Two highly experienced dance animateurs came along recently to the Centre for Arts and Humanities in Health and Medicine (CAHHM) to see if we might help mentor an evaluation of their regional Lottery-funded arts in health project. They were already well versed in what Penny Greenland of JABADAO has termed the 'Asking Difficult Questions' aspect of dance and movement research, and they had produced a clearly structured evaluation plan. They were perplexed, however, by the additional evaluation requirements of the Lottery grant; particularly by their focus on quantitative rather than qualitative measurement, as though evaluation were in essence about counting sheep. So, they were disappointed that the serious enquiry, which underpinned their practice, did not appear to be grasped by the funding system. Is satisfactory evaluation to be a difficult or easy task? It seems the monitoring wire is strung so low we are not sure if we are meant to hop over or limbo under. As one frustrated arts in health practitioner said to me recently: 'I just wish the Arts Council (of England) could see the enormity of what we're working on out here.' (1)
In building an evidence base for the value of arts in health, frustrations can be created just as much by the health sector's approach to the issue. I have recently observed an arts on prescription scheme in Newcastle, which is offered as a 'one-stop shop' by two Asian GP's who are also musicians. To try and corroborate the testimony of their patients as to the effectiveness of 'prescribed' singing, they used a standard assessment instrument for mild anxiety disorder known as questionnaire SF-36. Every patient taking part complained that filling in the questionnaire raised his or her stress levels. The creative edge became blunted by the measurement Maybe it is time for both arts and health funders (who do want to help us find evidence of benefit) to come back in through the out door because, to paraphrase a poem by Philip Larkin: They f*** you up ... They may not mean to, but they do.' (2)
Evaluation of arts in health is still in its infancy, the age when we learn most and fastest. I think we need first to understand better the field of practice and its diversity, and how we can learn to combine the differing perspectives and assumptions of cross-sector working in arts in health. To that end, CAHHM commissioned Tom Smith of the Judge Institute in Cambridge to evaluate an arts in health learning development programme known as Common Knowledge.
In 1998 the chief executives of Newcastle City Health Trust and Gateshead and South Tyneside Health Authority invited a bid for an ambitious three-year programme to place arts in health at the core of the Tyne and Wear Health Action Zone (HAZ), the largest HAZ in England. Gateshead Council's Arts Service with South Tyneside Art Studio, a voluntary sector facility catering for mental health referrals, developed a proposal. The bid was then refined through a steering group of local authorities' arts officers, health service personnel, and Northern Arts Board.
Under the twin banners of 'healthy citizenship' and 'creating capacity' the bid proposed to apply arts in health to the key themes and target groups of the HAZ, namely: mental health, cancer, heart disease, children's health and older people's health. The bid was awarded £225,000 over three years, making it one of the largest initiatives in the Tyne and Wear HAZ. It has resulted in Common Knowledge, a project that pioneers a new approach to placing arts activities at the heart of community health development and clinical practice. Across the region, it has created a vibrant network of artists and health professionals of all kinds, teachers and academics, local authority officers, voluntary sector entrepreneurs and community participants.
The goal is to achieve and practice healthier citizenship through creative collaboration, and the specific aims are to:
- disseminate useful knowledge and information
- mutually define arts in health for the Tyne and Wear HAZ
- achieve community participation
- support collective aspirations in community health
- change the way the people work
- create a positive emotional environment for the project.
There have been three stages in the Common Knowledge process: firstly, induction gatherings for up to 80 people of mixed professional background and interests. Two such events took place in Tyne and Wear in early 2000, each an intensive exploration of how the arts can both identify and address health needs, and renew first hand our experience of community. A team of artists led by Mary Robson, and including a dancer/choreographer, facilitated the process. These events were followed by regular meetings of groups of Common Knowledge participants in each of the five boroughs of Tyne and Wear, sharing ideas and formulating projects.
Secondly, there were pilot projects, and 20 of these were developed in 2001 across the HAZ, each tackling a unique application of arts in health for community or clinical settings, informed and supported by the network. These have ranged from musicians performing in an intensive care unit, to artist-designed information for primary care practice, to a friendship garden in a Sunderland primary school where children learn to resolve their own disputes and be inclusive in their play.
