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**

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# **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. Sometimes when people come to you, they're 'broken'. 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. These microcosms represent how small everything has become since falling ill and yet gives me

so much expanse to fall into. 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. You know, I mean, you're not worried about how to feed your children.

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.

This chapter is interested in what we can learn – both retrospectively and in terms of future thinking – from the COVID-19 prompted emphasis on experiences of togetherness while physically

and socially apart. Specifically, it examines what produces authentic and meaningful experiences of togetherness within online community arts practice. It will use as a key case study the Creative Doodle Book (CDB) project, which between November 2020 and June 2021 delivered online arts workshops with partners across the UK, in contexts including learning disabilities, mental health, care homes and young people.1 The chapter focuses on the work undertaken in the context of learning disabilities, which is where the CDB had its conceptual origins and where questions of inclusive online practice have significant future-oriented relevance. The insights from this project will be used to develop a more constructive understanding of togetherness. Drawing on this material, the chapter will reflect on how these will support the development of authentic forms of togetherness in future online community arts practice. Discussion considers insights from the CDB project in the context of ideas of *communitas* and selfhood, also drawing in reflection on the concepts of togetherness and inclusivity.

# **The Creative Doodle Book and community arts**

'Community arts' describes a broad range of participatory arts practices which Owen Kelly (1984) identifies as emerging from the 1960s onwards. Orientated around an ethos of cultural democratisation, community arts seek to bring to life Beuys' famous dictum that 'everybody is an artist'. The movement sees arts practice as a process through which opportunities for voice and expression can be facilitated for marginalised individuals and communities (Bishop, 2012: 177).

Within this framework, togetherness is a recurring if largely unexpressed component of community arts, which values the experience of being with other people as we make theatre, music and art *together*. Ideas of togetherness are accessible and immediately meaningful in a manner that aligns with a participatory ethos of community practice. Such togetherness was presumed to be in-person because, until fairly recently, nothing else was possible and nothing else was practised. While not entirely non-existent prior to 2020, online community arts was previously rare, largely dismissed and certainly seen as a distant second best – perhaps precisely because it ran counter to ideas of togetherness. COVID-19 prompted a rapid and radical shift to online delivery (CHWA, 2021).

The CDB project was both an example of this shift to online community arts practice and an investigation into its consequences. The Book was originally produced a year prior to COVID-19, through a collaborative research process with learning disabled artists at Mind the Gap, a learning disability performance company and training academy based in Bradford (UK). It was inspired by the work of people such as Keri Smith (*Wreck this Journal* 2013) and Julia Cameron (*The Artist's Way* 1992) and designed to employ playful tasks to help support reflective thinking within creative practice. When Mind the Gap had to send all their artists and academy members home in March 2020, the Doodle Book was immediately recognised as a providing a unique resource that would provide a structure for working remotely and online (see Figures 2.1 and 2.2 for example pages from the book).

Originally conceived for in-person practice, a core element of the CDB is that it is, put simply, a physical but extremely portable resource. As a physical object that could be easily posted to participants' homes, the books lent themselves particularly well to creative adaptation in response to COVID-19. They provided a physical tangibility that rooted online practice. That everybody, while engaging remotely, had the same tangible object in their hands produced experiences of connection that had strong

**Figure 2.1** 'Earworms', page from Creative Doodle Book

**Figure 2.2** 'Inspiring places', completed page from Confidance, inclusive dance company

resonance during COVID-19. The implications of this, for ideas of togetherness within online 'spaces', will be returned to in more detail later in this chapter.

From its starting point with Mind the Gap, funding from UK Research and Innovation (UKRI) as part of the rapid response scheme to COVID-19 enabled the CDB project to expand to work across the UK with 31 different partners, predominantly consisting of learning disability art organisations but also schools, care homes and mental health groups. A recurring feature for these organisations was the rapidity of the shift from in-person to online delivery, typically starting from the point of zero prior experience. As Laura Bassanger of disability arts organisation Starlight Arts put it: 'Prior to this [online delivery] never existed in our minds, because it was face-to-face and that's it' or Imogen Barton-Wells of Manchester-based disability-led theatre company Proud and Loud Arts, 'We quickly moved online, which is something we've never done before […] I think maybe we had a week break, and then move into Zoom sessions.' One of the questions or consequences therefore became what does it mean for community arts participants to be together within online practice and in a virtual space? What forms or practices of online engagement 'work' in developing meaningful experiences of togetherness?

