Creative approaches to wellbeing

# Creative approaches to wellbeing

# The pandemic and beyond

*Edited by*

Karen Gray and Victoria Tischler

Manchester University Press

Copyright © Manchester University Press 2024

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This work was supported by the Arts and Humanities Research Council.

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# **Contents**

# **Series preface: The pandemic and beyond**

*Pascale Aebischer, Fred Cooper, Des Fitzgerald, Karen Gray, Caroline Redhead, Melanie Smallman and Victoria Tischler*

In the first days of 2020, the coronavirus (COVID-19) pandemic began to spread across the globe. It prompted a concerted international research effort which set out to understand not just the workings of the virus, but the ways that we responded to, lived and died with it. This led to a significant body of work being produced at speed, in which arts and humanities played a crucial role. In the UK, *The Pandemic and Beyond: The Arts and Humanities Contribution to Covid Research and Recovery* was established by the Arts and Humanities Research Council (AHRC) early in 2021 to coordinate this research effort.1 Over the span of two years, *The Pandemic and Beyond* grew into a virtual hub that enabled over seventy COVID-19 research teams funded by the AHRC to meet, exchange ideas and work together to ensure that their research would make a difference on the ground.2

This series is a legacy of this collaboration and bears witness to an extraordinary period, in which arts and humanities research became an integral part of the UK's research response to an emergency, leading to tangible changes in the role, purpose and methods of the arts and humanities, and laying important human foundations for recovery. It is divided into four volumes, each corresponding to four research clusters co-produced during the coordination process. A first group focused on working with professionals and policymakers in the creative industries to investigate the existential struggles of creative workers and organisations impacted by the ban on live in-person performance, and to devise new ways of connecting people through live arts while trying to build more inclusive and sustainable industry structures. A second set of research teams connected arts and creative practitioners with cultural and community organisations, as well as care settings, with whom they worked to alleviate the social and mental health impacts of public health restrictions. These projects drew on arts- and nature-based activities to forge pathways for improving mental and physical health for individuals and communities. A third cluster examined the informational and epistemic experience of a pandemic that was a whirlwind of often deeply confusing and contested data. Artists, designers and linguists explored design solutions and devised how public health messages could be formulated so that they would reach the communities most severely affected by the spread of the virus. A final group of researchers concentrated on scrutinising legislation and guidance issued in haste, and grappled with thorny questions of rights and responsibilities, seeking to underpin developing scientific understanding with values-based frameworks that offered a more nuanced approach to balancing risks and benefits.

The richness of this research portfolio stems not only from its breadth but also from the ingenuity of the teams involved, members of which rapidly applied their expertise and creativity to a problem few had foreseen, working with communities whose vulnerabilities and prior marginalisation had been exacerbated disproportionately by the pandemic (Ryan, 2022: 198). What was initially perceived principally as a public health crisis was impacting on the population in myriad ways that branched well beyond physical health; encompassing mental health, but also social cohesion, crossgenerational justice, trust in governance, and economic distress. Looking back over the first few years of the pandemic, the authors of a report for the Higher Education Policy Institute (HEPI) conclude that the 'pandemic was a watershed moment for the Humanities because the importance of the variety and quality of individual human experience rose to the surface in our collective re-evaluation of priorities' (Thain et al., 2023: 13). Arts and humanities research concentrated on the human impacts of the crises that intersected in this moment, working to resolve them, mitigate harms and examine some of the most fundamental human questions across macro and micro crisis contexts, from the national and international to the local and hyper-local. As these volumes show, this work was characterised by cross-fertilisation between disciplines and an emphasis on partnership working. It featured collaboration; between academic and public institutions, but also, notably, with community groups and ix

frontline organisations, such as those representing health and social care. Collaborations also extended to industry, and regional, sectoral and national policymakers. We know from analysis of surveys of those involved in *Pandemic and Beyond* research that for many this involved drawing on existing relationships, which deepened and strengthened as the fluctuations of the pandemic necessitated constant dialogue and increased accountability on all sides (Aebischer et al., 2022: 26–29). For others, the pandemic resulted in potentially fruitful new connections, and the promise of further research, work that continues to be relevant and have impacts on policy and practice.

All of this required new ways of working, and the ability to reconcile the theoretically conceptualised and deliberative methodologies associated with humanities research, which often take years to mature into publication, with quick and direct application, which often left little scope for fine calibration and reflective writing. The temporal demand for research outputs, and their new or altered audiences, exerted intense and immediate demands on researchers. Policymakers expressed an appetite for actionable findings to support decision-making, and frontline workers, while exhausted and short of time and resources, were desperate for support; research, in consequence, was predominantly pragmatic and focused on solutions. This meant a sometimes uneasy pivot to new ways of working and new modalities and timescales for doing and sharing work. Researchers did not always find it easy to reach those for whom their findings might have been most relevant, but many published policy briefings or held private meetings to share their insights and recommendations with potential user groups. Some projects embedded researchers within policy or service delivery organisations, narrowing the gap between research and practice still further. Work was often cyclical or iterative, with results shared earlier and more frequently, for example through pre-prints or the release of preliminary findings; if not a direct prerequisite for funding, the word 'rapid' in the UK Research and Innovation (UKRI) COVID-19 call certainly implied that researchers had to reconsider how and when in the life cycle of a project potentially significant knowledge was shared. There was a flowering of online engagement and dissemination as research was translated into a rich variety of deeply practical resources. These included frameworks for action, advice for public health messaging, interventions that responded to real-time problems such as the isolation of residents and staff in care homes or the design of personal protective equipment (PPE), and coproducing guidance for employers of artists performing in digital live shows from their homes.

As *Pandemic and Beyond* researchers explored the dynamic nature of individual and collective experiences of the pandemic, they also demonstrated a particular sensitivity to those for whom its effects have been felt unequally, and for whom suffering has been most profound. Readers will find this concern consistently exemplified throughout these volumes. Indeed, our brief to the authors in this series invited them to create a space where those voices could be part of the conversation. Such work was by no means easy to do. It was ethically complex, requiring heightened reflexivity and cultural competency. It was complicated by the requirements for social distancing and the need to prioritise the safety and wellbeing of both participants and researchers. As one research leader put it: 'you cannot build diversity into a project from scratch under these conditions' (Aebischer et al., 2022: 27).

Carrying out research during a pandemic necessitated innovation and adaptation at all levels. This is reflected in the research methods adopted: mixed, interdisciplinary and often participatory or arts-based, with projects bringing immediate benefits to participants and communities even as policymakers were targeted with written work. In many of the projects, more reflective and long-form modes of writing were either not part of the research design or postponed to a later date, to allow for retrospective analysis and evaluation. Meanwhile, the nascent field of arts and health was propelled to the foreground by the pandemic. A growing evidence base demonstrates the importance of multiple artistic modalities (including music, visual art, poetry and drama) in supporting health and wellbeing for a range of physical and mental health conditions. In these contexts, research by *Pandemic and Beyond* teams was able to highlight the vital role of artistic and creative practice through exposing the dangerousness of working conditions for frontline staff, including for the predominantly female workforce in social care settings. Arts-based projects were able to offer practical tools and emotional support for care workers, while helping to alleviate the isolation that many felt when confined to their homes xi

by re-creating artistic activities that were delivered via post, online or outdoors. With remarkable speed, researchers working with arts and cultural providers pivoted to developing suitable resources and freely shared their work with collaborators and user groups.

At times, however, things moved frustratingly slowly, while structures around the research (including university recruitment, facilities, ethics and funding) creaked and failed to keep up; at other times, the most fundamental changes and compromises to research design had to be made at speed, to respond to events as they happened. When this research was at its best, there were refreshingly democratic opportunities for everyone involved to learn and apply new skills and take on new responsibilities. At their worst, however, the conditions in which research was conducted during the pandemic replicated existing structural problems in the academy. A great deal of the work was done by early career researchers on short-term contracts, for example, and researchers found themselves giving more than their contracted hours to this work, alongside their commitments to delivering newly remote or hybrid teaching, often while caring for home-schooled children or dealing with the impacts of the pandemic on their own networks and home environments. While it was often deeply rewarding, many researchers, like others in the population generally, found the lack of a distinction between home, work and the stresses of pandemic life difficult to negotiate. Remote working proved methodologically, physically and mentally challenging. However, as these chapters demonstrate so clearly, it led to the rapid creation and deployment of new tools and technologies for data collection, analysis and collaboration. These, in turn, are exerting pressure on funders and policymakers in UK Higher Education to adapt their frameworks to recognise the value and complexity of this type of crisis- and solutions-oriented collaborative response in arts and humanities research.

The work presented in this series as a distinctive and coherent portfolio is, of course, just part of a much wider programme of research to mitigate the effects of the pandemic and to address the COVID-19 emergency that was funded through UKRI.3 While the projects within the *Pandemic and Beyond* portfolio were all designed, in line with the parameters of the original rapid-response funding call, to take a largely UK focus, a range of other projects and funding calls cast their gaze further afield. For some existing projects with an international focus, this 'created new opportunities for exploration of existing topics' that were exacerbated by the pandemic (Pirgova-Morgan, 2022: 27). Other schemes which are not represented in these volumes, for instance the UKRI Global Research Challenges/Newton Fund, brought together researchers in the UK and in low- and middle-income countries. More than forty such collaborative projects sought to gain insights and provide support during the pandemic, including projects aiming to improve engagement with COVID-19 public health messages to develop online psychological support through the arts in Rwanda; and to find ways of engaging vulnerable communities in Brazil on the consequences of the pandemic. This range of international projects is likely to offer an opportunity for further reflection, comparisons, dialogue and lessons in the future.

At the same time, we should not forget that despite the COVID-19 pandemic being, by definition, a global phenomenon, it has also been markedly culturally specific, local and hyper-local. Even in purely scientific terms, the identity of the virus itself has not been a global constant. Different strains and variants have emerged in different geographies and populations, and symptoms and morbidities have varied from country to country, creating very different patterns of disease across the world. Similarly, our responses to the pandemic and our standards of evidence and certainty – alongside modes of reasoning, ways of knowing and understanding – vary across cultural contexts, as we encounter different policymaking arrangements and civic communities. This is clear from the comparative work of the 'Lex Atlas' research in the *Pandemic and Beyond* portfolio, whose researchers examined dozens of countries' legal responses to the pandemic (King and Ferraz, 2021–23). Lessons learned in one country do not, therefore, translate cleanly to others.

Even within the UK, the response to COVID-19 was not uniformly governed or experienced. Nor did the disease spread evenly across the country. Time and time again, low-income households and communities, as well as groups with pre-existing vulnerabilities, felt the worst effects of both the disease and the measures put in place to protect the population. This pandemic was perhaps also one of the most challenging instances in which the arrangements for devolved administrations in Scotland, Wales and Northern Ireland, and the powers of the Westminster Government to oversee or xiii

coordinate national responses, were put to the test, prompting comparative analysis of the different modes and mechanisms of parliamentary review across the UK. This was complemented by scrutiny of data-driven approaches to decision-making and research that probed ethical and human rights issues. A deep delve into the situation in the UK provides us with valuable insight into the state of the nation – as well as our collective experience of the COVID-19 pandemic – in the early twenty-first century.

