By Nicola Holt. Image above: “Tapestry” from a city-wide arts on referral project in Bristol led by CreativeShift, which was exhibited at Arnolfini gallery
Arts on prescription is expanding, with policy recommendations and schemes spreading globally, along with expectations of its positive impact on individual and community wellbeing. But what is art on prescription and what does the research on its efficacy suggest? In this blog post I will share the different strands of research that I have conducted with colleagues over the past few years, examining the impact of art on prescription, potential mechanisms for change, and systemic challenges with arts on prescription schemes. I hope that this blog post will be useful, condensing and sharing this body of work that can inform future arts on prescription delivery and research.
What is arts on prescription?
Arts on prescription (AoP), sometimes called ‘art on referral’, is one of the core pillars of social prescribing. In social prescribing schemes, people are ‘referred’ by trusted individuals (e.g., doctors, social workers) to relevant support or participation in community activities (e.g., cookery classes, nature walks) with the hope that this will improve their psychosocial wellbeing. In the case of arts on prescription these activities are art based, most typically the visual arts (e.g., painting, drawing, collage, clay work) but also music, singing, theatre or dance. Programmes of weekly art workshops vary in length, typically being between 6 and 12 weeks long. People are typically referred to arts on prescription programmes to help with experiences of loneliness, social isolation, low wellbeing, low to moderate levels of depression and anxiety, and chronic illness (e.g., chronic pain). Arts on prescription is part of an individualised pathway rather than an intervention (e.g., people may have several meetings with a link worker, choosing community activities, and may return to discuss progress with the link worker subsequently). It is supplementary to ongoing treatment (sometimes the metaphor ‘culture vitamins’ is used to convey this).
Arts on prescription workshops have specific aims – to facilitate ‘playing’ with art materials, and enjoying the artistic process in a safe and supportive environment, free from judgement. Unlike art classes, the emphasis is not on skill development, and unlike art psychotherapy, making art is not used as a tool to explore, express and share emotions. Arts on prescription is an invitation to take part in art activities with others, led by an arts for health professional.
Arts on prescription: Evidence and mechanisms of change
Several years ago, I met with Julie Matthews from CreativeShift to talk about ways to evaluate the wellbeing impact of their arts on prescription programmes. Julie was interested in the longitudinal impact of their programmes, and needed reliable methods to capture impact to help secure funding for future delivery. I had already worked with Julie’s co-director, Barbara Disney, the preceding year, where, with Finn White (Community Engagement Officer at M Shed) and participants of her ‘move on’ group at the M Shed, Bristol, we co-produced a method to evaluate the impact of the art workshops on wellbeing. Over several years, we slowly collected different sets of data with CreativeShift, asking different questions and conducting different analyses. This has led to the following outcomes and insights:
Increases in wellbeing and reductions in loneliness: The self-reported wellbeing of participants was, on average, at low levels before participation in arts on prescription programmes. Wellbeing increased significantly over time (after both 6 and 12 weeks of participation). Likewise, feelings of loneliness reduced over the course of programmes.
Mechanisms of wellbeing change: No previous work had looked at the immediate impact of participating in arts on prescription. This data showed improvement in mood after taking part in art workshops: participants reported feeling happier, less tense/anxious and more energised; as well as feeling less lonely. Improvements in ‘in-the-moment’ factors predicted who reported the most wellbeing benefits over time. Three potential ‘mechanisms’ for wellbeing change were identified: anxiety reduction; feeling less lonely after the workshops; and being in a state of ‘flow’ (attentional absorption) during the workshops.
Participants’ perceptions of change: Interviews with participants (conducted with myself and analysed by Caroline Elliott), explored how and why arts on prescription worked for them. Three themes were: “the embrace,” “the journey”, and “the ripple effect”. “The embrace” highlighted the supportive role of facilitators, and the crucial role they played in creating a ‘safe space’, where creativity could flourish and friendships could develop. This was perceived as crucial to the personal transformation experienced by participants. Participants described feeling empowered and more socially connected (along “the journey”), with many reporting that the benefits extended beyond the workshops into their daily lives (“the ripple effect”).
Longitudinal analyses: With Bethan Zalantai, we collected follow-up data one year after participating in arts on prescription. This suggested that wellbeing was maintained longitudinally, but that this was concurrent with being able to continue with art making and attending ‘follow-on’ art groups.
Participant quotes (Holt, Baber & Elliott, 2023)
Move-on groups: The ‘mothership’
Having a space and the opportunity to continue with artmaking is important to maintaining wellbeing after Arts on prescription, and the ArtShed programme at M Shed provides such a space in Bristol. Evaluation using the questionnaire methods described above, suggested that attendance helped to improve wellbeing, and interviews with participants illustrated the importance of the museum space itself. This was described by one participant as ‘the mothership’—a space in which they felt contained, safe, able to be creative, and also a space that offered both an aesthetic boost (with views over the harbourside), alongside a sense of pride and privilege—being able to explore the Museum when it was closed to the public, the day on which the art workshops were held.