Issues of mutual concern or curiosity have also been explored through Action Days, and these have included, for example, advice on setting up arts on prescription schemes, fresh thinking through emotional intelligence, and exploring the therapeutic uses of music. Programme content has been determined by the evolving network of Common Knowledge participants and through direct contact with the community groups they access or represent. There is now an Operational Group of network members guiding the future development of the programme beyond the term of the HAZ funding. The nature of the work has been not one grand construction, but many small ground works. The network has now grown to over 250 members.
Thirdly, and finally in the spring of 2002 an arts in health campaign is set to take place in health buildings and public transport systems across the region to celebrate Common Knowledge, gauge public awareness of the programme, and deliver the infrastructure for genuine joined-up practice in future in this field.
A unique feature of arts in health work, particularly in community contexts, is its ability to both identify and address health needs at the same time, accumulating testimony from participants as to its perceived benefits and moving, albeit slowly, towards intermediate indicators of health gain. The cycle of consultation, feedback and intervention becomes meaningful conversational exchange about health accompanied by tangible creative activity in a congenial space; a process described closely by John Angus in An Enquiry Concerning Possible Methods for Evaluating Arts in Health Projects.' (3)
As Common Knowledge has been able to evolve organically the research agenda which now underpins the work was not pre-determined; rather it has become identified in the process of building those cross-sector partnerships that initiate the projects. But because arts in health work proceeds from the personal it poses subtle problems for evaluation. Firstly, there is a tension between the aspirant nature of art and the collection of empirical data - one wings its way forward, the other retraces steps. Secondly, because there are different concepts and approaches to the practice of arts in health (sometimes even within the same project), it is important to establish where the work sits within the diverse and complex field of arts in health in order to understand what it is trying to achieve. These matters are considered extensively in the Common Knowledge Interim Evaluation Report by Tom Smith. (4)
Common Knowledge has had a particular emphasis on everyone participating in evaluation and encouraging reflective practice. Each project was given at its outset a large art-paper notebook in which to record informally in multifarious creative ways the progress of the work and the accumulation of participants' testimony as to what occurred. Several of these notebooks are incredibly detailed, rich in qualitative data, and have even become artworks in their own right.
Dance and movement have so far been under-represented in the pilot projects, being the lead art form in only one of them. That is a pity because dance, and creative writing are probably the art forms in which health gain from participation can be most clearly seen. Conversely, dance also faces the toughest scrutiny from the medical sector: 'Is it safe? Will the activity damage rather than improve clients' health?' Much has been done by the Foundation for Community Dance, JABADAO and others, to counter this criticism but, evidence notwithstanding, there is only so much one can do to convince sceptics about what is intuitively obvious.
In one of the Common Knowledge evaluation books Wendy Smith, a musician whose project took place in an Otolaryngology Department for people with severe speech problems, evoked images of dance and movement when trying to explain the transitional effect of art on health: 'We asked where are you most familiar and comfortable in terms of verbal and non-verbal worlds? What is it like to move from one to another? From making sound to describing what that experience is like, to step out of words into making music, or to move from singing to drawing to writing. What might we gain from exploring how we move between these two realms? What are the benefits? How could they be more integrated? If they could, we decided we might gain more influence, creativity and confidence in how we express ourselves, as well as better relationships.' (5)
The framing of the difficult questions and the creative engagement often occur simultaneously. There appears to be not a causal or sequential relationship between the activity and its evaluation but an organically entwined one. This is what makes research into the value of arts in health so fascinating and challenging.
Mike White director of projects, CAHHM. +44 (0)191 374 7169.
Email mike.white@durham.ac.uk
The Common Know/edge interim evaluation report (price £10, cheques payable to University of Durham) is available from CAHHM, The Business School, University of Durham, Durham DH1 3LB.
References
1. Anonymous, 2001
2. Larkin, P., This Be The Verse 1971 in Collected Poem, Faber and Faber, 1988
3. Angus, J., An Enquiry Concerning Possible Methods for Evaluating Arts in Health Projects, Community Health UK, Bath, 1999
4. and 5. Smith, T., Common Knowledge Interim Evaluation Report, CAHHM, Durham, 2001