While arts and humanities research on COVID-19 in the UK is ongoing, and many are now engaged in the more considered process of retrospective analysis and critique, this series, produced at the endpoint of the rapid-response funding period, does represent a significant milestone. As such, it offers an opportunity to reflect on the multiple temporalities and intersectional crises that have characterised the first two years of the pandemic, along with the wider epistemic structures and infrastructures at stake in the delivery of this research portfolio. While COVID-19 had a fairly temporally precise beginning in the final days of 2019, at least as a distinct viral emergency, and was formalised as a global emergency with the World Health Organization's (WHO) declaration of a pandemic on 11 March 2020, it can also be understood as, at least in part, the product of a deeper crisis in terms of anthropogenic climate change and how we interact with the non-human (Gupta et al., 2021). COVID-19 has been a profoundly transformative, rupturing crisis, with over two million dead in Europe alone (WHO, 2022b). Worldwide, anxiety and depression increased by 25 per cent (WHO, 2022a), and access to professional services was challenging; over 100 million lost their jobs (WEF, 2021), and while some accessed furlough and insurance payments, freelancers and those in the gig economy were often ineligible (Fowler, 2020). COVID-19 identified and shone a light on 'key workers', who were defined as those whose work was deemed essential during the pandemic and who often turned out to be poorly paid, socially marginalised and previously 'invisible'. These workers included healthcare professionals as well as bus drivers, food retailers, refuse collectors and care home staff. While healthcare staff were routinely celebrated in the UK, most notably through the 'clap for our carers' phenomenon, this was not accompanied by material changes in stagnant pay or harmful working conditions, and others – such as domiciliary workers in care homes with older people – remained largely invisible.

As the virus began to transform the ways that we live and die, it pulled a series of overlapping crises and temporalities into tension, muddying any clean imagining of a shared pandemic trajectory. When the UK government announced extensive restrictions to movement and social life in the spring of 2020, disability scholars and activists noted that many disabled people had effectively been in 'lockdown' for years (Shakespeare et al., 2021). Likewise, COVID-19 intersected with deep-seated inequalities in race and health, landing disproportionately among people who had their ability to resist the virus eroded by generations of structural racism, and who were knowingly figured as disposable and exposed to greater risk than their white counterparts (Qureshi et al., 2022). Whole groups of people, including frail older people and those with underlying health conditions, were disproportionately negatively impacted. Other long and slow disasters and matters of justice (such as poverty, burnout in healthcare workers, or our inability to sufficiently care for the old) further altered the temporal bounds of the pandemic and fragmented our experiences of pandemic time (Baraitser and Salisbury, 2020). For doctors, nurses, cleaners and porters in overstretched hospital departments, time sped up (often in catastrophic ways); for those who were shielding or placed on furlough, the opposite was frequently true.

Among this profound and intractable messiness, attempts to impose a temporal order on the pandemic have always done a particular kind of political work. Across the conception and execution of these four volumes, rates of infection, illness and death have been in considerable flux; the state of the pandemic at the date of publication is impossible to know as we write this introduction in early 2023. We do know, however, that pandemics rarely – if ever – cleanly end (Greene and Vargha, 2020). The overlapping contexts and crises detailed above also frame wildly divergent apprehensions and realities of risk. Any intimation that we are becoming 'post-pandemic' must be met with a question the arts and humanities are uniquely poised to ask: for whom? The bereaved, still shielding, sufferers from 'long COVID', carers and healthcare professionals, after all, will continue to live pandemic time in different ways (Callard and Perego, 2021). One role of the arts and humanities amid this crisis xv

is (or has been) to make and preserve *meaning* out of what has been experienced. In each of these volumes, 'rapid-response' arts and humanities work has had to navigate these slippery experiences of time. If many of our projects responded to the pandemic first in ways that were 'quick and dirty', acting to comprehend, forestall, or inform the present, the research assembled here is more inclined to the future, seeking to take a tentative and reflective step back from the immediacy of the pandemic while acknowledging its ongoing nature.

The format of the crisis-driven rapid-response call is itself an unusual approach to the organisation of arts and humanities research, with its distinctively longitudinal and reflective modes of relating to social problems. In one sense, this speedy deployment of the arts and humanities at a moment of crisis is welcome: it positions researchers within these disciplines as having skills that are critical for intervening in moments of emergency and lifts humanities research out of the epistemic position of providing commentary or representational analysis after the event. It thus refuses the disingenuous political position that cultural, literary, historical and theory-informed analysis is incompatible with the crisis resolution. Indeed, as this is a moment in which arts and humanities research is *itself* widely understood to be in crisis (see Thain et al., 2023), this instrumentalisation presents important new possibilities, and perhaps one or two pitfalls, for scholars within these disciplines. The assumption – implicit in the funding announcement – that research in the arts and humanities is already collaborative, engaged, pragmatic, problem-oriented, public-facing and interdisciplinary, an image which many in the humanities research community have been promoting for some years, often in the face of opposition from colleagues, is itself worthy of note.

This also follows a long-standing trend in which humanities research, whose structures have predominantly been based (somewhat stereotypically) on the model of a lone scholar, working diligently on their idiosyncratic topic over a period of years, is remade to resemble a more scientific model. Such a 'scientific model' notably involves the organisation of a project into research teams and work packages, the breaking down of disciplinary boundaries that are not methodologically salient, larger amounts of money being awarded to smaller numbers of research teams, the need to clearly articulate the public impact of research, and responsiveness to government and industry priorities. This trend has been clearly accelerated by the reorganisation of humanities research infrastructures during the COVID-19 pandemic, which, as we noted above, led to a much greater degree of collaboration, with several authors working remotely to write together, crossing institutional, geographical, disciplinary and hierarchical boundaries. The epistemic effects of such reorganisation have been real – and mixed. The organisation of research, after all, plays a large role in governing not just the type of writing possible in such circumstances, but also what research can and cannot be done. While the funding that framed the *Pandemic and Beyond* portfolio opened up many new possibilities for humanities researchers, it simultaneously foreclosed others. Scholars without a desire to work in teams, whose research did not need significant money or have clearly defined short- to medium-term impacts, will have struggled to contribute; a significant loss that mostly remains invisible. This portfolio showcases many new opportunities, but it also hides the opportunity costs – not only for humanities work directly on COVID-19, but for humanities research generally, as already scarce resources were poured into immediate responses to a single public health crisis.

In the context of a UK government research funding strategy which, as the March 2023 HEPI report notes, 'appears to downplay the position of the Arts and Humanities in the UK's ambition to become a "science superpower"' (Thain et al., 2023: 19), there is a wider political dimension to this, too. The COVID-19 crisis also coincided with a series of crises around Brexit, one of the most prominent of which concerned the possibility of the UK's participation in (or exclusion from) the EU's Horizon research programme. This created a context in which research was wielded openly as a token of national competitiveness, and international collaboration was reframed as a luxury that could be removed at a government's whim. While the UK focus of the *Pandemic and Beyond* research shielded this portfolio from some of these pressures, we nevertheless continuously faced the need to demonstrate, in a political climate ill-disposed to critical humanities thinking, the relevance, success, impact or transformational potential of this body of research. Against this backdrop, it was often tempting to frame our work xvii

to make it align with (party) political slogans such as 'build back better' or 'levelling up' to demonstrate a willingness to engage with political priorities. The need to establish such 'synergies' is now a common and perhaps unavoidable feature of research coordination and curation efforts such as that of *Pandemic and Beyond*. Indeed, the research we share through these volumes should also be understood in the context of a wider, global attack on the humanities, whether departmental closures in the United Kingdom, the driver for teaching efficiencies in Denmark, or legislative attacks in countries such as Hungary and the United States. The quick pivot to rapid-response work on COVID-19 is both an affirmative rebuttal to such attacks (our work is indeed both important and useful) *and* a frank recognition of how successful they have been (our work is only viable to the extent that we can successfully position it as both important and useful). Our work, then, while bearing witness to the importance, usefulness and practical applicability of arts and humanities research in crisis contexts, also situates itself within broader national and international debates about the role arts and humanities play in fostering and sustaining the creative and open-ended critical thinking that underpins democratic political structures.

# **The** *Pandemic and Beyond* **series**

The aim of this series is to preserve the breadth of the approaches taken by *Pandemic and Beyond* researchers in addressing the crisis, showcasing a form of arts and humanities research that has learned how to respond to, and mitigate, COVID-19 as it unfolded, and that has constantly adapted its methods and research questions to ongoing developments and the needs of research participants. Reflecting the variety of the *Pandemic and Beyond* research portfolio, the chapters we have selected range from in-depth reflection on schools of thought and social and governance structures that have influenced approaches to the pandemic to those that are much more 'hands-on'. These latter chapters address subjects sometimes sidelined in conventional academic writing, as their focus on working structures, industrial practices and lived experience does not always lend itself easily to conceptual debates and theorisation. Written from the retrospective vantage point of late 2022 and the first months of 2023, these chapters offer a rare insight into the findings and often invisible facets of research projects whose primary focus was rapid on-the-ground impact, knowledge exchange, and direct engagement with communities, organisations and decision-makers. The chapters we collect not only offer reflection on what the research teams achieved, but also on what could be learned from their experiences to guide future responses to ongoing, accelerating and emerging crises, whether in relation to climate, migration, violent conflict, the threat of vaccine-resistant coronavirus variants, or other pathogens that could develop into new pandemics. The result is a series which models how, in responding to a crisis, the creativity, cultural sensitivity, community-reach and knowledge base of arts and humanities researchers can be one of the best tools to understand a novel virus in all its dimensions, steer policy and alleviate suffering on the ground.

In our volume *Adaptation and Resilience in the Performing Arts*, we explore how live performing arts in the UK innovated during public health restrictions to everyday life to overcome the obstacles to co-presence and performance in shared spaces that were a sideeffect of pandemic mitigation measures. The volume explores the financial hardship and mental health impacts experienced by industry professionals as governmental discourses regarding the 'viability' of arts careers, alongside the difficulties of connecting with networks and accessing arts opportunities, put a particular strain on creative workers and freelancers in the UK at a time when some Latin American countries were leading the way in valuing and supporting the arts. Against this backdrop of existential struggle for creative workers, this volume celebrates the ingenuity and creativity of artists and researchers who applied themselves to finding both digital and analogue solutions to the problem of co-presence, and who, in so doing, broadened the access of previously marginalised communities to live performing arts. It highlights projects that explored how motion-capture and green screen technologies can enable performers to come together despite geographical distance and interact in a shared virtual space to create new work, and how such digital work affects their art, wellbeing and ability to reach wider audiences. It also champions the value of local initiatives in outdoor spaces and suggests avenues for artists and local governments to xix

reimagine towns and cities as performance venues in which diverse communities can gather to celebrate their location and ability to communally enjoy art amid a pandemic.

The mobilisation of existing natural, community and cultural assets and resources to support individual and community wellbeing – conducted at speed and often using novel modes of delivery – was a notable feature of pandemic responses across the UK. Our volume *Creative Approaches to Wellbeing* presents detailed examples of research looking at how these kinds of activities sought to address issues such as the challenges of isolation, to support health and care workers, or to create spaces that could enable coping, recovery or renewal. Common to the chapters here are reflections on what it means and what tools and systems might be needed if we are to develop resilience during and after such crises in future, alongside examination of ideas of 'vulnerability'. Authors bring to these discussions a particular focus on the experiences of those most marginalised during the pandemic because of mental or physical ill-health, age, or due to deep-seated structural and systemic inequalities. Individual contributions include an interrogation of the idea of 'togetherness' itself; an invitation to consider the benefits of 'walking creatively', a study of the work of small organisations in promoting health through interaction with urban nature; and investigations of the contributions of the cultural, museum and literary heritage sectors to wellbeing. Looking forward, authors invite us to consider how adaptations to ways of working for individuals, within organisations, and even at the level of a whole city region, could lead to changes in provision and lessons for practice.