Participant quote (Holt, Baber & Elliott, 2023)
Can the Arts on prescription model work in Hospitals?
Working with Donna Baber at FreshArts, Southmead Hospital, we extended our research into clinical settings. Participants were referred from hospital departments to tailored arts on prescription groups for chronic pain, cancer, chronic breathlessness, drug and alcohol and weight management. Our findings echoed our community findings—improved wellbeing, mood and attentional absorption. However, interviews revealed that arts on prescription also transformed participants’ perceptions of clinical care. Participants described how engaging with FreshArts on Referral changed their relationship with the hospital—feeling cared for in a more personal way, feeling like the hospital was a kinder place—humanising their experience.
Participant quote (Holt, Baber & Elliott, 2023)
Remote delivery: Arts on prescription during lockdown
During the coronavirus lockdowns the arts on prescription teams at CreativeShift and FreshArts changed their practices to continue delivering arts on prescription remotely, creating arts interventions using Zoom, phone calls, and for people with no digital access, postal art activities. Likewise, I shifted our evaluation practices from paper and pencil to online mood and wellbeing forms, that could be accessed through links or QR codes. We still found that remote delivery had beneficial impacts on mood and wellbeing, and the success of this impacted future delivery, where, for some participants (e.g., when experiencing social anxiety, transport or mobility difficulties) having the option to access arts on prescription remotely is beneficial, and a step on the pathway to further involvement with arts on prescription.
Examples of participants’ artwork from an ‘exquisite corpse’ postal intervention (Holt, Baber, Matthews, Lines & Disney, 2022)
Feeding research back into practice
Working with FreshArts and CreativeShift, we held a staff training day with artist facilitators, where I discussed the outcomes of our evaluations, focusing on the ‘mechanisms of change’: relaxation, flow and social connection. We spent the afternoon working in groups on each ‘mechanism’, discussing how artists worked to create the conditions for each in their practice. It was useful to consider how these factors were facilitated during arts on prescription workshops and to share best practice. This then fed into training programmes for new artist facilitators.
Thriving Communities: Developing culturally inclusive arts on prescription programmes
A further strand of work, led by Lerato Dunn from Bristol Culture, piloted culturally inclusive arts on prescription programmes in urban settings across Bristol. Working with local communities and cultural institutions (e.g., Arnolfini), these programmes included: drama in nature for children and young people, body movement and art for women, child and carer art groups, and art making in nature. The findings underscored the importance of cultural relevance, intent, and location in shaping outcomes. Once again, therapeutic relationships and safe spaces were described by participants as central to effectiveness. Arts on prescription workshops were described as spaces where moments of joy, awe, escape, relaxation and flow could occur. However, challenges were identified in the wider evaluation that related to scalability, inclusivity, and long-term funding. In particular, it was emphasized that the work of the artist facilitators (e.g., in carefully working with participants, sometimes over a long period of time before they even felt able to attend a workshop), was not fully recognised in the planning and funding of social prescribing services.
Participant quote from the arts in nature group (Holt & Dunn, 2023)
Addressing challenges: A critical review of arts on prescription
Despite the encouraging findings about the efficacy of AoP, there are numerous problems with both practice and the evidence base, which are crucial to consider. With Hilary Bungay (Anglia Ruskin University) and Anita Jensen (Lund University) we conducted a review of such issues. A lot of the communication about arts on prescription does not consider issues critically, hence, we sought to redress this.
Our review identified numerous challenges with delivery, such as inconsistent referral practices, varying levels of awareness among healthcare providers about arts on prescription, and the need for better training for artist facilitators. There is a crucial need to develop consistent best practice across arts on prescription programmes and support for artist facilitators. We know that engagement with the arts is not always positive, e.g., group dynamics can cause feelings of exclusion rather than inclusion, and art activities can be perceived as stressful if scaffolded inappropriately. This needs to be acknowledged in order to develop guidelines and training for arts in health facilitators. These insights, and others, are vital for refining arts on prescription models to ensure they are accessible, effective, and sustainable.
Collective evidence: Systematic review and meta-analysis
Since there was no overview of the existing research on arts on prescription, again, with Hilary Bungay and Anita Jensen, we conducted a systematic review of the literature. We assessed 25 studies across multiple countries, including the UK, Australia and Sweden, analysing the data from all of these studies together. The findings suggested that arts on prescription programmes lead to significant improvements in individual wellbeing. Participants reported enhanced social connections, and increased psychological wellbeing, including confidence and self-esteem, as well as arts on prescription opening new opportunities. These outcomes underscore the potential of arts on prescription as a viable component of public health strategies.
However, the review also highlighted problems with the existing evidence base, including a reliance on pre-post designs (measuring wellbeing at the start and end of programmes) with no control or comparison groups, making it difficult to attribute the wellbeing change to the programmes. There was also a lack of follow-up data, making the long-term impact of attending programmes unclear. Another problem was a lack of specific health outcome measures (overly relying on generic wellbeing measures), meaning that it is not clear whether arts on prescription is useful to help with specific symptoms or experiences, like social isolation, managing pain or anxiety and depression. Additional issues with the evidence base were highlighted, such as a lack of demographic diversity in attendees, and barriers to access for people who may benefit from arts on prescription the most (e.g., people experiencing multiple challenges).
