https://orcid.org/0000-0003-3982-8940
Abstract
We propose that arts based methodologies can be of value in the production and exchange of evidence in supporting public health related policy. This article reports on a collaborative piece of work resulting from two projects which took place in a former coal mining town in South Wales.
We used a participatory framework whereby researchers, community members and artists co-produced ‘evidence’ through the creative arts to inform public policy. We collected a range of data using a number of different techniques, including interviews, focus groups and observation, but also included an extensive range of creative activities.
The data provided a diverse range of perspectives on how people of different ages live their lives. The People’s Platform was a performance-based debate which was the culmination of the collaboration. The show involved a series of short performances with time for facilitated discussion in-between. It was felt that the show facilitated knowledge exchange on health and wellbeing issues that are usually difficult to express and understand through traditional forms of evidence.
Whilst arts-based approaches are not free from risk, they offer an alternative form of knowledge as a necessary complement to the range of data available to policy makers.
Introduction: other ways of knowing
In public policy development (including health) there is often a disconnect between the available data on the one hand, and both the wider social, material and cultural contexts, and the everyday lived experiences of health and wellbeing on the other. This is often exacerbated by neo-liberal approaches to policy that focus on individual characteristics and capacities and, in the context of public health, a narrow focus on deprivation and individual lifestyle and behaviour.1,2 In the context of steep income and related health inequalities, the results are public health interventions and approaches that fail or fall short of their objectives because they do not resonate with the priorities and lived experiences of the people at whom they are aimed. Like others who have noted the international shift towards what Parkinson and White3 refer to as the a shared agenda of re-imagining public health, we are interested in drawing on local knowledge as evidence for public health interventions which incorporate the overlapping spheres of time and place; ways of living; health and wellbeing and inequality. This temporal, spatial and holistic approach moves us away from traditional evidence-based approaches that are quantitative and probabilistic4–6 to methods that bridge the gaps between data, the production of ‘living knowledge’7 and interventions. Furthermore, it is argued that they provide alternative ways of engaging different communities in conversations about the meaning and significance of different kinds of evidence. This paper proposes that arts based methodologies can be of value in the production and exchange of evidence in supporting public health related policy. In particular, this article provides insight into the Welsh policy context and highlights arts based methods used to support the Well-Being of Future Generations (Wales) Act.
Whilst attempts to quantify aspects of the social and material context are important,8 qualitative methods are also important in exploring the hidden features of lived experience, the meaning of contextual factors related to health and wellbeing, and the limits and possibilities of health interventions. Whilst this type of evidence is still often considered inferior to quantitative evidence, the contribution of qualitative studies to public health is increasingly being recognized.9–12 What remains clear is the need for other ways of knowing and understanding people’s lives, not amenable to numeric calculation, which enable us to understand how people living under varying conditions actively engage and resist the demands and affordances of social and economic change.
In the field of social sciences for example, this includes research approaches and methods that draw on inventive,13 live14 and real time,15 all aimed at capturing the complexity of everyday life. New ways of capturing data and knowledge are developed through the integration of multiple methods and tools which are used within participative and socially situated contexts. In a similar view, and in keeping with a growing body of work on sociality16 our attention is rooted on the approaches and methods that allow for a focus on the nuanced and diverse aspects of everyday health and wellbeing.
In this article we will draw on a research project in which data were both collected and communicated using methods derived from arts practice. The researchers, not being artists, worked alongside a community arts project to generate data and then, together with a national theatre organization, co-produced a performance-based dialogue about everyday wellbeing to inform recently implemented legislation on wellbeing. In this paper we go beyond qualitative methodologies and explore the contribution that arts-based research can make to debates in public health, and how arts-based knowledge continues to make problematic our understanding of what counts as evidence.3,17
The value of arts
There is a significant body of work that acknowledges the therapeutic value of different kinds of participation in arts based activity.18–22 However, there is an emerging literature on arts based research practice23 including in health research.24 This research integrates arts practices into the methods of engagement and data collection as well as knowledge production and exchange. Perhaps unsurprisingly, the field of arts-based research has received some critique, as the boundaries of what constitutes ‘research’ are being pushed and blurred. For example, David Pariser25 has challenged arts-based research by arguing that research is a ‘quest for truth’ and that art can make no truth claims. Pariser highlights the lack of peer review in the field, which he argues leaves the arts relatively unchecked compared to many other research approaches. Arts-based research has also been challenged for relying too heavily on personal testimony, rather than inviting ‘sceptical scrutiny and criticism’.26
However, as Seigesmund27 points out, the arts are useful for addressing ‘secondary ignorance’, where we do not know what we do not know. The arts can be a mechanism to shift perceptions and move to a position of ‘primary ignorance’, where we DO know what we do not know, and are therefore more open to addressing a need for growth.