*Knowing COVID-19* looks at how different kinds of knowledge and meaning have been created and communicated, and the repercussions this has had – and continues to have – for how COVID-19 is managed, experienced, understood and remembered. Knowledge-making, it suggests, took various forms, and these are reflected in the diversity of chapters this volume curates. In the first instance, it demonstrates a rich humanities tradition of constructive critique, as 'official' communications around 'staying home', 'keeping distance', safety on buses, lateral flow testing, and vaccine hesitancy are tested and interrogated. Through this collective work, we see one of the clear, indisputable values of the humanities; their attentiveness to the human, and the clarifying or reflective power this might have had with greater embeddedness in policy and information design. In the second instance – and frequently both are accomplished in the same short chapter – this volume collects a series of interventions which set out specifically to create and sustain meaning, particularly when dominant cultural narratives over the pandemic rely on those meanings slipping away from political or popular memory. Thus, we have rich and detailed explorations of the experiences of museum workers, people told to 'stay home', older victims of gender-based violence, people with deafblindness, and racialised nurses working in the NHS; as well as extensive reflection on what it was like to make the projects which formalised this knowledge work. Taken as a whole, this volume critiques and redefines pandemic epistemologies, assembling a partial blueprint for making future crises legible.

Finally, *Governance, Democracy and Ethics in Crisis-Decision-Making* explores what it means to be in a situation in which rational or epistemic framings of the COVID-19 pandemic, with a focus on data and scientific ways of knowing the world, rub up against more entangled accounts. In these accounts, humans, the virus and governance arrangements coexist as a broader, relational whole. Human connections, personal fulfilment and social groupings are inextricably intertwined with matters (and meanings) of governance, ethics and authority, the rule of law, the economy and, crucially, public health. Looking at issues ranging from the authority of the WHO and the power of data during an emergency, to the role of public engagement as a source of policy evidence, we reflect on what it means to govern *ethically* in a pandemic, and whether the expected standards and norms of public life, evidence and decision-making should be different in times of crisis. We also reflect on how the long tail of the pandemic seems impossible to disentangle from a reduced trust in power and authority, creating an urgent need for ethics to move beyond normative assertions of the law and regulations. Our authors provide some suggestions as to how these things might be balanced more ethically and effectively in the future.

In 2020 and 2021, when televised government briefings on COVID-19 remained commonplace, ministers insisted time and again that they were 'following the science' (Colman et al., 2021). Even when critics called the accuracy of this rhetorical device into xi

question, they rarely troubled the governing logic that, were we only willing to follow it, scientific and medical evidence offered an unclouded route map through the pandemic. However, '[c]oping with the pandemic was (for the lucky majority who were not severely ill) not so much a medical crisis as an existential one' (Thain et al., 2023: 13); indeed, given the complex interplay of social, cultural, ethical, economic and political framings of health, illness and disease, there is no such thing as a purely medical crisis (Ryan, 2022). The *Pandemic and Beyond* series reveals how the arts and humanities research community rose to the challenge of this complexity, growing in confidence as it became increasingly clear that our methodologies, forms of knowledge and creative mindsets were key not only to tackling this all-encompassing human emergency, but, in so doing, to alleviating human suffering. As one of our researchers commented:

What has been evident across our COVID-19 research projects is that arts-based research methods and approaches can generate much more nuanced narratives, capture the complex experiences and engage people that wouldn't otherwise find research accessible. Whilst of course medical research in such a crisis is fundamental, so too is understanding different people's experiences, responses and how their lives have been impacted so we can make more effective policies and support people's recovery and resilience looking forward. (Aebischer et al., 2022: 30)

If, as another *Pandemic and Beyond* researcher put it, this work 'has been a game-changer' in revealing the skill and generosity of the research community (Aebischer et al., 2022: 29), then it is also a call to action in the future, as we face a multitude of ongoing and emerging crises, from climate to migration and economic decline, which demand collective and civic responsibility and the willingness to continue to combine nuanced and context-sensitive thinking with a solutions-focused approach.

Without the vast collective knowledge, experience, methodological tools and expertise on which this type of research draws, our responses to ongoing challenges and future crises can only ever be impoverished. Expecting politicians of the future to say that they are 'following the humanities' might be wishful thinking. A pandemic response which made more extensive use of the kinds of evidence and interventions on show in these volumes, however, would have been far more attentive to questions of power and justice; understood how, why and when particular people felt – and became – less safe; had a far better handle on how we engage with public health advice or vaccination drives; and begun from a richer knowledge of what the arts can do to keep us feeling human in the most difficult of circumstances. As a recent essay on climate change suggests, the arts and humanities have to be equal to the series of interlocking emergencies which frame our present historical moment (Pietsch and Flanagan, 2020). Over the past three years, scholars and practitioners have painstakingly built a 'pandemic humanities' – and a pandemic arts and cultural sector – which demonstrates that the arts and humanities are more than equal to the task. Creating the conditions for this work to (continue to) thrive must, surely, constitute one of the best forms of crisis preparedness we have.

# **Notes**

# **References**

Aebischer, Pascale, *et al.* (2022), *The Pandemic and Beyond: The Arts and Humanities Contribution to Covid Research and Recovery*. Final Project Report. Available at http://hdl.handle.net/10871/132640 (accessed 30 March 2023).

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# **Figures**

Unless otherwise stated, all rights are reserved. For permission to reproduce any of these images please contact the rightsholder.

# **Contributors**

**Pascale Aebischer** is Professor of Shakespeare and Early Modern Performance Studies at the University of Exeter. She is a specialist in performance technologies who, during the COVID-19 pandemic, worked on Digital Theatre Transformation (AHRC) and took on the leadership of an interdisciplinary team at the University of Exeter for The Pandemic and Beyond: The Arts and Humanities Contribution to Covid (AHRC).

**Antonia Anisimovich** is a media and communications scholar with a particular interest in the role of culture and cinema in negotiating traumatic memories. Her broader scope of research interests includes arts in health and wellbeing, media memory, cinema-going and nostalgia.

**Chloe Asker** is an academic researcher, writer and Queer creative health practitioner. They have worked with universities and third sector organisations across the UK and internationally. Their work is cross disciplinary, spanning arts and health, health geography and medical humanities.

**Ekaterina Balabanova** is Professor of Politics and Media, at the University of Liverpool. She is an expert in communication/media and human rights and has published widely on media and politics with respect to marginalised groups including the impact of social media on rights-based communication.

**Josie Billington** is Professor in English Literature at the University of Liverpool, where she specialises in Victorian fiction and poetry. She co-leads the Arts, Mental Health and Wellbeing theme of the Centre for Health, Arts, Society and Environment (CHASE) and has led multiple interdisciplinary studies and published widely on the value of literary reading and the arts in relation to mental health.

**Melissa Chapple** is Lecturer in the Department of Primary Care and Mental Health at the University of Liverpool. She specialises in research on autism. Her PhD was on the value of literary reading for people with a diagnosis of autism.

**Helen J. Chatterjee** is Professor of Human & Ecological Health at University College London (UCL). Helen is a founding trustee of the National Centre for Creative Health, co-founder of the Culture, Health and Wellbeing Alliance and leads a Master's in Creative Health at UCL. Her research explores the interconnections between the health of the environment and the health of people, and includes evidencing the impact of cultural and natural participation on health.

**Fred Cooper** is a historian of loneliness and shame, presently working at the University of Bristol as a Senior Research Associate on the Wellcome-funded Epistemic Injustice in Health Care project (EPIC). With Luna Dolezal and Arthur Rose, he co-authored *Covid-19 and Shame: Political Emotions and Public Health in the UK* (Bloomsbury Academic, 2023), and was co-investigator on the AHRC grant Scenes of Shame and Stigma in COVID-19.

**Amy Corcoran** is a postdoctoral research associate at the Royal College of Art. She has a background in psychology and, in particular, child mental health. Her doctoral research explored connections between creative practices and social movements, with an emphasis on opening up space for wider public engagement in complex societal discussions.

**Bella Eacott** is a Research Associate at Performing Medicine. She has degrees in History and Philosophy of Science and Medical Humanities, a background in dance and she also works as a Massage Therapist.

**Graham Easton** is a GP and Professor of Clinical Communication Skills at Queen Mary University of London. His career has combined general practice with medical education and medical journalism for the BBC. He has a particular interest in the consultation between xix

healthcare professionals and patients, and the use of stories in communication and teaching.

**David Farrell-Banks** is a practitioner–researcher associate at the Fitzwilliam Museum, University of Cambridge. His research is focused on the impact of heritage and the past on lived experiences, with a particular interest in the politics of inclusion and exclusion in and through museums and heritage practice.

**Des Fitzgerald** is Professor of Medical Humanities and Social Sciences in the Radical Humanities Laboratory, University College Cork. His most recent book is *The City of Today is a Dying Thing* (Faber & Faber, 2024).

**Breda Friel** is a Senior Lecturer in Community Youth Work at Ulster University. Her research is focused on trauma, suicide prevention, autism and mental health with a particular interest in cross-sectoral collaboration in practice.

**Karen Gray** is a Senior Research Associate at the University of Bristol with a particular interest in research at the intersection between culture, health and wellbeing.

**Eliz Hassan** is Research & Project Manager at Performing Medicine. She holds an MSc in Global Health & Social Justice at King's College London, and has experience in academic and market research.

**Dee Heddon** holds the James Arnott Chair in Drama at the University of Glasgow and is the author of many outputs exploring creative walking, ranging from essays to creative research. Dee's ongoing project, The Walking Library, is a collaboration with Dr Misha Myers and explores the relationships of books, walking and environments.

**Paul Heritage** is Professor of Drama and Performance at Queen Mary, University of London and Director of People's Palace Projects, an arts research centre bringing together artists, activists, academics and audiences to challenge social, health and climate injustices through the power of the arts – in the UK, Brazil and beyond.

# xxx *Contributors*

**Anna Jorgensen** holds a Chair in urban natural environments, health and wellbeing at the University of Sheffield, where she is Head of the Department of Landscape Architecture. Her research focuses on how nature-based solutions can make cities healthier and more liveable.

**Philip McDermott** is a Senior Lecturer in sociology at Ulster University. His research focuses on the relationship between the state and the heritage of minority groups. He has published widely in the area of culture and identity in divided societies.

**Rabya Mughal** is a Research Fellow in University College London (UCL) Biosciences: Culture, Nature, Health Research Group. Her background is in developmental psychology including atypical development. She holds a PhD in Education Psychology and has worked in education policy and public service design.

**Sandra Nicholson** is Chair of the Association for the Study of Medical Education (ASME) and the Founding Dean of the Three Counties Medical School at the University of Worcester. She joined the University following twenty-five years as a medical academic at QMUL and as a GP in the East End of London.

**Maggie O'Neill** is Professor of Sociology & Criminology at University College Cork. Maggie is an inter-disciplinary scholar interested in critical, cultural and feminist theory, the development of creative, participatory and arts-based biographical methodologies and praxis.

**Clare Qualmann** is an artist/researcher, founding member of the Walking Artists Network and Associate Professor at the University of East London. Clare's teaching, research and art practice explore the interconnections between art, activism and the radical potentials of participation.

**Matthew Reason** is Professor of Theatre and Director of the Institute for Social Justice at York St John University. He has an interest in participatory and creative methods across a range of contexts including audiences, theatre for children, disability arts and applied theatre.

xxi

**Caroline Redhead** is a Research Fellow in the Centre for Social Ethics and Policy, part of the Law Department at The University of Manchester. Having worked as a commercial solicitor for many years, in the UK and in Hong Kong, she moved from private practice to academia in 2020. Her research interests lie broadly in the dynamic interplay between law, ethics (particularly bioethics) and social change.

**Morag Rose** is a walking artist, activist and academic and a Lecturer in Human Geography at the University of Liverpool. In 2006 Morag founded psychogeographical collective The LRM (The Loiterers Resistance Movement), and her research interests focus on public space, access and equality in urban environments, and walking as an artistic, political and cultural practice.

