The arts in public health policy: progress and opportunities

There is a growing body of evidence indicating the arts have a role to play in promoting good health and preventing and managing illness. WHO has called for governments to take an intersectoral approach, both within and across traditional areas of policy, to realise the potential of the arts for public health. To explore what global progress is being made towards this aim, we present examples of arts and health policy development from diverse government areas: health, arts, local governments, and cross government. These examples, which have been selected from a scoping review of 172 relevant global policy documents, indicate that many health and arts policy makers view the relationship between arts engagement and improved health in quite general terms, although some are investing in more targeted applications of the arts to address specific public health issues. The most promising and concrete commitments are happening when health and arts ministries or agencies work together on policy development.


Introduction
Over the past decade, there has been increasing interest from researchers, health practitioners, artists, and policy makers in the role of the arts in addressing some of our most pressing public health challenges. In 2019, WHO's Health Evidence Network released a landmark scoping review of over 3000 research studies that explore the effect of the arts (including participating in performing arts, visual arts, and literature and engaging with culture and heritage) on health and wellbeing. 1 These studies included experimental research highlighting the effect of arts interventions targeted at different clinical needs (eg, mental illness, neurodevelopmental and neurological disorders, non-communicable diseases, acute conditions requiring hospital care, and end-of-life care), and observational studies of cohort data showing population-level associations between arts engagement and reduced incidence of ill-health (including depression, chronic disease, and age-related decline). Overall, the review concluded that the arts could have key roles to play in the prevention of ill health, the promotion of good health, and the management and treatment of a range of different conditions. This area, often broadly referred to as arts and health, can include arts and cultural activities undertaken in everyday life (not for a health purpose but having a secondary benefit for health) or within bespoke arts programmes designed with targeted health or wellbeing goals, or therapeutic arts programmes delivered by trained arts therapists. 1 But how might public health leaders and policy makers realise this potential?
With rapid social change and societal uncertainty, brought on by events such as the COVID-19 pandemic, public health leaders are seeing an ever-increasing need for interventions that address health inequalities, mental illness, loneliness, and isolation. The evidence indicates that these are areas where arts and culture can have a positive effect. 2,3 The WHO regional office for Europe, in a brief for the Health 2020 policy framework, described the arts as "often low-risk, highly cost-effective, integrated and holistic treatment options for complex health challenges". 4 To unlock this potential, WHO advocates for an intersectoral approach, arguing that "stronger pathways between the arts, health and social care can provide creative solutions to help to achieve the Health 2020 targets and the Sustainable Development Goals". 4 WHO recommends that action is targeted towards ensuring equity of access to arts and culture, training for health and arts practitioners, and identifying specific public health areas for collaboration. 5 However, it is unclear what progress is being made towards these goals globally. In this Health Policy, we highlight promising examples of arts and health policy developments from across different government areas (arts and culture, health, cross government, local governments, and between governments), and explore what these policy documents reveal about how international policy makers are approaching this topic and where there are opportunities for policy growth and development.

Examples of promising policy developments
Central or state government: arts and culture policies WHO recommends that arts and cultural policy makers ensure equal, accessible arts engagement opportunities for all their citizens and explicitly recognise the relationship between good cultural provision and population health benefits. 5 In many of the documents we found, this recommendation is being promoted, with several making general reference to health and wellbeing as a perceived benefit of arts and culture provision. [6][7][8] Some policy documents list more specific (although still fairly broad) public health benefits of the arts-most commonly to mental health, healthy ageing, or reduced social isolation-and a handful of policies also recognise a clear role for arts and culture in supporting population mental health and economic recovery from the COVID-19 pandemic. 8-10 A few docu ments make commitments to health-focused work in particular settings, such as the National Arts Council Singapore's Arts Strategy for 2018-2022 that pledges to "bring the arts to underreached communities in places such as hospitals and nursing homes". 11 Government arts and culture ministries and councils are also beginning to publish separate statements and strategies regarding arts and health. The Australia