What arts-based research does is to place emphasis on embodied responses to the world and non-conventional ways of meaning-making,28 with attention and experimentation of form and creative presentation in terms of both research processes and outputs.29 Sullivan,30 in problematising research that seeks to explain human behaviour in order to establish causal pathways which can then be re-created to produce desired behaviours, makes the case for arts practice as research by arguing that there is a gap in current knowledge derived solely from quantitative and qualitative research methods. Often using participatory methodologies, arts-based research has been used to research with people and communities in more considerate and empathetic ways. Boydell et al.17 argue further that it is important to pay attention to the spaces within which different types of knowledge are produced. This resonates and extends some of the work of Elliott and Williams31 who, in thinking about the knowledge that both a public sociology32 and citizen science33 might contribute, argue that we need ‘new knowledge spaces’ within which contentious public issues can be discussed. They highlight the implications of these pluralistic epistemological environments for different forms of expertise.
Wales: a devolved policy context
In Wales, health is a devolved policy area and has had more recent powers to create new legislation. The Wellbeing of Future Generations Act (Wales) 2015 has seven broad priorities, or wellbeing goals, for the future of Wales, which it expects all public bodies to address through their practice (A prosperous Wales, a resilient Wales, a healthier Wales, a more equal Wales, a Wales of Cohesive Communities, a Wales of vibrant culture and thriving Welsh language and a globally responsible Wales.). This requires newly created Public Service Boards (comprising Local Authorities but also a range of other organizations) to conduct a wellbeing assessment of its population, and to set ‘wellbeing objectives’. The quality and range of evidence available in order for these tasks to be completed is therefore crucial, as they will shape the work and activities of all public bodies in Wales. The legislation also requires Public Service Boards to implement the Act by involving the diverse communities in the area that the public bodies serve. This, more clearly than other forms of legislation, connects the requirement for evidence alongside that of engaging publics. The legislation calls for forms of evidence that provide a different understanding of local contexts through the lens of some constructs (e.g. resilience, cohesion, wellbeing and culture) which require a more nuanced understanding of local context and the structures that regulate and support wellbeing in people’s everyday lives. From a public health perspective it also provides a mechanism to connect the wellbeing goals within a social determinants of health framework.
In Wales the focus, since the National Assembly of Wales was created, has been on participation as the driver for change.34,35 More recently, as in other devolved administrations and in research, there has also been a turn to co-production as a way of delivering services, driving innovation and creating living knowledge.7 In Wales the then Minister for Health and Social Services, Mark Drakeford, also highlighted its democratic potential writing (in a guide to co-production) that ‘our ambition is not for co-production to replace the state, but for it to democratise and animate it.’36 In other papers, available for readers to draw their own conclusions, we have offered a more critical perspective on co-production but what it has done is to enable us to acknowledge that academic knowledge is part of a wider ecology of knowledge.37,38 This is particularly the case with knowledge of local context which requires different knowledge holders, and different methods, to generate knowledge of the local in the context of wider structural changes.