**Pedro Rothstein** is a PhD Drama candidate and Teaching Associate at Queen Mary University of London, as well as a Fellow of 'la Caixa' Foundation and Project Manager at People's Palace Projects.

**David Rudrum** is a Senior Lecturer in English Literature at the University of Huddersfield, with many years' experience of collaborating with literary heritage sites and museums. He is also the secretary of the Elmet Trust, which cares for the birthplace of Ted Hughes. His publications include *New Directions in Philosophy and Literature* (2019), *Supplanting the Postmodern* (2015) and *Stanley Cavell and the Claim of Literature* (2013).

**Melanie Smallman** is Associate Professor in Science and Technology Studies and Co-Director of UCL's Responsible Research and Innovation Hub. Melanie's research looks at the role of science and innovation (particularly data-technologies and AI) in increasing inequality, and how the social impacts of these technologies can be included in ethical and policy considerations.

**Qian Sun** is a Reader in service design, policy and social innovation at the Royal College of Art. Her recent focus is on the use of design in trans-disciplinary innovation that addresses contemporary societal challenges in health and wellbeing, community resilience and sustainability.

**Linda J. Thomson** is a Cognitive Psychologist at University College London (UCL), specialising in learning and memory and mixed methods research. Linda led the research for the AHRC-funded 'Museums on Prescription' project and developed the UCL Creative Wellbeing Measures for assessing the benefits of cultural, heritage and nature-based activities.

**Victoria Tischler** is Professor of Behavioural Science, Faculty of Health and Medical Sciences at the University of Surrey. She is a Chartered Psychologist and Associate Fellow of the British Psychological Society. Her research focuses on creativity and mental health and multisensory approaches to promote healthy ageing and innovative dementia care.

**Helen Williams** is Associate Professor of English Literature and Acting Deputy Director of Cultural Partnerships at Northumbria University. Her research has centred on partnerships with a range of literary archives and museums, principally the Laurence Sterne Trust at Shandy Hall. She is the author of *Laurence Sterne and the Eighteenth-Century Book* (2021) and co-director of the Laurence Sterne and Sterneana dataset hosted by Cambridge Digital Library.

**Suzy Willson** is Artistic Director of performance company Clod Ensemble and leads the company's Performing Medicine initiative. She is Professor of Movement, Arts & Medicine at Queen Mary University of London.

**Harry Wilson** is Lecturer in Digital Theatre at the University of Bristol. His research focuses on interdisciplinary explorations of live art and performance, photography, documentation, digital art and new media through critical theory and artistic research.

**Joanne Worsley** is a Lecturer in the Department of Primary Care and Mental Health at the University of Liverpool. She has a diverse portfolio of research activities centred on public mental health, including the role of the arts in promoting health and wellbeing.

**Hannah Zeilig** is a Reader in Arts and Health at the University of the Arts, London. Her research focuses on the arts for people with dementia, mental health and wellbeing and co-creative approaches.

# **Acknowledgements**

newgenprepdf

The editors would like to thank the Arts and Humanities Research Council for the funding that made *The Pandemic and Beyond*, and therefore this book, possible. The project has benefitted hugely from the talents and commitment of a remarkable team at the University of Exeter, under the leadership of Pascale Aebischer. It has been a pleasure to work together, as it was to work with all the researchers involved in COVID response research and now with all our contributors in this volume. We are also grateful to the University of Exeter for support and funding to enable the publication of the Pandemic and Beyond book series as Open Access.

# Introduction: creative approaches to wellbeing during a pandemic and beyond

*Karen Gray and Victoria Tischler*

'What the COVID-19 pandemic teaches societies is that, in times of crisis, culture is a major resource for resilience, connection and recovery (even when the forms of engagement for creators, producers and audiences are in flux).' The UNESCO's Assistant Director-General for Culture introduced a 2022 report seeking to 'reshape' policies for creativity and cement ideas of culture as a 'public good' with these words (UNESCO, 2022: 30). As an ambition, this resonates strongly with the contents and the aims of this collected volume of work.

The nine chapters that follow reflect on and look forward from research conducted during the pandemic that examined the intersections between arts and culture, nature, community, and health and wellbeing. The field of arts, health and wellbeing is a relatively new but expanding field for scholarship, policymaking and service delivery. It is an explicitly interdisciplinary realm that involves health, social and cultural sector colleagues. Activity in this area has been developing over the past three decades with growing numbers of research clusters in North America, the United Kingdom and Australia.

In the UK, a seminal report: *Creative Health: The Arts for Health and Wellbeing* was launched in 2017. This documented the widespread use of arts and creative approaches to support a range of physical and mental health conditions, across the lifespan, advocating for their increased use and further research. It arose from a two-year review led by the All-Party Parliamentary Group: Arts, Health and Wellbeing, a cross-(political) party initiative that documented relevant activity and held a series of events, developing and establishing the field. Since then, the World Health Organization (WHO) has commissioned a scoping review of literature in the arts and health field (Fancourt and Finn, 2019) and Arts Council England has published a ten-year strategy, Let's Create (2020), that advocates increased diversity in the sector and acknowledges the role of arts and culture in supporting health and wellbeing. In 2020, the National Centre for Creative Health was established, a charitable enterprise aiming to increase research evidence, to lobby policymakers and to improve practice. To give a sense of the global scale of activity, the National Organization for Arts in Health (NOAH) was established in the USA in 2016 to 'unite, advance, and serve the field of arts in health'1 and in Australia the Australian Centre for Arts and Health promotes the use of arts for health and wellbeing. The international journal *Arts and Health* has a growing audience with a 43 per cent increase in downloaded articles in 2022–23 and an increasing number of submissions from global majority scholars including from India and China.

Alongside these strategic developments in England, the Culture, Health and Wellbeing Alliance provides collaborative advocacy, support and resources across the creative health sector. The National Academy for Social Prescribing (NASP) was launched in 2019 to develop and champion the use of social prescribing, the use of community-based non-medical approaches to support long term and chronic conditions such as loneliness and obesity.

Overall, this activity shows that the field of arts, health and wellbeing is growing and thriving. The research evidence underpinning the field is also developing fast with increased funding supporting larger and more ambitious collaborative studies. International cooperation is benefitting the field by widening definitions of what constitutes arts and creativity, and wellbeing, in diverse populations. This will benefit global majority communities as well as racialised groups and diaspora populations in the West. The COVID-19 pandemic provided a unique and challenging opportunity to explore the role of arts and culture and its use in responding to a global public health emergency. As editors we have sought to bring together a series of diverse contributions that reference both the creative strategies employed by individuals and communities to manage responses to the pandemic, and the role of creativity, and of arts and culture. Our aim is that this will serve to spotlight learning emerging from COVID response research in

this area and, through this, support continued critical reflection on concepts such as 'coping', 'resilience' and the role and nature of creativity in times of crisis.

The concept of everyday creativity has influenced developments in the field. Everyday creativity or 'little c' creativity refers to actions performed daily that involve making and novelty, for example baking and knitting. In 2016, Arts Council England published a report on everyday creativity that aimed to make art and creative practice more inclusive and accessible, to benefit the wider community (64 Million Artists, 2016). The confinement and restrictions that most people experienced during the pandemic led to new light being shone on home-based and community creative practices; it indicated that these venues can provide an important context for instances of everyday creativity that are also shaped by wider social, cultural and economic forces (Mansfield et al., 2022). While this attention may help democratise creative practices that provide and inspire wellbeing, they also reflect and bring to our attention inequalities, for example the impact of poor-quality accommodation and lack of access to green space (Wright, 2022).

Coping is a psychological construct that encompasses cognitive and behavioural efforts to manage and overcome stressful situations. It is often categorised in terms of the types of strategies used by individuals which can be either emotion or problem focused. Emotion-focused coping includes internal responses to minimise stress such as avoidance and reappraisal whereas problem-focused strategies represent active behavioural attempts to address a stressor and find solutions such as seeking information or taking action. Problem-focused strategies are often thought to be more successful than emotion-focused coping. However, it is much more nuanced than that as factors such as developmental stage and culture play an important role. There is a body of evidence supporting the important role that coping plays when humans experience stress and trauma that can otherwise overwhelm them.

Various research studies explored coping used during the pandemic. These showed, for example, that experience of financial worry was associated with problem-focused and avoidant (emotion-focused) coping while overall, social support was used less which may reflect the social isolation that many experienced (Fluharty and Fancourt, 2021). People took to walking in green spaces as a way of coping during the pandemic (Mental Health Foundation, 2020), and the WHO issued #HealthyatHome guidance advising individuals to use and maintain their social support networks and to minimise or avoid alcohol and drug use. Arts, craft and creative activities were taken up by many as part of coping lifestyles, used to distract from anxiety and to manage stress (Bradbury et al., 2021).

Resilience – how we recover from trauma and our capacity to bounce back from stressful conditions – is another key psychological concept of relevance to this text. As the UNESCO Assistant Director-General's quote with which we opened attests, culture should be viewed as 'a major resource for resilience'. According to the American Psychological Association, resilience refers to 'the process and outcome of successfully adapting to difficult or challenging life experiences, especially through mental, emotional, and behavioural flexibility and adjustment to external and internal demands'.2

Within the mental health field, it is recognised that building and maintaining resilience is important to protect an individual when stressors are experienced, to help them cope successfully and to recover. As well as helping us successfully respond and adapt to stress and trauma, resilience can involve personal growth such as re-evaluating one's priorities, as many people did during the pandemic, for example establishing a better work-life balance. Therefore, it is possible that our lives can change for the better after experiencing trauma; this is referred to as post-traumatic growth (Joseph, 2012). A South American study undertaken during the pandemic indicated that creative activities that were practised during lockdown, supported psychological resilience (Elisondo, 2021). Several chapters in this volume reflect on the understanding that as a concept, 'resilience' is not uncontentious, particularly when applied beyond the realm of individual psychology, since structural conditions will severely limit the capacity of individuals to 'bounce back'. For example, the idea of 'community resilience' is examined in depth in Chapter 5 and the politics of the term in relation to the pressures placed on healthcare staff in Chapter 8.

Each of the following chapters demonstrates, how, during the pandemic, arts and creative practitioners and cultural and community organisations worked to promote interaction or connection and to create spaces with the potential to support coping or to

enable individual and community recovery. In doing so, they identify important lessons for policy and for practice in the arts as well as for provision of health and care. Readers will find many of these highlighted in the 'Key insights' sections at the end of each chapter. The impacts of COVID-19 on health and wellbeing have not been felt equally across society. Threaded through all the contributions is an attentiveness to the experiences and voices of people marginalised or rendered vulnerable during the pandemic because of their lived experiences of structural inequalities, or because of mental or physical ill-health or age. Several authors ask explicitly that readers consider how society and its structures might build on these experiences; specifically, they present case studies and detailed examples to show how arts, culture and other community assets can be mobilised to enable greater and more equal access to resources and skills beneficial in helping develop resilience now, and if or when we face similar crises.

The volume is divided into three thematic sections. The first deals with isolation and its opposite, connection or 'togetherness'. The second includes explorations of some places and spaces in or through which people met, moved, or engaged in cultural or creative activity together to support their wellbeing. The third and final section outlines some lessons for future practice.