Health Policy
Council for the Arts, in their document on health and wellbeing, recognise that the arts "save expenditure and provide returns on investment across health services and social care, helping meet major challenges such as ageing, loneliness, chronic conditions and mental health". 12 In the UK, we also see promising examples: the Arts Council of Wales's 2018 study of arts and health in Wales makes specific proposals for the council to increase funding for arts activities that promote prevention, wellbeing, and recovery for mental ill health (including early interventions with children and young people) and dementia. 13 The Arts Council of Wales's commitment to partnerships with health bodies is also stated and has since led to some promising cross-governmental policies covered later in this Health Policy. Arts Council England's 2022 Creative Health and Wellbeing statement also includes commitments for the Council to work more strategically with the health and social care sectors and focus on developing skills for creative practitioners, 14 one of WHO's recommendations. To explicitly tackle health inequalities, the Council also commits to prioritising investment in arts and culture for those experiencing inequality. And in the USA, the National Assembly of State Arts Agencies has published a series of so-called strategy samplers, reviewing the evidence and giving policy recommendations for the arts in specific public health arenas, namely the opioid epidemic, 15 ageing, 16 and clinical settings. 17 Central or state government: health policies WHO recommends that health policy makers seek active collaborations with the arts sector and incorporate the arts into the training of health professionals. 5 There is evidence from our search that some policy makers are beginning to follow these recommendations, at least in part. The Australian state of Victoria's Health Department Arts Strategy 2019-2023 identifies specific public health areas, such as creating healthier food environments, and commits to "harnessing arts and cultural settings as powerful enablers to influence awareness, attitudes and behaviours". 18 This document also cites the key evidence that has underpinned the department's commitments. In its health policy document titled Wellbeing, Health and Promoting Security 2030, the Finnish Government has made similar commitments to increase the use of art activities in rehabilitation, by increasing cooperation between social and health care, nutrition, exercise, and cultural professionals. 19 This pragmatic approach clearly identifies both why and how arts and culture could help meet a particular public health challenge in a focused and evidence-led way.
Other health policy documents take a broader and less specific approach. Ireland's Healthy Ireland Strategic Action Plan 2021-2025 marks out a commitment to ensuring "that local authorities are sufficiently supported to allow the fulfilment of long-term strategic cultural and arts planning at a local level" as a core driver of public health and wellbeing. 20 Ethiopia's Mental Health Strategy is also notable for its recognition that a multisectoral approach that includes the Ministry for Culture is needed to tackle poor mental health. 21 Some documents also link population health and wellbeing to the preservation of culture and cultural traditions, particularly for First Nations citizens. 22,23 Cross-governmental policies Some of the most pioneering examples we found are those that follow WHO's recommendation for an intersectoral approach and are authored by groups that span health and arts public bodies. One example is Greece's Memorandum of Cooperation for Cultural Prescription Between the Ministry of Culture and Sports and the Ministry of Health, which sets out a specific cross-governmental programme of work to train artists and cultural workers and health-care workers concurrently, deliver culture on prescription, and raise awareness of the scheme with the public. 24 The Arts Council of Wales and Welsh NHS Confederation have also signed a memorandum with comparable commitments, including raising awareness of the benefits of the arts in health and policy settings and offering training and support networks for arts and health practitioners. 25 Importantly, they also commit to investing in an arts and health coordinator post in each of the seven Welsh health boards, the local NHS organisations responsible for commissioning and delivering care in Wales. This memorandum is one of the most concrete commitments we found, both in terms of the intersectoral approach and the specific investment and action.
In the USA, the state of Rhode Island's Department of Health partnered with The Rhode Island State Council on the Arts to release a joint report and policy proposals in a State Arts and Health Strategy. The proposals include establishing a policy convening group, investing in research, and focusing on developing arts practice to support several key public health issues (opioid addiction, veteran mental health, and chronic conditions). 26 In England, a different example of crossgovernment work in this area is the UK's All-Party Parliamentary Group on Arts, Health and Wellbeing, which convenes government representatives with general responsibilities, identifies key policy areas (social determinants of health, environmental adversity, etc), then hears and collates evidence of the effect of the arts on those areas to inform policy recommendations. The group's 2017 Creative Health report 27 was an important moment in England, spurring on subsequent investment in arts and health practice and policy networks, a key recommendation of the report. Although not making as concrete commitments as Greece and Wales's memoranda of understanding, these US and English documents play an important role in working towards increased com mitment and investment in arts and health from policy makers and funders.

Local government policies
Local and city authorities contributed some interesting examples, many of which also indicated concrete policy commitments. One such policy is the Region Skåne's strategy for culture and health in Sweden, which recognises that "efforts within culture and health [are] an integral part of the work for equal health", 28 explicitly recognising the need for universal, appropriate access to arts and culture to support public health. This approach is promising, since arts and culture infrastructures are highly place-based and tackling complex public health issues such as health inequality often requires a localised approach, 29 since "place-based interventions can be effective at improving physical health, health behaviours and social determinants of health outcomes". 30 Notably, several of the documents detailing concrete local policy commitments come from Finland, reflecting the coordinated national effort to publish local cultural wellbeing plans at the same time. [31][32][33] Many of these plans directly reference and build on WHO's recommendations, identifying target groups (ie, families with young children, people in health and care insti tutions, and older people) and modes of using the arts for health (from general arts provision to cultural prescriptions from general practitioners), with detailed delivery plans. 33 The theme of multidisciplinary and multisectoral cooperation runs throughout all these plans, showing how local, national, and international policy movements can intersect to build momentum and increase effectiveness of policies in this area.