A case study in arts research practice
This article reports on the role that arts practice played (through co-production with community and national arts organizations) in one case study out of five across the UK in a study entitled Representing Communities: developing the creative power of people to improve health and wellbeing. In this case study the focus was on a post-industrial area in the south Wales valleys. It is a place which has become highly stigmatized through national and local media stories and programmes alongside local profiles which place it as one of the most deprived in the UK. In the context of current welfare policy which focuses on conditionality and sanctions, marginality and poverty are framed in terms of failure.39 Whereas ‘working class’ could previously have been a resource for positive identities and action (for instance through workplace institutes and trade unions) the loss of an industrial base and its wider impact on the loss of opportunities for social, economic and civic participation, means that places, as alternative forms of identity construction, are risky.40 Stigmatized places, in particular, are fragile bases for asserting positive collective identities that could challenge structural inequalities, as places themselves are framed as the problem.41,42 It was these framings of inequality that this project sort to challenge, both through new data as well as by creating a space in which alternative ways of understanding local wellbeing could be articulated by local people to representatives of public bodies.
However, given the focus on art as a process to generate new forms of knowledge and understanding of health and wellbeing, the study could not be conducted by academic researchers alone. The focus on arts and creativity, along with the theme of health and wellbeing and the geographical location of the study, facilitated a number of university–community partnerships. One partner was a bilingual arts project called POSSIB: Lleisiau Mewn Celf/Voices in Art supported by the Big Lottery and based in a Welsh language cultural centre. The purpose of POSSIB was to explore issues relating to health and wellbeing through arts participation, exploration and co-creation. Activities were focused on school aged children, their parents and working aged men in the area. For three years, the two projects worked in partnership, developing a number of activities and events. Both used a participatory framework whereby researchers, community members and artists co-produced ‘evidence’ (or ‘intelligence’) through the creative arts to inform public policy. A range of data were collected, from people of all ages accessed through schools and a range of community based projects, using a number of techniques (Table 1). These started with traditional qualitative methods such as interviews, focus groups and observation. However, as the research developed, arts-based practices and methods became used more productively to ‘articulate’ the thoughts and experiences that people found ‘unsayable’ in terms of the everyday, and often mundane, experiences of local wellbeing. In particular, wellbeing was seen as relational; not just in terms of the residents themselves, but also the craft-like contributions of community development workers to the fabric and feel of everyday life. Many of the children and adults who participated in the research revealed moments when community development workers, employed as part of the Welsh Government’s Communities First anti-poverty programme (The Communities First programme in Wales is currently being phased out and will no longer exist from March 2018.), subtly intervened in their lives by creating connections, ideas or resources that helped at a particular moments in time. Digital stories showed and narrated the importance of particular places and people in ensuring that moments of sociability and shared enjoyment were part of the pattern of their week. In the background, the street-level practices of care, the importance of which were unseen through the reporting structures to Government, were enacted like invisible thread, holding livable lives together. Photographs chosen as part of one digital story about the community centre showed a group of older people smiling and sharing lunch—the community development worker a faded figure in the background (see Fig. 1 below).
Overview of data
| Data | Participants | Details |
|---|---|---|
| Interviews | 13 Working age people |
|
| Interviews | 5 Older people |
|
| Video interviews | 38 Year 4/5 pupils |
|
| Group discussion | 15 Older people |
|
| Group discussions | 2 × groups of young people |
|
| Group discussion | 8 Working age women |
|
| Poems | 27 Year 4/5 pupils |
|
| Song/music video | 27 Year 4/5 pupils |
|
| Drawings | 27 Year 4/5 pupils |
|
| Photographs | 10 Year 10 pupils |
|
| Data | Participants | Details |
|---|---|---|
| Interviews | 13 Working age people |
|
| Interviews | 5 Older people |
|
| Video interviews | 38 Year 4/5 pupils |
|
| Group discussion | 15 Older people |
|
| Group discussions | 2 × groups of young people |
|
| Group discussion | 8 Working age women |
|
| Poems | 27 Year 4/5 pupils |
|
| Song/music video | 27 Year 4/5 pupils |
|
| Drawings | 27 Year 4/5 pupils |
|
| Photographs | 10 Year 10 pupils |
|
Overview of data
| Data | Participants | Details |
|---|---|---|
| Interviews | 13 Working age people |
|
| Interviews | 5 Older people |
|
| Video interviews | 38 Year 4/5 pupils |
|
| Group discussion | 15 Older people |
|
| Group discussions | 2 × groups of young people |
|
| Group discussion | 8 Working age women |
|
| Poems | 27 Year 4/5 pupils |
|
| Song/music video | 27 Year 4/5 pupils |
|
| Drawings | 27 Year 4/5 pupils |
|
| Photographs | 10 Year 10 pupils |
|
| Data | Participants | Details |
|---|---|---|
| Interviews | 13 Working age people |
|
| Interviews | 5 Older people |
|
| Video interviews | 38 Year 4/5 pupils |
|
| Group discussion | 15 Older people |
|
| Group discussions | 2 × groups of young people |
|
| Group discussion | 8 Working age women |
|
| Poems | 27 Year 4/5 pupils |
|
| Song/music video | 27 Year 4/5 pupils |
|
| Drawings | 27 Year 4/5 pupils |
|
| Photographs | 10 Year 10 pupils |
|
Image of cooking group.