As we note above, research has shown that increased individual engagement in creative activities of many kinds was both a response to lockdown conditions and a tool used by some to successfully enhance their health and wellbeing. Through participation in virtual creative communities such as online choirs or art groups, it also served to maintain and even increase social connection. Enforced and repeated lockdowns encouraged creative practitioners used to in-person working to find new ways to work with or alongside their participants. In the chapter by Rabya Mughal and colleagues the focus is on how creative, community and cultural activities helped to combat loneliness and social isolation for individuals considered most 'vulnerable'. The Community COVID project examined the creative experiences of people who self-identified in this way during the pandemic, along with the experiences of social prescribing practitioners and voluntary and community sector organisations working to connect people with and through creative activity. The authors reflect on these experiences, their meaning for individuals and what they tell us about how to identify the value of creative activity. Their conclusions provide insights to inform the use and positioning of community assets to serve those facing severe inequalities of health and opportunity now and in the future.

Inverting the notion of isolation, Matthew Reason has chosen to interrogate the meanings and experiences of 'togetherness'. Deployed in 'we're all in this together' slogans and political rhetoric to convey the need for individual sacrifice to enable national public good, the idea of 'togetherness' became contested ground during and following the pandemic, given the manifest truth that its impacts were far from equitable. Working in contexts that included learning disability, mental health, care homes and young people, during COVID-19, the Creative Doodle Book project expanded community arts activity through online workshops and into autonomous and private spaces. Reason shows how the careful relational processes used by practitioners involved in the project helped to create authentic moments of connection, employing novel online and physical modalities. The results, he argues, are suggestive of how arts practice can better enable inclusion but also pose difficult questions about practices that exclude and isolate.

From discussions of how creative arts practice connected individuals through building valued temporary communities during the pandemic, we move into our volume's middle section where the focus is on places and spaces. In these chapters we explore urban green spaces, environments that can be 'walked', museums and literary heritage sites. Authors describe independent engagement in and with these spaces. They outline activities and opportunities and that were facilitated or mediated through artists, and through cultural and voluntary sector organisations. Inequalities of access and adaptations that had to be made to address these in response to pandemic conditions, are common themes.

The section opens with a chapter from Dee Heddon and her fellow authors, reporting on research exploring how adults across the UK experienced walking during the pandemic and the role played by creativity in their walking practices. Employing the concept of 'just walking', the authors address questions of equity and justice in examining some of the systemic barriers that face those who walk or wish to walk. Creativity is shown to have been integral in challenging such barriers and in opening up spaces and

creating opportunities for individuals and groups to connect with each other; the chapter includes discussion of commissioned art projects foregrounding public and private acts of walking and reflection upon these.

Green space and whether or not people had access to it took on particular significance during the pandemic; in urban environments, public green spaces became vitally important places in which people could exercise, meet socially in ways that were planned or serendipitous and in which they could seek to relieve stress. Qian Sun and colleagues discuss the challenges and opportunities involved in making greater use of natural urban spaces to support wellbeing. In a detailed case study of Walsall in the West Midlands, their research uncovers a fascinating and complex ecosystem of overlapping jurisdictions, collaborations and sometimes competing interests that are governing how natural urban spaces are viewed and valued by different stakeholders as well as how they are managed and used.

When lockdowns forced museum and gallery buildings to close at various points during the pandemic, the work of their staff did not cease. Many museum organisations focused on the digital space and some pivoted 'towards purpose and people', leaning into their participation and engagement strands and taking their work out and into their surrounding communities (Walmsley et al., 2022). Friel and colleagues invite readers back into the physical space of the museum itself; they examine the potential contribution of cultural and heritage spaces to recovery in the context of the pandemic and past and future crises. The projects the authors describe took place in Northern Ireland, and the authors ask us to consider what the conduct of this thoughtful work reveals about how spaces within museum buildings could and – perhaps should – be constituted as 'restorative': places in which trauma can be 'held' and individual and community stories safely told and retold.

In the final chapter in this section, David Rudrum and Helen Williams describe the impacts of the pandemic on the literary heritage sector, demonstrating how it continued to offer experiences of value to its visitors despite long periods of physical closure. Alongside virtual tours, the sector increased its use and promotion of outdoor spaces such as gardens, grounds and natural landscapes. In doing so, organisations were able to embrace the public's evidenced increased interest in exploring interior psychological spaces of imagination and memory through books and reading and their desire to escape physical pandemic restrictions by moving into the outdoors. The wellbeing benefits of reading and engagement with natural environments are well understood, and this chapter suggests significant opportunities for the literary heritage sector to continue building on these understandings. Organisations are encouraged to engage more deeply with their local publics in blurring the divide between culture and nature.

The three chapters in the volume's third and final section provide in-depth examples of adapted creative practice during COVID. There are distinct lessons here for health and care delivery, for researchers, for arts and cultural organisations and for policymakers. People living with dementia were among those to have been disproportionately impacted by COVID-19. They experienced high levels of illness and mortality, and many were denied the social and physical contact that is essential to wellbeing during successive lockdowns and because of COVID mitigation measures. Arts and cultural practitioners and organisations have worked closely throughout with people with dementia and their professional and informal carers with the aim of alleviating some of the pandemic's worst effects. In their chapter for this volume, Asker and colleagues examine what we can learn from Culture Box, a project that provided care home residents and staff with stimulating creative activities and resources designed to enhance social interaction. The chapter explores how these resources were used and their effects for people living with dementia and their professional carers. It also highlights the methodological innovation required of researchers in capturing these understandings. The authors outline an agenda for future practice that encompasses care, creativity and research.

Healthcare is an emotionally and physically demanding profession, and during the pandemic healthcare professionals found themselves facing often overwhelming pressures, with implications for their own wellbeing. Many reported that communication and relationship building, key elements of good patient care, were being compromised by the safety and infection control restrictions brought in during the pandemic. Building on many years of practice working in the field, the chapter from Suzy Willson and her colleagues (a combined team of researchers, artists and healthcare

professionals) presents the findings of a project exploring the use of arts-based strategies derived from the skills and knowledge held by poets, theatre-makers, musicians, digital artists and dancers to address some of these challenges.

Moving from examples of innovative creative practice within health and care settings, in our final chapter, we highlight a project that takes a whole city region as its subject. The work of Josie Billington and her fellow authors highlights how the arts and cultural sector across Liverpool responded to the pandemic, including through novel solutions designed to support those already facing health and mental health inequalities. Mapping these responses across large civic institutions to small grassroots enterprises, their research also gathered the views of those benefitting from ongoing provision about how their mental health and wellbeing had been impacted because of changes to arts and cultural provision during lockdowns. What emerges is a picture of a dynamically responsive regional arts in health infrastructure, capable of adapting at speed and of delivering positive outcomes for individuals and communities.

Arts and humanities research conducted during the pandemic has illustrated how, through re-orienting and adapting existing resources and creating new ones, arts and cultural organisations and grassroots voluntary and community groups were able to address issues relating to wellbeing, mental and physical health and social support of individuals and of communities during the crisis. As the summaries above suggest, the chapters included in this volume will provide an insight into the breadth and depth of this research activity, but they do only represent a subset of it. Other projects not represented here but brought together under the umbrella of *Pandemic and Beyond* explored how families and individuals used and adapted their domestic spaces. Researchers studied the creative adaptations made by faith communities, and they sought to understand the social benefits of ritual during the pandemic. They examined the impact of the shift to the digital on arts workers and on young people taking part in arts activity. They supported young people and community groups to develop their criticality, agency and feelings of belonging through developing creative skills. Despite such diversity, it is important to recognise that there were limitations created by the nature of the funding call and the *Pandemic and Beyond* project itself (details of which are described in the series introduction which opens this volume). Although you are about to read chapters from authors who were based across the United Kingdom, many funded projects were conducted in England or had an English focus. And while we are certain they will hold implications for work internationally, the research we describe here is UK-based.

Taken as a corpus however, these essays speak to calls that, as a society and globally, we should learn from the pandemic by strengthening and expanding community-led social and local cultural infrastructures because they can support services that are vital to health and wellbeing (including health, care and education), as well as by valuing the everyday creative skills that have proved fundamental for many in negotiating their way through the crisis. Communities that went into the pandemic with this infrastructure already developed and networked through historic investment were better placed to respond and recover when crisis hit (British Academy, 2021; Walmsley et al., 2022). Whether or not these calls are answered with action remains to be seen, however the examples presented by work in this volume support a sense of cautious optimism. In part this is because they so convincingly demonstrate the capacity of cultural, creative and community practice for adaptation and change, and for compassion, when called upon to support those needing it most.

# **Notes**

# **References**

# **Part I**

Isolation and connection

# Community COVID: how can community assets redress health inequities?

# *Rabya Mughal, Linda J. Thomson and Helen J. Chatterjee*

The need to better understand the health of the public has never been more urgent. The COVID-19 pandemic both highlighted and exacerbated stark inequalities in society which have disproportionately affected the health and wellbeing of its most vulnerable members. The research project discussed in this chapter1 sought to understand how individuals engaged with community assets during pandemic restrictions such as lockdown and shielding, and the effect that this participation had on health and wellbeing. It focused on engagement with resources designed to inspire ideas, stimulate creativity and physical activity, combat loneliness and improve social connectivity, such as packs of craft materials sent through the post, or colouring books and crayons included with food drops, downloadable art projects, recipes and sewing patterns, and online choirs, orchestras, yoga and fitness classes. A series of surveys, desk-based research and interviews informed the qualitative and quantitative aspects of the Community COVID project. Interviews were conducted with practitioners working in the third sector (including link workers and arts and charity workers), and members of the community, with a subset of vulnerable and shielding individuals.

Substantial evidence demonstrates how community assets, such as libraries, museums, arts and voluntary organisations can play a key role in tackling inequalities through supporting vulnerable people. Here, the term 'inequalities' aligns with that of the 'Build Back Fairer' Marmot review, to incorporate socio-economic and health inequities (Marmot et al., 2020b), specifically those widened and made more apparent by the pandemic (Thomson et al., 2021). The term 'vulnerable' expressly refers to people with psychological, physical, or socio-economic vulnerabilities but not necessarily to those classed as 'extremely clinically vulnerable' at a high risk of contracting COVID-19 (Office for National Statistics, 2022). For the purposes of the reported research, members of the community self-identified as being vulnerable. This enabled the project to give voice to those facing extra hardship, while understanding lived experience through the lens of those willing to speak about socio-economic, physiological and psychological difficulties.

Given the evidence for its benefits, there is an obvious need to develop and augment existing mechanisms for connecting people with each other and their wider communities. Social prescribing, a process by which healthcare professionals or link workers connect people to community groups and statutory services for practical and emotional support, offers one route to achieving this. In the UK, a huge surge in social prescribing during the first and second waves of COVID-19 led to increased recognition of the importance of community assets such as green spaces, arts and culture to support outdoor, nature-based, arts and other non-clinical, creative interventions.

Many studies have provided evidence to suggest that taking part in arts and cultural activities stimulates creativity, enhances health and wellbeing, and generates a range of other positive outcomes (Bungay and Clift, 2010; Bygren et al., 2009; Camic and Chatterjee, 2013; Chatterjee and Nobel, 2016; Cuypers et al., 2011; Konlaan et al., 2000). Community COVID aimed to critically evaluate the immediate short- and longer-term impacts of creative engagement through lockdown and beyond, considering issues such as those associated with social prescribing.

COVID-19 facilitated a proliferation of creative responses to lockdown, the bulk of which took the form of online creative arts, crafts and nature-based resources that encouraged creativity at home to reduce isolation and increase connection through virtual communities of practice, such as online choirs or art groups (Mughal et al., 2022). The project documented the effects of creative responses to COVID-19, and the conditions and mechanisms for effective engagement. It also explored ethical issues of safeguarding and accessibility, particularly for audiences who were not digitally literate, did not have access to the internet, or who were living in areas with limited access to community assets and resources.

