A GUEST BLOG BY DR STEPHEN CLIFT
In this second guest blog by Stephen Clift, he questions the WHO scoping review of arts and health (Fancourt and Finn, 2019), particularly its headline: ‘Arts ‘crucial’ to reducing poor health and inequality’. Here, Stephen asks if the existing body of evidence really supports such ‘grand claims’.
Stephen Clift (BA, PhD, PFRSPH) is Professor Emeritus, Canterbury Christ Church University, and former Director of the Sidney De Haan Research Centre for Arts and Health. He is a Professorial Fellow of the Royal Society for Public Health (RSPH) and is also Visiting Professor in the International Centre for Community Music, York St John University. Stephen has worked in the field of health promotion and public health for over thirty years, and has made contributions to research, practice and training on HIV/AIDS prevention, sex education, international travel and health and the health promoting school in Europe. His interests relate to arts and heath and particularly the potential value of group singing for health and wellbeing. Stephen is one of the founding editors of the journal Arts & Health: An international journal for research, policy and practice. He was the founding Chair of the RSPH Special Interest Group for Arts, Health and Wellbeing, and a founding trustee of Arts Enterprise with a Social Purpose (AESOP). He is also co-editor with Professor Paul Camic of the Oxford Public Health Textbook on Creative Arts, Health and Wellbeing published in November 2015. Currently, he is working on developing a series of provocations in arts and health research. a special collection of critical papers on arts and health with Frontiers in Psychology, and a special issue of the International Journal for Community Music on the impacts of the COVID-19 pandemic.
THE NEED FOR ROBUST APPRAISAL OF RESEARCH IN ARTS AND HEALTH: MORE ON THE WHO (2019) REPORT, BY STEPHEN CLIFT
A press release on the University College London website (UCL, 2019) announces the WHO scoping review of arts and health (Fancourt and Finn, 2019) with the headline: ‘Arts ‘crucial’ to reducing poor health and inequality’ and it goes on to quote lead author Dr. Daisy Fancourt as saying that the report:
“… highlights that engagement with the arts can affect the social determinants of health, improving social cohesion and reducing social inequalities and inequities. Crucially, the arts can support the prevention of illness and promotion of good health.”
But are these grand claims for the arts in relation to health really supported by the existing body of evidence?
Recently, I have written a critical review of the WHO report (Clift, 2020). I welcome the scoping review for the recognition it represents from the World Health Organisation of the potential significance of the arts in relation to health. I also compliment the authors on the clarity and usefulness of the map of the field they provide. It is clear that the WHO report has received considerable attention (WHO, 2019a,b; Sandborg, 2019, Laitinen, 2020); it has led to a special issue of the WHO journal Public Health Panorama on arts and health (Fancourt, et al. 2020), and will form the basis for further practical, co-ordinated country-level work in the WHO European region (WHO, 2019c). However, I highlight several concerns about the evidence presented in the WHO report. This is based on a close examination of sources related to the contribution of music in addressing health inequalities and the contribution of dance in preventing falls in older people. What this revealed is an unfortunate lack of critical scrutiny of these sources, which in some cases signally fail to support the case made by the review, or more worryingly still, involve a misrepresentation of the activities or interventions evaluated in the research.
The approach I adopted in my review deserves to be repeated for each of the topics listed under ‘prevention and promotion’ (19 specific topics) and ‘management and treatment’ (20 specific topics) in Figure 2 (p.8) in the WHO report. I focused on specific areas within just two of the 39 topic areas covered in the scoping review.
Some of the specific topic areas do overlap. For example, research studies covered in the sections on ‘social cohesion’, and ‘engagement with hard-to-reach groups’ have in common work with disadvantaged, marginalised or traumatised people – and a concern to address questions of social inequalities, lack of access to health services, and inter-group relations and conflicts. In all these respects, arts may be mobilised in the interests of addressing social injustices and social problems, as well as health challenges. The population groups referred to are: homeless people, sex workers, ex-offenders, prisoners, traumatised veterans, children in care, refugees and asylum seekers, LGBTQ people, groups in conflict etc. Such initiatives therefore, could be seen as constituting a more ‘radical’ approach to arts, health and wellbeing – with the arts as ‘an agent of social change’ or a ‘provocateur’ – rather than being an instrument of ‘intervention’ within a medical model framework (Phillips, 2019; Broderick, 2011).