The data provided a diverse range of perspectives on how people of different ages take part in the sociality of everyday life and findings covered diverse subjects including the physical environment, housing, volunteering, the jobcentre, benefits sanctions, drug misuse, vandalism, social and informal support, networks, community spirit, future aspirations and pride. These were experiments ‘with’ people, the difference being that people were always the producers and owners of the arts (data) they produced.
Please see Table 1 for an overview of the data.
The People’s Platform
Whilst photographs, poems, songs and stories were useful for gathering data, they were limited as forms of knowledge exchange. For instance photographs depicting, on the one hand loneliness, and on the other hand the conviviality of public spaces, invited private responses from people visiting an exhibition over a 2-week period. In seeking to push beyond some of these limitations, throughout the project researchers were in conversation with National Theatre Wales (NTW), itself an organization that is self-reflective of its responsibilities both to engage with different publics but also to produce high quality theatre. As a form of co-produced research the emphasis was on the forms of knowledge that could be generated and exchanged through the medium of theatre. Through NTW a writer/dramaturg and director were commissioned to work with the data and community members to create a performance. The director and writer worked with a group of working age people, some of whom had already taken part in interviews and others who were new to the project. Through workshops, the style and mode of engagement in the production were established. Another director was also commissioned to establish a ‘Young Company’ involving pupils at the local high school as the highly physical and emotive processes of creating a finished performance highlighted the need for smaller spaces for sharing and expressing ideas and experiences in ways that felt ‘safe’.
The details of the rationale, process and outputs of the People’s Platform is reported elsewhere37 but it provided an opportunity to create a space, a sensory landscape, which embodied the spirit of the place and in which local people in the project felt comfortable. It was held in a social club, and fragments of data were thematised and performed around the audience who were sat at T-shaped tables to encourage discussion. At each table was a community member who had been trained in facilitation techniques and a mix of community and policy audience members—around 200 in total. Even the set design and lighting were designed to reflect the nature of the data and purpose of the event; to generate discussion of the wellbeing goals, and local people’s involvement in, the Wellbeing of Future Generations Act.
Most of the performance was through monologues and characters that were built from interviews and data throughout the project. The characters were historically located and the problems and joys they narrated were familiar to local people. They could not have come from ‘anywhere’ but their stories touched on universal experiences of how poverty and inequality impact, and are managed, in everyday life. For instance ‘Angharad’ talks about the everyday struggles of being a mother, bringing up her boys, struggling with chronic depression and negotiating the resources that appear and disappear. As a character she performed and brought alive, cognitively and emotionally, the importance of the fragile organizational and interpersonal resources that have kept her going in times of trouble. Her monologue (through its context and the way in which she performed her story) challenged the discourses of resilience which focus on individual characteristics and qualities at the neglect of public and relational structures and resources. In witnessing the data through a shared aesthetic experience, audience members were able to exchange knowledge and dialogue in a space where professional and lay roles were not as visible as in other, more formal, spaces for discussion (such as consultation groups, AM surgeries or town hall meetings). Representatives from the National Assembly for Wales and from National Theatre Wales commented on the diversity of audience members and the depth of discussion resulting from the show. This demonstrates the role that research can play in community development, public policy making and arts and culture; the show brought value to people at all of these levels, as the feedback demonstrates. The feedback from audience members, ranging from representatives from the National Assembly of Wales, Welsh Government, Local Authority, Arts Council and Westminster, was that the show was able to convey powerful messages about everyday health and wellbeing and that it was able to challenge stereotypical views held about particular groups. Messages left on post-it notes, postcards and tablecloths conveyed a wide range of responses, including reflections on the current community conditions and the structural factors which shape health and wellbeing; suggestions of what the community needs in order to improve health and wellbeing; the existing strengths of the community, and emotional responses to the show (See link to a film which provides a narrative of how some of the local people, performers and audience members responded http://bit.ly/2qn5Akr.).