From the initial scoping it became clear that the pandemic was bringing with it intense changes to everyday life, particularly for vulnerable people. For older or disabled members of the community, those with mental health issues, who felt socially isolated or were living in situational poverty, life changed dramatically. Under phases of lockdown, people were ordered by the UK Government to 'stay at home'. Many people who normally commuted were required to work from home or were 'furloughed' under the UK Government's Coronavirus Job Retention Scheme and paid 80 per cent of their salary not to work (House of Commons Library, 2021). Social contact outside of the household was severely restricted and people were asked to 'socially distance' keeping two metres between themselves and the next person. Once sufficient personal protective equipment was available for hospitals, people were required to wear face coverings in public places and on public transport. These public health restrictions, designed to contain the spread of COVID-19, served to isolate people both mentally and physically from their family, friends and colleagues. For some, loneliness was combined with anxiety triggered by daily press releases of the numbers of people who had succumbed to the coronavirus and, prior to the onset of vaccination, the fear that they or their loved ones might be next. Two million people across the UK deemed extremely clinically vulnerable were asked to 'shield' meaning that, in addition to not leaving their homes, contact with other people was restricted to reduce the possibility of infection. These measures led to a reduction of access to healthcare services and increased anxiety and depression due to isolation, with more than one in three shielded people experiencing a decline in their mental health and wellbeing (The Health Foundation, 2020).

Consequently, as the research continued, a further focus of Community COVID was not only that of determining how the pandemic affected vulnerable and shielding individuals, but how creative, community and cultural activities could be used to counter vulnerability. Key aspects of the research concerned determining which provisions and activities were suitable, how these resources could be shared, and the processes by which engagement stimulated creativity and physical activity and combated loneliness and social isolation.

The focus of this chapter is on the research outcomes for vulnerable individuals as well as how lessons learned from the pandemic might be used by social prescribing professionals, practitioners and organisations to create effective resources in the future. The authors describe the background for the research and outline the differing approaches taken to provide converging evidence. After an overview of the quantitative findings, the chapter moves onto a thematic analysis of the qualitative data, addressing the issues of those most vulnerable in society. As part of this research, vulnerable participants were asked to document their creative journeys. The chapter presents a cross section of these before considering participant responses to being asked the question: if you could have a voice in the research, what would you say? We conclude with a discussion of the key findings and suggest some lessons for the future.

# **Background**

Holistic approaches to healthcare are well evidenced, having been utilised by community referral specialists since the mid-1990s (Howarth et al., 2020; Luker and McHugh, 2002). Engaging in art, nature, exercise and music, and creative, expressive, social or philosophical activities can elicit stimulatory benefits such as heightened emotional, cognitive and sensory processing, increased social interaction, adoption of healthy behaviours, promotion of physical movement and activity, and decreased stress hormone responses (Fancourt and Finn, 2019). Alongside improvements in health and wellbeing indicators, holistic approaches to health also lead to improvements in other areas such as employment and skills, economic development, civic pride and social cohesion (Cyril et al., 2015). In turn, engagement in community and cultural activities plays a public health role, contributing to prevention and treatment of long-term conditions that are currently putting pressure on the healthcare system (Kelsey and Kenny, 2021).

In the UK, social prescribing programmes have been developed with the intention of using non-clinical approaches to improve health behaviours and manage long-term conditions (Chatterjee et al., 2017). These societal, political and public health approaches

sit alongside the wider UK governmental responsibility of infrastructure upgrading, such as the Levelling Up Agenda (Department for Levelling Up, Housing and Communities, 2022). As part of the Levelling Up Agenda and to encourage economic regeneration, the Towns Fund and the Communities Ownership Fund are open to applications from communities to buy or take over local community assets and amenities at risk of being lost and run them as community-owned businesses (Tomany and Pike, 2021). Concurrently, there has been an increasing emphasis on the development of social infrastructure, physical spaces in which social capital may be accumulated, for instance in cafes, libraries, museums, community organisations and public institutions (Tomany and Pike, 2021). As social animals, people benefit from the accumulation of social capital and accordingly, individuals living in areas rich in community amenities experience lower rates of mental ill-health such as anxiety and depression, and physical ill-health such as obesity, chronic pain and diabetes (Marmot et al., 2020a,b). Indeed, negative health outcomes are closely related to asset-deprivation in towns (Marmot et al., 2020b).

During COVID-19, living in poverty, receiving low wages or being a single parent household indicated a likelihood of the highest levels of net COVID-related impact and those dwelling in areas of deprivation were more likely to be exposed to the pandemic (Bibby et al., 2020). Furthermore, risk of dying among those diagnosed with COVID-19 was also 'higher in males than females; higher in those living in the more deprived areas … and higher in those in Black, Asian and Minority Ethnic groups' (Public Health England, 2020: 4). Consequently, vulnerable populations entered the pandemic from uneven starting points (Marmot et al., 2020b) and were put at risk of severe outcomes exacerbated by pre-existing structural and institutional disadvantage (Marmot et al*.*, 2020a,b; Patel et al., 2020). Those with chronic physiological or psychological health conditions were most likely to be disproportionately and adversely affected by viral load as well as socio-economic impact (Marmot et al., 2020b). Outpatients and those with chronic health conditions experienced delays to care plans, including elective treatments (Propper et al., 2020), while changes to the landscape of mental health services in the UK called for the development of remote tele-health video calls to community care (Johnson et al., 2020). Although tele-health supported prompt responses and allowed services to keep going despite infection control procedures, it seemed more difficult to form and maintain good therapeutic relationships; equipment and internet connections could be of low quality, and service users and staff, in some cases, lacked confidence and training (Johnson et al., 2020).

# **Research approaches**

Several different approaches provided converging evidence to address Community COVID's objectives. Over the 14-month life of the project (July 2020–August 2021), researchers conducted 86 interviews, five focus groups, three anonymous online surveys, two creative workshops and a rapid evidence review of literature published over a 12-month period (February 2020–January 2021). Interviews comprised 72 with community members including 34 who were vulnerable and shielding, and 14 with community providers, namely charities, commissioned groups and community organisations. Focus groups were carried out with link workers, social workers, community workers, community providers and third sector practitioners. The three surveys were completed by over 4,000 respondents. The first survey was disseminated among third sector organisations and received 197 responses from communitybased practitioners. The second, 'Community COVID: What have you been doing?', survey was distributed by collaborators via their mailing lists to community members and was completed by 312 respondents. Questions from the second survey were also embedded within the Royal College of Music's Health, Economic, and Social Impact of the Arts (HEartS) 'Culture, Health and Nature-based Engagement' Phase 2 survey (Perkins et al., 2020) which had 3,647 respondents. In addition, vulnerable individuals participated in online creative workshops to express their experiences of the pandemic. Participants' creative journeys were documented, and participant voice was recorded in connection with the question: 'If you could have a voice in our research, what would you say?' Data derived from these different approaches were analysed using mixed, quantitative and qualitative methods.

# **Quantitative findings**

Our first survey of community-based practitioners showed that they jointly worked with 18,000 vulnerable people. Nearly 90 per cent of respondents reported barriers to participation, particularly for those with psychological, physical and socio-economic vulnerabilities, and 75 per cent asserted that there were more barriers during COVID-19 than pre-pandemic. The second, 'Community COVID: What have you been doing?' survey, showed that 80 per cent of respondents took part in activities more often during COVID-19 restrictions than before the pandemic, and 75 per cent participated more in offline than online activities. More offline activities were carried out alone whereas more online activities were carried out with other people. Respondents listed 73 activities, participating in around five each. Activities typically included fitness; gardening; sewing and crafts; painting and drawing; DIY and home improvements; reading and writing; and volunteering. Participation produced measurable increases in psychological wellbeing significantly associated with a reduction in loneliness. There was a high level of similarity between the 'Community COVID: What have you been doing?' survey and 'HEartS Engagement' survey in terms of measures of loneliness, proportion of respondents in each age range and region, and type and frequency of participation. For both surveys, sports and fitness, gardening and reading as a pastime were found to be frequently occurring activities.

# **Qualitative findings**

Data from multiple sources were combined and evaluated using inductive thematic analysis (Boyatzis, 1998). This revealed six main themes: Tangible benefits, evaluation and impact; Barriers to participation; Coping and adapting; Evolving health service; and Fragility of the ecosystem. The research contributed to a new and novel understanding of the types of interaction by members of the community including those who were vulnerable with community, nature, arts and cultural resources offered by arts and third sector organisations, as well as insights into evaluation techniques

used by organisations during the pandemic. These insights are illustrated below, with quotations from participants and arts and third sector professionals, alongside findings from the rapid evidence review.

# **Tangible benefits, evaluation and impact**

# *Challenges of evaluation*

Third sector organisations reported that formally evaluating the benefits of their provision to community members was challenging, particularly during the pandemic. Those interviewed for this project felt that they needed to provide an evidence base for the financial return on investment, despite not having extensive knowledge of evaluation techniques. During the pandemic, it became more difficult to partner with specialist evaluation companies and universities due to pressures on the workforce. Professionals often felt there was a lack of consensus around effective evaluation, and overly quantitative, medicalised evaluative techniques felt incompatible with the ethos of arts and charity organisations, more so during the pandemic. Some turned to simpler means of assessment such as whether participants turned up. One professional for example, an artist working with young refugees, told us: 'if they didn't enjoy being in that environment or enjoy what we're doing … or didn't get any benefit from that, they would stop coming … because it's completely voluntary'.

Third sector professionals also preferred to observe non-verbal outcomes, as exemplified by a community arts practitioner working on a psychiatric ward: 'for me, the thing about art in that context isn't measurable. It's having a communal space and starting a dialogue and opening up a sense of curiosity. The benefit will come – you have to just facilitate the environment.' Another third sector professional working with those with dementia in the community mentioned that 'as professionals, we're observing people, so being able to monitor some of the nonverbal stuff that's going on between that person and that person, I see interactions happening or relationships building and I think okay, I can see

the satisfaction – and also dissatisfactions as conflicts happen'. Others found evaluation forms unsuitable for their observations, as illustrated by this third sector professional:

Someone said to me once – just came up to me and said 'I gave a talk, you know, using a microphone and everything to a room full of 50 people. And I've never done that, and I wouldn't have had the confidence to do that if I hadn't come to our group'. Some people you can just see it. You can observe it. You can see it week by week; you can see the change in people. But it's so hard to convey that in an evaluation form.

# **Barriers to participation**

# *Logistical barriers*

Vulnerable participants listed logistical barriers to participation as: transport; finance; childcare, and anxiety about issues such as the length of time participation would take related to this; location of toilets and ability to have comfort breaks (particularly during lockdown when public toilets were closed); and disruption to routine.

# *Psychological barriers*

Participants were not motivated to attend socially prescribed activities for many reasons. One participant spoke about the stigma of mental health coupled with the pressures of COVID-19 on the NHS: 'there are services, but people don't know or there's embarrassment about it. Especially at the moment. You don't want to feel like you are taking resources out of the NHS when you don't need to.' The same participant spoke about how someone they knew was apprehensive about using NHS services despite being in crisis: 'One of my friends, she's been having a pretty serious manic episode for months. It's been months and trying to convince her that it's alright to see a psychiatrist, it's fine. The NHS is not going to collapse. She's really resistant because she's like "they're really stretched".'

# *Socio-economic barriers*

Socially prescribed activities tended to be seen as a 'waste of time' when other aspects of people's lives were more relevant, as expressed in: 'Yeh. I've been to one of those. The thing is my wife left me and I can't see the kids and so [my care co-ordinator] was like "go do this art thing" and I'm like "what good is that?"' Another participant told us 'Sometimes when there's been a busy day … and [it takes] everything I have to just get the dinner on and the kids to bed and sleep. I would love to have a bit of time to do some embroidery or slow down, but I just don't have that time.'