Forest plot illustrating mean wellbeing change (and confidence interval) for each study in the meta-analysis and estimated overall effect size (Jensen et al., 2024)
Narrative reviews: So much work to do!
Further narrative reviews of the literature with colleagues (Julie Matthews, Caroline Elliott, Sofia Vougioukalou [Cardiff University], Helen Chatterjee [UCL]), have expanded on these critical issues, considering possible future directions in research (e.g., using the experience sampling method to track longitudinal wellbeing), and the need to further research of the benefits of arts on prescription for specific groups, e.g., children and young people and older adults. There is so much work to do and issues to address, to:
- Improve the existing evidence base: especially for specific outcomes (e.g., anxiety and depression, pain management, loneliness) and longitudinal impact.
- Disseminate and share best practice and training: often research papers do not explain what arts on prescription practitioners actually do (meaning that impact may be inconsistent across programmes).
- Develop inclusive and culturally relevant programmes: currently arts on prescription has a limited demographic reach.
- Improve systemic practices: along the referral pathway (e.g., it is not always clear who holds health responsibility for participants along their journey, and outcomes from participation are not always fed back to referrers).
Conclusion
The research that I have been involved with has hopefully helped to validate and expand the role of the arts in social prescribing. The work not only evidences the positive impacts of arts on prescription on individual wellbeing but also provides critical insights into optimizing programme delivery and accessibility. As arts on prescription continues to gain recognition within public health frameworks, I hope that these contributions help to shape effective, inclusive, and culturally sensitive interventions using the arts to improve health and wellbeing. However, there is much work to be done, and a need to consider evidence and practice critically, to ensure best practice and improve the quality and specificity of the evidence base.
References
Bungay, H., Jensen, A., & Holt, N. (2024). Critical perspectives on arts on prescription. Perspectives in Public Health, 144(6), 363-368. https://doi.org/10.1177/17579139231170776
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. https://doi.org/10.1177/1757913920913060
Holt, N. J. (2023). The impact of remote arts on prescription: Changes in mood, attention and loneliness during art workshops as mechanisms for wellbeing change. Nordic Journal of Arts, Culture and Health, 5(1), 1-13. https://doi.org/10.18261/njach.5.1.1
Holt, N., Baber, D., & Elliott, C. (2023). Arts on referral at Fresh Arts: A mixed-methods report on the efficacy of arts on prescription in a hospital setting for people experiencing chronic health conditions. UWE Bristol. https://uwe-repository.worktribe.com/output/12712211/arts-on-referral-at-fresh-arts-a-mixed-methods-report-on-the-efficacy-of-arts-on-prescription-in-a-hospital-setting-for-people-experiencing-chronic-health-conditions
Holt, N., Baber, D., Matthews, J., Lines, R. & Disney, B. (2022). Art on referral: Remote delivery in primary and secondary care during the coronavirus pandemic. UWE Bristol.https://uwe-repository.worktribe.com/output/9852574/art-on-referral-remote-delivery-in-primary-and-secondary-care-during-the-coronavirus-pandemic
Holt, N., & Dunn, L. (2023). Thriving communities Bristol evaluation report. Bristol Culture. https://uwe-repository.worktribe.com/output/11603659/thriving-communities-bristol-evaluation-report-2023
Holt, N., Elliot, C., & Jenkinson, E. (2021). Nobody can fail at it, everybody succeeds”: Perceived processes of change following attendance at an arts on prescription programme. In Culture, Health and Wellbeing International Conference Research Proceedings (pp. 66-68). https://uwe-repository.worktribe.com/output/7240845
Holt, N., Matthews, J., & Elliot, C. (in press). Art on prescription: practice and evidence In P. Crawford and P. Kadetz (Eds.). Palgrave Encyclopedia of the Health Humanities. Cham: Springer International Publishing. https://www.researchgate.net/publication/345501419_Art_on_prescription_Practice_and_evidence
Holt, N., Vougioukalou, S., & Chatterjee, H. (in press). The arts in social prescribing. In (Eds.) Holt, N. Tischler, V., Vougioukalou, S., & Corvo, E., Routledge Handbook of Arts and Health.
Jensen, A., Holt, N., Honda, S., & Bungay, H. (2024). The impact of arts on prescription on individual health and wellbeing: a systematic review with meta-analysis. Frontiers in Public Health, 12, 1412306. https://doi.org/10.3389/fpubh.2024.1412306
Zalantai, B., Holt, N., Chase, M., & Jenkinson, E. (2021). A mixed-methods evaluation of the longitudinal impact of arts on prescription. In Culture, Health and Wellbeing International Conference Research Proceedings. https://uwe-repository.worktribe.com/output/7240027