An example drawn from the WHO (2019) report on arts and health
To test, for a third time, the critical approach I adopted in my review (Clift, 2020), I want to look at the claim made by Fancourt and Finn (2019) that music can have a role in addressing prejudice and related issues:
‘Songs promoting social inclusion can reduce prejudice, discrimination and aggression between groups and promote cultural understanding.’ (p.10)
A study by Greitemeyer and Schwab (2014) is cited to support this claim and here is the abstract as it appears in the journal Aggressive Behavior:
Three experiments are reported, but I restrict my comments to the first of these, as they serve to highlight the problems which beset the whole study. The set up in experiment one was simple. Students arrived at the laboratory and were randomised into one of two groups. In the ‘intervention’ group they were asked to listen to songs considered to have ‘pro-integration’ lyrics; in the ‘control’ group they were played ‘neutral’ songs. Following the ‘music exposure’, they were asked to complete a questionnaire to measure their attitudes towards Turkish immigrants.
The main problems with this study
- Greitemeyer and Schwab’s investigations are of questionable relevance to a review of research on arts and health. Prejudice is a social evil (JRT, 2008), and can certainly impact on the health and wellbeing of those affected by it, even leading to death, but in what sense is prejudice per se a health issue?
- The study is ‘WEIRD’ (Rad et al. (2018) as it involves university students in Austria who live in a society which is predominantly ‘White, Educated, Industrialised, Rich and Democratic.’ Such characteristics impose limitations on the study which severely compromise the generalisability of any findings.
- The study took place in a laboratory setting, with isolated individuals were asked to consider members of a target population (Turkish immigrants) they had no contact with during the experiment. Nor is information given on the degree to which participants had any contact with this group outside the setting. As a laboratory study, it is subject to all the problems of social psychology experiments highlighted by Rom Harré during the 1970s ‘crisis of social psychology’ (Moghaddam and Harré, 1992; Harré, 2001).
- The participants were kept in the dark about the purpose of the study. It is very likely, however, that the demand characteristics of the study, and the natural desire of intelligent young people to make some sense of what they were engaged in, would have led them to formulate their own ideas of the study objectives, and then to decide to act either in line with, or in opposition to, such assumptions.
- The title of this study – ‘employing music exposure to reduce prejudice and discrimination’ is very telling, as it indicates that the active agents in the experimental scenarios were the researchers and not the participants. The experimenters ‘exposed’ ‘subjects’ to their choice of music – rather than considering individuals as active agents making their own choices in how they engage with music and how they use it. This very setup may well have induced ‘reactance’ on the part of participants, leading them to resist the material they were ‘exposed’ to.
- No data was gathered prior to playing the songs, so there was no assessment of change in prejudicial attitudes. The design was randomisation, exposure to songs, assessment of prejudice. It is fair, no doubt, to assume that the participants in the intervention and control groups were equivalent with respect to their attitudes, on average, at the start of the experiment, but still there are no data presented on ‘reductions’ as implied in the title.
- No details are given by the authors of the length of the songs, nor the length of the whole of the experimental procedure. It is likely, however, that the intervention under test was no more than ten minutes in length. The official video of one of the songs, used in the first study, Willkommen in Deutschland by the band Die Toten Hosen (2015) lasts just over four minutes. For each individual, therefore, the experimental procedure from arrival to departure, may have taken from half an hour to 45 minutes at most. Why would anyone imagine that a ten-minute intervention through music could possibly shift prejudicial attitudes?
- Finally, and coming now to the crux of the matter in this critique, we need to ask whether and to what degree, the students involved in the study were prejudiced towards Turkish people? In fact, the researchers’ own data indicates that, on average, the participants in the study were at the ‘non-prejudiced’ to ‘neutral’ positions on the scales they used. In other words, neither the intervention nor the control group expressing prejudicial attitudes towards Turkish immigrants.
I think the only sensible conclusion to draw from this detailed analysis is that the claim made by Fancourt and Finn (2019) that ‘songs promoting social inclusion can reduce prejudice’ is simply not supported by this experiment. The best that can be said is that German and Austrian students generally hold neutral to positive attitudes towards Turkish immigrants, and that being ‘exposed’ to pro-integration songs encourages them to express their positive views a little more strongly.
But, such a detailed analysis of this study is not really required to question the assertion that music can challenge prejudice. We just need to use some common sense and think through possible and realistic empirical tests of this hypothesis. Here is one, as an example: what role could music play in challenging the anti-gay prejudice among the men pictured below, taking part in a recent demonstration in Poland (Dehnel, 2019)? Perhaps we could play them Sing if You’re Glad to be Gay by Tom Robinson or Lady Gaga’s Born This Way?
That’s not an experiment I would like to try!
- To the authors of the WHO Scoping Review: Do you accept the critique of your review that I have mounted (Clift, 2020)? Do you accept that the paper scrutinised here is not an example of ‘arts and health’ research and should not have been included in your review? Do you accept that the study cited fails to adequately address the potential role of music in confronting prejudice?
- To the commissioners of the Scoping Review at WHO: Why was a ‘scoping review’ initiated which did not involve critical scrutiny of the sources identified and summarised? Were you aware of the potential risks to the credibility of the review given the lack of critical perspective?