Intergovernmental (international) policy making
In addition to the previously mentioned WHO report and briefings, 1,2,4 there were some interesting contributions from other intergovernmental agencies. These agencies include the African Union, that, in their policy framework African Union Agenda 2063, established the theme for the year of 2021 as arts, culture, and heritage. 22,34 This approach highlights the role that the arts, culture, and heritage sector and its cultural workers play in promoting good health and wellness, and mitigating the social and mental health effects of COVID-19. 22,34 A Pacific Community press release from a convening of 15 Pacific island countries and territories also mentioned "strong support for the increased integration of Pacific arts and culture into government areas such as education and health and stressed the need for increased investment in culture both at national and regional level". 35 A new scoping review 36 on culture, wellbeing, and health interventions and their evidence com missioned as part of the Culture For Health project (an initiative cofunded by the European Commission, with partners all over Europe) also shows a commitment from countries across Europe to collaborate on relevant policy recommendations. The report builds on the WHO report, discussing how the arts can address new global challenges such as the COVID-19 pandemic and dynamic changes to work and the economy, as well as identifying avenues for future research and policy action.
These initiatives show the potential for cross-country collaboration in arts and health policy developments, with many of these alliances focusing on sharing best practice and considering joint recommendations to use in their own countries' public bodies. Although it ultimately remains up to individual countries to develop specific policies in this area, international initiatives and cooperation clearly helps to legitimise and encourage nations to value the inclusion of the arts in health policy and settings, and creates space for international partners to learn from each other. 36

Discussion and recommendations
There is a substantial amount of policy interest in arts and health internationally. Notably, the variety of policy domains and approaches reflect the many possible policy making areas that could support developments in arts and health. There are also many deep-rooted practical considerations policy makers must grapple with, from deciding which public health topics to focus on to ensuring equal and equitable provision of arts and cultural experiences to support public health, embedding arts and creativity in health settings, building the credibility of the arts among health professionals and the public, and supporting creative practitioners. 37 Acknowledging the complexities policy makers must navigate, our Health Policy shows that more could be done to support and strengthen policy work in this area. Arts and health policy making requires a more equal commitment from both sectors than we currently see, with health policies integrating an increased contribution from the arts, as well as arts bodies investing more in exploring health outcomes. The current evidence is that greatest volume of activity is coming from arts and culture policy makers and the number of health policy documents remains small; within our search, the number of documents from the health sector was rather low, just 13 (10%) of 130 published in 2017-22. This might partly be due to the search methods we used; for example, clinical guidelines were outside the scope of our search. However, it could also indicate that the relationship between public health and arts and culture is currently less likely to be accepted by health bodies than by arts bodies. Beyond the examples mentioned here, it is also still somewhat difficult to systematically identify which public health issues are receiving most interest, since most policies Health Policy and policy makers still tend to talk about the relationships between arts and health in relatively general terms. However, the few documents we did find provided focused and compelling ideas around implementing the arts to address specific public health issues.
It is important that policy makers continue articulating the arts' role in supporting public health, since the evidence shows that investment in the arts is linked to better public health outcomes 5,38-41 and governments need to be aware that any cuts to arts investment could probably have a negative effect on public health. This link is particularly pertinent if countries are looking to implement sustainable public health policies, as people need a range of high-quality accessible arts and culture participation opportunities, throughout all stages of their lives. Unfortunately, there is a clear social gradient in arts and cultural participation in multiple countries inter nationally, evident not just at the individual level but also at geographical levels. [42][43][44][45][46] Notably, individuals with mental and physical health needs, who could potentially benefit the most from arts engagement, can have lowest rates of engagement. 45 As a result, work to improve accessibility must come with a special focus on improving provision for people who currently have the least access to arts and culture, to avoid exacerbating health inequalities. 6 Also of note is the emerging area of local policy making, which recognises that cultural provision in local areas is one of the structural determinants of health and, as such, must be protected and receive investment.
The most promising areas for concrete policy commitments, such as social prescription and workforce development, were seen in those policies reflecting the intersectoral action between health and arts policy makers that WHO recommends. 5 This progressive approach is strong because it denotes a shared responsibility for public health across different sectors and helps public health leaders to realise that investment in the emotional and social wellbeing of citizens through the arts is also an investment in public health. 1 The cross-governmental, intersectoral examples of policy making are some of the most useful blueprints for how public bodies can work together in a focused and specific way, spanning traditional departmental divisions to develop evidence-based policy in this novel area. The hope is that more countries might adopt this cohesive approach, with governments identifying specific areas for collaboration between policy departments and better defining roles for public bodies. 47 Furthermore, international cooperation between policy makers, through organisations such as WHO, can also enable countries to share evidence, experience, and policy strategies and continue to build momentum in this area.
Finally, there is still a need to build stronger relationships between research and the development of new policies. Although policy makers are beginning to focus on some specific areas of public health for which there is a strong evidence base for applying the arts (mental health, dementia, ageing, pain, etc), more work is needed to operationalise other strong domains of evidence into policy, particularly for social determinants of health. The most promising policy examples highlighted here show a concerted effort to understand the evidence base, which helps policy makers take an informed approach that makes the most of the opportunities the arts can offer to public health. However, evidence-based policy making in arts and health has been criticised within academia as being rarely impartial and having an advocacy agenda, promoting only the positive effects of the arts. 48 Thus, it is important to ensure there are continued conversations between researchers, health and arts leaders, and policy makers regarding the kinds of evidence that underpin policy, ensuring accurate reporting and an understanding of different epi stemologies and remaining alert to emerging research and practice.