The new Chair of the Arts Council in Wales, reflecting on the role of arts and, in this case, theatre in a post-Brexit world wrote:
There’s a well-lit mini boxing ring with a fighter training; a washing-line monologue about a mother and her teenage son. Issues are raised which stimulate discussions at tables around the club lounge. It’s called The People’s Platform and it’s focused on celebrating the people of this feisty, talented and massively disadvantaged town.41
Perhaps it is not surprising that a national body with a responsibility for commissioning arts should articulate the social value of art in this way. After all the cultural sector is under pressure to demonstrate its public value in the context of cuts and austerity. However, it has stimulated discussion about the possibilities of using art as a mechanism for engagement and its contribution to public health could be in its close attention to the interplay and impact of social and economic determinants on a micro-scale.
Conclusion
Collaborative, relational partnerships between the researchers, community organizations, community members, schools and artists have enabled the many facets of community engagement in creative, artistic processes to form, in-form, per-form and present lived experiences, culminating through The Peoples Platform in evidence that is co-produced, sensory and affective. We argue that creative arts activities which are relevant and meaningful emerge through the building of relationships that happen with a collaborative investment of time, a commitment to the making of something and an openness to exploration. It is a combination of what ‘happens’ (i.e. the self’s experience of the present), what has gone before (the past) and what is imagined (the future).42 The purpose of imagining is in its engagement of what is possible when ‘what happens’ might hold us back, this in turn can reveal a freeing and confidence with which to explore issues, and how to address them, that might otherwise be difficult to articulate. This is as important in the devolved policy context in Wales, as it is for all governments seeking to connect with publics living in different places or with users of particular services.
In terms of contributing to the agenda of re-imagining public health, we argue that the use of arts-based approaches can facilitate both the production of evidence and genuine knowledge exchange between the public and decision makers. When attempting to improve public health, and acknowledging the importance of survey and statistical data, it is also essential to attend to the nuances of more mundane aspects of everyday life and those aspects of health and wellbeing that are most intangible and difficult to express. Arts-based approaches are not free from risk; as with other qualitative research methods, there are risks associated with over-disclosure and emotional distress, and with arts-based work participants often want to be named as the creators of their own work, which goes against what we are used to in terms of assurances of confidentiality and anonymity. However, arts-based approaches do offer an alternative form of knowledge that can be a powerful complement to the range of data available to policy makers. Used effectively, the arts—and in our example, theatre—can also enable citizens to engage in dialogue with those making decisions about their lives in a way that disrupts power relationships and creates an environment of understanding and respect.
Acknowledgements
The support of the Arts and Humanities Research Council (AHRC) is gratefully acknowledged. The work here is part of a multi-University, collaborative project ‘Representing Communities’. We are grateful to a large number of co-investigators, researchers and PhD students: Eva Elliott, Gareth Williams, Ellie Byrne and Madeleine Phillips (Cardiff University); Pete Seaman and Claire McKechnie (Glasgow Centre for Population Health); Qulsom Fazil and Joanna Skelt (University of Birmingham); Clare Barker and Jamie Anderson (University of Leeds); Roiyah Saltus and Adeola Dewis (University of South Wales); Sarah-Anne Munoz and Issie McPhail, University of the Highlands and Islands. We are also grateful for the support and insights we have received from our community partners.