# *Systemic barriers*

The main systemic barriers this project found concerned the lack of service adoption due to social prescribing services not being sufficiently well known to community members. Many vulnerable participants interviewed had never been offered social prescribing, although one interviewee expressed an interest in the idea:

I get told all the time [by the social worker] and for good reason, to try and get outside every day. It would help me with my mental health … So, if someone offered me what you're saying [social prescribing], I will absolutely bite their hand off or something like that, though. That sounds right up my street.

# **Coping and adapting**

Some community and third sector practitioners were able to foster an 'agile' ad hoc work ethic which represented a refreshing change, as bureaucratic barriers were temporarily lowered to accommodate pandemic restrictions. For example, they reported being able to freely do things such as call participants on their mobile phones, visit them on their doorsteps, add them to social media or talk to them over video. These things would have been difficult to do prior to pandemic restrictions due to General Data Protection Regulation (GDPR), health and safety, or risk concerns and, consequently, may not have been viewed as a wholly positive development. For other practitioners, adaptation felt more difficult and they highlighted

barriers to participation such as levels of digital literacy of community members unable to use social media or video communication.

Practitioners working for community arts projects described new demographics attracted by activities offered on online platforms and social media: 'Sometimes we reach new audiences. People with anxiety, for example, who would never leave their house to join a group, suddenly feel safe in an online space. And so that's providing new opportunities for people who might not have considered engagement with these activities before'.

One practitioner documented the change to online working: 'the pandemic meant that, in March, we had to cancel everything and rethink our programme … Just as we were about to launch phase two, everything stopped. Since then, we've been working online and via Zoom.' Others used postal services for those unable to access the internet, as this practitioner reported:

We started posting our art packs to members. People have loved getting something delivered to the door or through the post. One person said that they found it difficult to find the motivation to do the activity, but they just love the fact that it still makes them feel better … It's like receiving a present.

# **Evolving health service**

During the pandemic, the role of public sector workers became dynamic, responding to the changing needs of the health service. Link workers for example wore several different 'hats' – one day acting as a stand-in social worker, the next day a carer, the next being pulled away to help with the vaccination effort. One reported that 'during the pandemic we have done hampers, food parcels, then putting leaflets in there to point people to mutual aid groups and different things that are going on in the community' whereas before the pandemic 'it would have just been totally not professional. But we just had to'. Another link worker noted that the pandemic, particularly lockdowns, had resulted in an increase in the use of social services and incidents of domestic violence: 'We suddenly became a lot more involved with social services and mental health services. While some people were baking sourdough and doing Joe Wicks [online exercise classes],

other people were really having a miserable time. We had a huge increase in self-referrals to women's refuges.'

Additionally, it became clear from talking to link workers that the role of the arts or other community-based activities within health often came second to more 'pressing' concerns for those in vulnerable populations. Often there appeared to be a hierarchy of needs, which was exacerbated during the pandemic. Pressing concerns prior to the pandemic involved housing, debt, wages and benefit entitlement. During the pandemic, these concerns became even more of an issue due to loss of wages, less availability of public services and backlogs within the system. One link worker reflected on how they were required to respond to this:

As a link worker, when you meet a person, you have to try helping them by finding the root cause.  And there's many different layers. And you have to build their trust. So, you tackle one problem, then they come back to you with another problem … To be successful in the role, you need to know how to adapt to these different situations and help with these different problems … but during COVID, it just added a totally different and new dimension. At the end of the day, we want to improve GP visits, get a handle on health. During the pandemic, a whole new set of problems opened up.

# **Fragility of the ecosystem**

Community COVID highlighted the fragility of community ecosystems. The response from the arts, cultural and voluntary sector was impressive, particularly the way in which some organisations tried to adapt to changing needs caused by the pandemic. However, others were unable to continue. A health professional explained: 'some community and voluntary groups are not able to function just because of COVID restrictions. Things just physically can't take place anymore. A lot of my patients were involved in the community beforehand. And now that's all been taken away.' A third sector professional expressed a similar view about mental health provision: 'the mental health service almost doesn't exist at the moment. The bereavement services have been difficult. Counselling too. I think every single service in mental

health has been affected. Some of our befriending work sort of makes up the gaps.'

The fact that many third sector organisations continued to operate even when budgets were finished, implied that they could provide a reduced service at a lesser cost. This led to concerns among link workers as the following extract from an interview with one demonstrates:

The services I am linking to have been really watered down. A lot of them were doing face to face stuff before, like breakfast clubs and exercise groups, and they've gone down to practically nothing. But they are still surviving. My worry is that with money afterwards, commissioners are going to think that we can work on this watereddown budget, and they won't be putting the services back to how they were before.

Some services that are watered down are working their socks off to deliver the same efficiency of service and are volunteering their time and going above and beyond to deliver services that, miraculously, are working just as well as before. The perception is going to be well, we've taken the money out, but the services are working just as well.

# **Surge in social prescribing**

In interviews, link workers reported that social prescribing referrals increased during the pandemic alongside growth in recognition of the importance of community assets such as green spaces, arts and culture. A rapid review of evidence conducted as part of this project showed a plethora of newly set up, ad hoc, mutual aid, charity and civic organisations that arose as a direct result of the pandemic (Mughal et al., 2022). The authors reviewed the evidence for arts, creativity, nature, music and cultural engagement among UK communities during the pandemic, with a focus on provision accessed by and targeted for vulnerable groups. The review recorded hundreds of examples of art lessons, online choirs, nature-based activities, doorstep performances, dance classes, jam sessions and virtual museum visits among other offers. There was an abundance of peer-to-peer, online and face-to-face voluntary and community organisations seeking to help vulnerable and shielding individuals. Some were new groups set up in response to the pandemic; others were adaptations of existing services or novel partnerships between community assets and those identified as being at greater risk on the Adult Social Care Risk Registers. While effective outreach was generally observed and commented on by numerous organisations, more robust and longitudinal evidence as to the efficacy and impact of such programmes, services and activities was lacking. Such evidence could, for example, describe the correlational effects of provisions on health and wellbeing outcomes and connect them to longer term outcomes. With longitudinal evidence, providers could offer a better evidence base for the long-term efficacy of their provision.

# **Creative journeys**

Capturing the value of engagement in community-based activities tended to be challenging for practitioners due to the multifaceted nature of engagement involving multiple stakeholders and a host of data collection challenges. Traditional or standardised quantitative and qualitative techniques were not necessarily adequate to capture feedback, views, ideas or differing perspectives, and there is increasing emphasis in this area of research to draw upon creative methods (e.g. Fleetwood-Smith et al., 2022). Community COVID included two online art workshops, one using collage, the other using mobile phone photography. Both workshops were carried out with the aim of understanding the experience of COVID-19 through the eyes of vulnerable individuals using expressive and visual artforms. Collage can be used to tell a story; individuals pick out certain pictures, words, textures and colours to create a picture with meaning. Photography, equally, can be used to tell a story about an individual's life. A participant, for example, can be asked to photograph using their mobile phone the 'three most important things in your life'. Meanings can be observed through exploring the resulting artwork and importantly, the process gives a voice to the participant. The following four creative journeys represent artistic approaches to capturing these individual experiences (See Figures 1.1a-e below which accompany the participants' words.)

# *Creative journey 1: Out of sight, out of mind*

I made this collage at the Community COVID collage workshop. Out of sight, out of mind was just a phrase that kept running through my head in relation to the COVID-19 lockdown situation and having a non-visible disability and chronic condition. I felt that people with conditions struggling to manage were very much out of sight out of mind certainly when it came to government policy and media – seen with the devastation wrought on the care homes and people with disabilities both mental and physical. For someone with a chronic condition, lockdown is maybe not that different from every day. Being isolated is normal. I don't see or hear from friends much anymore since I became much more unwell. It is a constant struggle to have your difficulties understood by those who don't have them and seem unable to put themselves in other's shoes. The tree/plant is my daily pushing towards having accomplishment in my life, the importance of creativity and self-expression which can give social connection and moments of joy. The hand pointing accusingly is the judgement be it from strangers/family or from the constant need to prove your difficulties. The colours are bright because that is what I am drawn to, I enjoy colour, but it is what stood out for me when cutting when making the collage. Maybe it also helps represent hope and joy rising out of difficulty.

# *Creative journey 2: Art allows me …*

I'm a self-taught, disabled artist. My practice involves travelling into surreal landscapes and mythologies using watercolour, dip pens, textiles or clay. Each of the materials brings a different dimension. There is a lot of whimsical animism in my work created by the ink layers I add to the watercolours. These stories only come through once the piece is finished and I spend some time looking and watch it all unfold. My process with the watercolours is rapid as is the ink laid on top. My pen dances in all directions adding the tiny ink marks. Art allows me to travel in ways I no longer can due to being mainly housebound. There is flow and energy and movement, everything my disability has taken from me.  I love to explore and disappearing into these worlds for a few hours brings me deep wellbeing and that is my motivation, the end results are the joyous by-product.

# *Creative journey 3: November sunshine memories*

I have generalised anxiety disorder and like to plan and have contingencies for when those plans inevitably fall through, so when it comes to collage, I like to just let it be intuitive and free of structure … My approach was to look at what I had and what came to mind from those items. Back in March 2020, I realised that masks would be important, and I did a lot of research and started making them. I don't like waste and tend to keep things in case they'll have a use and so I decided to use the face shapes in my collage pack layered with fabric cuttings from my mask-making to show that. Before that, though, I had a block of mixed pastel and I like making rubbings, so I did that all over my card before beginning to place anything. I didn't go for the position and play approach. I just got in there with the glue and whatever happened, happened. For me, the process is in the moment and if there are mistakes or things that don't work, they can be layered over, and it only adds to the texture. When I had done all I could with the faces, I looked at what else I had. There were strips of coloured tissue paper, and it strangely sent me back to doing art in primary school and using a method of crumpling it and gluing it, so that's what I did along the bottom until it ran out. And all those googly eyes. Well, we've been watching each other more than ever in so many different ways, and in my past life as an academic, surveillance was one of my research areas. With that done, I sifted through the other paper to see what caught my eye. I don't like the texture of magazine paper, so I avoided those. There were some sheets from what seemed to be a children's play book about unicorns and such. It had nice textures and colours. I feel I'm quite a dreary person (in how I dress at least), and although I am very near-sighted, I see colour very well, so I'm drawn to working with vivid colours when I can. There were pages with lists of words, and I looked through to see if any words grabbed my attention. One of the lists had the months of the year printed on it, and I wanted something to mark in some way a dear

friend I lost to COVID in November. I don't do neat unless it's required and I find texture and continency interesting (almost like chance is a collaborator), so I ripped the paper instead of cutting it. I ripped through the word November a bit, but I thought that's quite fitting actually to have it fragmented. Sunshine and memories were other words I opted for, and that's what I call the piece: 'November Sunshine Memories'.

# *Creative journey 4: Listen to us please*

My first collage is called 'Love India' – it has been of enormous concern to me about what is going on in the world and in particular India with COVID currently. My second collage: I have realised that it might be expedient to concentrate on what has come from my own camera or my own pen and paper and computer. I have altered the original collage. It is about Oxygen for everyone, and it reads: Listen to us please, Oxygen for everyone. It is about how our voices should be heard above the raucous. What we need now is help, kindness and oxygen. People are currently in respiratory distress and are in urgent need of oxygen to stop them from dying.

# **Participant voice**

When participants were asked 'If you could have a voice in our research, what would you say?' many referred to funding and the economy. For example, one said: 'In general, we need better funding. Because there is and was never enough. I mean, I was on a mental health waiting list for over a year, and I'm considered to be a priority case.' Another expressed the wish that the project would contribute to calls for further funding for culture and creativity.