- To the independent reviewers of the WHO report: Did you identify the concerns I have raised in my review (Clift, 2020)? Do you accept that the criticisms I made in this review, and continued here are valid?
- To all researchers in the field of arts and health: What have been your responses to the WHO report? Do you accept my critique as valid? Will you look more closely at the evidence cited in the WHO report and come to your own independent assessment of what the evidence does and does not show?
Broderick, S. (2010) Arts practices in unreasonable doubt? Reflections on understandings of arts practices in healthcare contexts, Arts & Health, 3, 2, 95-109. https://www.tandfonline.com/doi/full/10.1080/17533015.2010.551716
Clift, S. (2020) Review: Fancourt, D. and Finn, S. (2019). What is the evidence on the role of the arts in improving health and well-being? A scoping review. Nordic Journal of Arts, Culture and Health, 2, 1, 77-83. https://www.idunn.no/nordic_journal_of_arts_culture_and_health
Dehnel, J. (2019) The struggle for LGBT equality: Pride meets prejudice in Poland, The Guardian, Sunday 28 July: https://www.theguardian.com/world/2019/jul/28/lgbt-gay-rights-poland-first-pride-march-bialystok-rage-violence
Die Toten Hosen (2015) Willkommen in Deutschland official video: https://www.youtube.com/watch?v=8eU5HPgCAyo
Fancourt, D., Scheel, A. and Fitje, N. (2020) Arts and health: building on the evidence to create sustainable policies and practices, Public Health Panorama, 6, 1, 8-10. https://apps.who.int/iris/bitstream/handle/10665/331554/php-6-1-8-10-eng.pdf
Greitemeyer, T. and Schwab, A. (2014) Employing music exposure to address prejudice and discrimination, Aggressive Behavior, 40, 542-551. https://onlinelibrary.wiley.com/doi/abs/10.1002/ab.21531
Harré, R. (2001) Towards a methodological critique, In Bunn, G.C., Lovie, A.D. and Richards, G.D. (Eds.) Psychology in British: Historical Essays and Personal Reflections. London: British Psychological Society.
JRT (2008) What are Today’s Social Evils? London: Joseph Rowntree Trust. https://www.jrf.org.uk/report/what-are-today%E2%80%99s-social-evils
Laitinen, L. (2020) A summary of the launch of the WHO report on the evidence base for arts and health, Helsinki, Finland, 11 November 2019, Nordic Journal of Arts, Culture and Health, 2, 1, 74-76. https://www.idunn.no/file/pdf/67220408/a_summary_of_the_launch_of_the_who_report_on_the_evidence_b.pdf
Moghaddam, F.H. and Harré, R. (1992) Rethinking the laboratory experiment, American Behavioral Scientist, 36, 1, 22-38. https://journals.sagepub.com/doi/pdf/10.1177/0002764292036001004
Phillips, K.J. (2019) A constructive-critical response to Creative Health: The Arts for Health and Wellbeing (July 2017) by the All–Party Parliamentary Group on Arts, Health and Wellbeing, International Journal of Art Therapy, 24, 1, 21-29. https://www.tandfonline.com/doi/abs/10.1080/17454832.2018.1491612
Rad, M.S., Martinganoa, A.J. and Gingesa, J. (2018) Toward a psychology of Homo sapiens: Making psychological science more representative of the human population, Proceedings of the National Academy of Sciences of the United States of America, 115, 45, 11401–11405. https://www.pnas.org/content/pnas/115/45/11401.full.pdf
Sandborg, B.M. (2019) Summary of an Arts and Health political symposium at the WHO Regional Office for Europe in Copenhagen, Nordic Journal of Arts, Culture and Health, 1, 1, 64-67. https://www.idunn.no/file/pdf/67158615/summary_of_an_arts_and_health_political_symposium_at_the_wh.pdf
UCL (2019) Press release on the launch of the WHO report on arts and health: https://www.ucl.ac.uk/news/2019/nov/arts-crucial-reducing-poor-health-and-inequality
WHO (2019a) Political Symposium on the Arts and Health in the Nordic region: State of the Evidence. Copenhagen: World Health Organization Regional Office for Europe. https://www.euro.who.int/__data/assets/pdf_file/0007/410200/20190322-Note-for-the-Record-Political-symposium_EDITED_FINAL.pdf
WHO (2019b) web page – Launch of first WHO report on the evidence base for arts and health interventions. See announcement for a video of the event. https://www.euro.who.int/en/media-centre/events/events/2019/11/launch-of-first-who-report-on-the-evidence-base-for-arts-and-health-interventions
WHO (2019c) Inter-sectoral Action: The Arts, Health and Well-being, Copenhagen: World Health Organization Regional Office for Europe. https://www.euro.who.int/__data/assets/pdf_file/0015/413016/Intersectoral-action-between-the-arts-and-health-v2.pdf