Conclusion
This Health Policy, and the research underlying it, has revealed a marked policy interest in the relationship between the arts and public health, with promising examples of policy development. The documents found in our mapping exercise show a broad range and scale, reflecting the complexity of the policy ecosystem, but also showing that more could be done by policy makers, particularly in public health. Since this area might appear to both arts and health policy makers to be outside their usual scope, finding mechanisms both within and across traditional areas of policy are necessary to support scaling up, and providing infrastructures that enable policies to be effectively implemented.
Future work is needed to explore the challenges, opportunities, and effect of implementing effective policy in this space. The clearest limitation of this analysis is that policy documents cannot necessarily give an accurate picture of the relationship between policy commitments and practice or investment in arts interventions actually taking place. A good policy environment does not necessarily lead to increased investment and innovation; conversely a country could have a thriving arts and health movement in practice without any real policy recognition. There might also be variance in how different countries view the role of the state in arts and health development; in some countries, public bodies might have a more active role in commissioning arts and health projects, whereas in others it might be led by a groundswell of grassroots arts and health collaborators with relatively little involve ment from policy makers. For example, of the 32 British documents, only four (13%) contained policy-setting commitments; most documents were recommendations or reports, and the non-governmental voice in the UK is particularly strong. By comparison, Finland and New Zealand had a higher number (and proportion) of policy-setting documents, with more coming from public bodies than non-governmental organisations.
It would also be interesting to investigate if and how clinical guidelines are recommending arts activities and therapies as treatments for specific conditions and, conversely, how art made about specific health conditions might be informing and influencing health policy decisions. In the terms defined here, it also seems on the surface that high-income countries have a more developed (or discoverable) public health policy environment than low-income countries for arts and health. However, the search methods, criteria, Western bias, definition of arts and health, and language of the research team might have played a part in this result. Further exploration on these variances would be very useful in establishing global trends in this area, as would more research to help understand whether the policies and strategies identified here are proving to be effective in improving population health.

Contributors
DF and KW conceived of the manuscript. DF, KW, RD, and PL conducted the literature search. RD and DF drafted the manuscript. All authors reviewed and edited the manuscript and approved the final manuscript for publication.

Declaration of interests
We declare no competing interests.

Search strategy and selection criteria
We searched grey literature to identify international policy documents that included a discussion on the contribution of the arts to health and wellbeing. The initial full searches were done between January and April, 2022, but further documents were added as they became available. We set no language or date restrictions and included policy briefs, policy-based white papers, health plans, government reports, and policy frameworks. We excluded non-policy documents such as published studies, theses, clinical guidelines (eg, National Institute for Health and Care Excellence guidelines), and training guides.
We searched databases and repositories (appendix pp [1][2][3][4][5] with the terms arts AND health OR culture (and variations of cultur*, such as cultural) OR well-being (and wellbeing, etc) OR create (and variations of create*, such as creative, creativity) OR heritage OR wellness OR performance (and variations of perform*, such as performing) OR singing OR painting OR dancing OR pottery OR crafts OR creative writing OR story-telling OR drama OR theatre OR acting OR magic OR digital art OR film OR photography.
See Online for appendix