analysis suggests that promising directions involve resisting instrumentalist approaches and embracing plurality of thought in relation to knowledge and theory building. This chapter does not provide a comprehensive review of all relevant literature (for example, of note is the lack of attention to the rich body of thought and literature on aesthetics). It is also very important to note that the literature identified is primarily from Western sources and lacks detailed input from the very rich and diverse traditions of community-based art from majority world and Indigenous contexts. This chapter seeks to provide an initial roadmap for ongoing work and discussion, which—despite inherent tensions—suggests fertile ground for further study and praxis.