Treat people like humans. We are not just creatures, animals, we are creative. We have interests beyond our little cubicle working lives. If you let us just be who we are then actually the economy may grow. If we choose austerity, we choose to de-fund all of these things. Maybe your research project can demonstrate that doing creative things is good for people and that in turn is good for the economy.

**Figure 1.1** Participants' creative journeys

**Figure 1.1a** Collage: Out of sight, out of mind

**Figure 1.1b** Ink illustration: Art allows me …

**Figure 1.1c** Mixed media: November sunshine memories

**Figure 1.1** (Cont.)

**Figure 1.1d** Collage and computer graphics: Love India

**Figure 1.1e** Collage and computer graphics: Listen to us please

Participants drew attention to other aspects of their lives that they felt should be funded.

I think probably quite a few big things actually. Fund the arts. Fund the arts and humanities. Fund education – fund a universal basic income for weirdos like me who work all the time but not for really any money. Give people time and space in their working lives to rest properly, and to pursue creative things. It doesn't matter if you are a master painter or any of that, it doesn't matter if you're good at drawing as long as you enjoy it, and it makes you feel good.

Typically, participants with mental ill-health and low household incomes compared themselves to those people with no financial issues who also had mental ill-health.

There's this idea that mental health is depression and celebrities do mental health awareness week and Gary Barlow off Take That goes on the telly talking about his battle with depression, how terrible everything had been for him when his multi-million-pound record deal fell through. And I'm not suggesting that he didn't have a horrible experience … But he talks about how like he recovered, and it was this story of redemption, and everything got better for him. So, it's like, well, it's a lot easier to get over depression when you have tens of millions of pounds in the bank.

Others referred to their own earlier experiences of the care system in terms of cost.

That charities and social prescribing, and leisure activities shouldn't replace medical care. I'm a victim of the care system. I've experienced when they just give you the cheapest, lowest intensity treatment first. I wish I'd just been assessed properly in the first place and got help when I was a lot younger. I would have been in a much better place now.

# **Discussion**

Community COVID aimed to critically evaluate the impacts of creative engagement during pandemic restrictions as well as after the UK emerged out of lockdown, when tiered restrictions and other public health measures were diminished, and programmes

of vaccination were put in place. The project documented creative responses to COVID-19 and the conditions and mechanisms for effective engagement. It also explored safeguarding and accessibility particularly for audiences who were not digitally literate, did not have access to the internet, who were vulnerable, or who lived in areas with limited access to community assets and resources. The objectives were to scope the range of 'creative isolation' resources; evaluate the impact of participating in online and offline activities; provide recommendations for good practice regarding the provision of high-quality activities accessible for a wide diversity of people irrespective of digital literacy or connectivity; and synthesise evidence from creative engagement in ways that could feed into post-lockdown strategic planning. A further focus, and a key area of discussion for the research, was to determine how COVID-19 affected vulnerable and shielding individuals, and how creative, community and cultural activities could address vulnerability during this time. It also became important to understand the complexities of evaluating this field of creative health during the pandemic, and to identify where providers and community organisations felt they needed most help.

A key outcome of Community COVID was an appreciation of the value of developing creative health partnerships with healthcare, social care and third sector services to maximise the benefits of local cultural and natural assets. The project showed that these partnerships led to new and unexpected collaborations such as museums, libraries or arts organisations working with food banks and local authority risk registers.

Social prescribing link workers, charity and third sector employees spoke about how they adapted their services during the pandemic. Most provisions went online, over the phone or doorto-door. Additionally apparent from the research was the fragility of the community 'ecosystem'. While responses from the arts, cultural and voluntary sectors were impressive, particularly in the way in they adapted to the changing needs of the population, many organisations operated on shoe-string budgets and faced permanent closure due to cuts. In the final stages of the pandemic, these changes resulted in several implications for the arts, cultural and voluntary sectors. First, health and social care professionals reported that agile ways of working allowed them access to participants in ways that were not possible pre-pandemic because they might have been perceived as 'unprofessional' (for example, visiting a community member at home). Second, hosting sessions online allowed organisations to access a larger number of participants as it broke down logistical and psychological barriers to participation. Third however, there was concern that working in this agile way with fewer staff and lower budgets would consequently become the new normal and that while it was feasible during the exceptional circumstances of the pandemic, it might not be sustainable in the long term.

It became clear from the research that reporting tangible benefits of art, music, cultural or nature-based activities remained challenging for many community providers. Providers reported that local commissioning frameworks were based on cost effectiveness and evidence collection in which impact must be *proven*. Collecting this kind of evidence seemed problematic for newer, smaller or underresourced third sector organisations and those without a previous evidence base. Given that the pandemic resulted in the involvement of a diversity of organisations in terms of size, scale and familiarity with the commissioning context, this problem is likely to become exacerbated. Consequently, there tended to be little consensus around what was regarded as effective evaluation.

Another issue highlighted by the research was the difficulties faced by practitioners in aligning outcomes to evaluation; an assessment of 'happiness', for example, would not necessarily be a sufficient outcome measure of wellbeing. A further issue was whether realistic feedback, considering the challenges and successes of a service, was provided for participants and staff. The professionals interviewed were generally optimistic about outcomes of their projects and felt that long-lasting impact to health and wellbeing had been achieved. Researchers felt, however, that feedback and impact reporting could be overly optimistic and that these were not generally independently conducted, making it difficult to gauge the realistic outcomes of a project. The professionals interviewed pointed out that even outside the pandemic, evaluation methods were difficult to implement without appropriate training and support, and a lack of time and capacity within the third sector impinged upon providers' ability to evaluate. Both before and during the pandemic, collection of robust data around the kinds of

activities being considered was challenging. The arts professionals interviewed expressed that commonly used social science methods, such as pre-post session measures, felt contrary to the ethos of arts organisations. During the pandemic these challenges increased; it was unclear, for example, whether an individual's subjective wellbeing changed because of the psychological impact of the pandemic or as an artefact of the evaluation process. Such influences are difficult to calculate without specialist statistical knowledge and large, preferably longitudinal, datasets.

The project found, however, that there was interest from the community and voluntary sectors in evaluation, despite the challenges outlined above. With this in mind, creative evaluation techniques offer a promising area of future research. Creative and expressive outputs can tell a story and could be analysed by methods such as interpretative phenomenological analysis (IPA), phenomenological art therapy or photovoice. Alongside validated and standardised measurement techniques, organisations might want to innovate and try out new, more artistic forms of evaluation. For example, letters or postcards could be used to capture the mental health and wellbeing of clients who are less inclined to fill in evaluation forms. Photovoice, which uses participant photos to tell the story of how they feel over time, could be used periodically to record extracts of information about individual health and wellbeing**.** Alternatively, the principles of art therapy could be used to capture the mood of the participant, to understand their mental health and wellbeing. During the pandemic, organisations did use alternative and innovative methods such as 'check in postcards' for elderly community members and homeschooling parents. While these provided interesting and promising ways of measuring subjective wellbeing, such methods still need to be proved reliable and validated statistically if the intention is for them to be used in research or to meet the needs of commissioners or providers wishing to measure impact or cost.

# **Conclusion**

If we are to derive lessons from COVID-19, it is vital to capture novel ways of working that emerged during the pandemic so that in the coming years, community engagement can become a properly

integrated part of the endeavour to improve public health. In particular, the centring of participant voice has helped to illuminate the inequalities exacerbated by COVID-19 and strengthen the call for engagement with the social determinants of health as a UK Government priority. Questions arising from the Community COVID research included those relating to how community assets could be repositioned to support individuals facing severe inequalities; how systemic barriers could be addressed for community assets to become far reaching; and whether the types of provision adapted for COVID-19 (for example, breaking down bureaucratic barriers or making more provisions available online) would be useful for redressing future health inequities. Through work conducted during the pandemic, we have gained insights into how community assets could be repositioned to address some of the psychological, logistical, systemic and socio-economic barriers vulnerable people faced during and beyond the pandemic. This research has shed light on how creative, community and cultural engagement could be used to tackle some of the major social determinants of health such as isolation, digital poverty and inequality. However, although the research has provided a better understanding of how arts, creativity, nature and other community assets can be deployed, there is still a long way to go to ensure equitable access to community assets.

# **Acknowledgements**

The authors are grateful to the participants of this project: members of the community, health and social care providers, and statutory, voluntary and community organisations who participated in the surveys, focus groups and interviews. We are extremely grateful to all of the project partners and investigators for their time, expertise, insights and scrutiny: Daisy Fancourt (UCL); Norma Daykin (University of the West of England); Miles Richardson and Carly Butler (University of Derby); Aaron Williamon and Neta Spiro (Royal College of Music) and for the Hearts Engagement survey; Martin Cattermole, James Sanderson and Nic Gitsham (NHS Personalised Care); John McMahon (Arts Council England); Dulcie Alexander (National Academy for Social Prescribing/Arts Council England);

Victoria Hulme (Culture, Health and Wellbeing Alliance); Jim Burt (National Academy for Social Prescribing/Natural England); Robin Simpson, Damien McGlynn and Claire Sharples (Creative Lives); Mah Rana (Lived Experience Network). We would like to mention a special thank you to advisors Alejandra Carles Tolra, Francesca Green and Mayra Salazar Volkmann for their contributions.

# **Note**

1 Combating Social Isolation through Creative and Community Engagement: COVID and beyond, otherwise known as Community COVID. The project was funded by the Arts and Humanities Research Council, as part of UK Research and Innovation's COVID-19 funding (project reference: AH/123456779), and a UCL Rapid Response grant funded via the UCL-Wellcome Institutional Strategic Support Fund (Ref: ISSF3/H17RCO/C5) and NIHR BRC Moorfields-UCL Therapeutic Acceleration Support (TAS) Fund (Ref: BRC3-305). The project was conducted by University College London's Culture, Nature and Health Research Group in collaboration with the Royal College of Music; Universities of Derby and West of England; Arts Council England; Creative Lives; the Culture, Health and Wellbeing Alliance; Lived Experience Network; March Network; National Health Service Personalised Care; and Natural England. Ethical consent was obtained from University College London's Research Ethics Committee (REC: 4526/003).

# **References**

survival: A Swedish fourteen-year cohort follow-up', *Scandinavian Journal of Public Health*, 28, 174–178.

# Together while apart: interrogating togetherness in the context of COVID-19 and online community arts practice

# *Matthew Reason*

This chapter interrogates the meanings and experiences of 'togetherness', specifically in the context of the COVID-prompted expansion in the online delivery of community arts practice. It frames the simultaneous loss and pursuit of togetherness as a key territory of the pandemic, something that occurred at both community and individual levels, became problematically politicised and yet was also genuinely desired. The utilisation of online community practice to instil a sense of togetherness, wellbeing and resilience has the potential to be a lasting legacy of COVID-19. The objective of this chapter is to think through virtual togetherness, developing a critical framework to help us better evaluate experiences of being together while apart.

'Together' and 'togetherness' are ordinary, everyday words. They lack a specific underpinning conceptual framework, although this chapter will draw on cognate areas – most specifically Victor and Edith Turner's concept of *communitas* (1969) – in order to allow us to think into them more critically. They are also indisputably loaded with positive connotations and, perhaps as a consequence, are particularly prone to hijacking in a way that can feel hollow or even pernicious. As this chapter will discuss, during the pandemic phrases such as 'we're all in this together' sought to actively conceal inequalities and stark societal divisions that COVID-19 highlighted. Given these characteristics, togetherness often risks becoming an empty signifier: under-theorised at the same time it is over-utilised.