In conjunction with its partners, the project delivered online workshops based around the CDB. These were designed by inclusive arts practitioners Vicky Ackroyd and Lisa Debney, with a focus on creative processes and inclusivity. With the shared tasks within the Doodle Book as a starting point, a recurring feature of the workshops was a period where participants would remain connected online but would be occupied in individually responding to a page, often in silence. Then the group would come together again to share their responses. In her reflection on the project, lead facilitator Vicky Ackroyd noted:

I learned that creativity isn't about talent, ability or event activity, it's about curiosity and connection and kindness. There was always some laughter in the sessions, and always some peace. Through our little Zoom boxes we managed to feel connected and safe.

This evocation of the particular experiences of connection through 'Zoom boxes' will be returned again in this chapter. The discussion presented here, draws upon reflections and observations from the CDB project, including feedback from the participants and expert interviews with lead practitioners from all the partner organisations. The evidence it presents is based upon insights from relational practice, practitioner knowledge gained through the accumulation of small, fragmentary, ephemeral moments of intersubjectivity. Across many professions COVID-19 produced multiple instances where experienced practitioners had to creatively adapt years of experience to new circumstances. Through its interviews with community arts practitioners, the CDB was able to capture this (re)learning as it happened, as new knowledge about facilitating togetherness through online practice was made and recognised in the moment. This chapter seeks to place this knowledge within appropriate theoretical frameworks in order to formulate a nuanced understanding of togetherness within online community arts. It is important to retain the learning here that can guide future practice, particularly about the gains of online creative practice when working with underserved communities and individuals. For a fuller discussion of the methodology, and questions on online inclusivity in relation to the CDB, see Reason (2023).

The next section will examine how togetherness become contested territory through the course of the COVID-19 pandemic.

This will establish the need for a more nuanced understanding of togetherness that can withstand political grandstanding or empty appropriation.

# **Togetherness and COVID-19**

One consequence of the pandemic was a radical disruption to the ways in which people engaged with other people. The lockdowns and social distancing measures eradicated hugs and handshakes, erected invisible 2 metre personal bubbles around individuals and forced schools and workplaces to shift online whenever possible. All manner of activities – weddings, funerals, theatre, sports – had to find different ways to construct shared experiences. In this context it is unsurprising that a discourse of togetherness became a recurring motif of the pandemic occurring across government, education, health, business and the arts to describe attempts to create a sense of community and combat fears of what was often described as a loneliness epidemic.

However, while togetherness might largely be considered an apolitical and interpersonal social good, it certainly was not unproblematic and uncontested. As a response to the isolation and dislocation of social distancing, the desire for togetherness while apart was utilised in ground-up initiatives but also co-opted by government and commodified by corporations. We can see this even within the phrase that forms the title for this chapter, variations of 'together while apart' were a recurring hashtag on social media used by arts projects or other community initiatives but also by corporate accounts and within advertising. Francesca Sobande (2020) describes this in terms of 'commodified notions of connectivity, care and community' in a time of crisis. Looking at the UK alone, Sobande identifies 'we're all in this together' videos and marketing campaigns from brands including Asda, M&S, Fitbit, Disney and more, all seeking to present themselves as 'essential, ethical and invested in people'. For Sobande these campaigns are 'platitudes' that mask underlying inequalities and deny lived realities. Moreover, 'not everyone feels part of a collective experience or a "we" during this crisis, and the intense social isolation that many people are contending with, of course, cannot be solved by the slogans of brands'.

This dynamic is even more loaded when ideas of togetherness were employed as a rhetorical device within government narratives and public health campaigns. Calls upon togetherness were used to justify lockdown restrictions and social and economic hardships in many different countries. 'We are all in this Together' was the title of UN Secretary-General Antonio Guterres' declaration of a public health emergency in April 2023 (Guterres, 2020). The phrase was also evoked by US Chief Medical Advisor Dr Anthony Fauci, while UK Prime Minister Boris Johnson's rhetoric often evoked descriptions of togetherness, such as his 22 September 2020 Downing Street address, which included the line 'We pulled together in a spirit of national sacrifice and community' (Johnson, 2020).

Such claims, of course, are rhetorical devices that call for sacrifices while concealing the unequal impacts and suffering that resulted from COVID-19. With hindsight such governmental assertions can only be read through a lens of irony – something dramatically underlined as the very next sentence in Johnson's address is 'We followed the guidance to the letter' (Johnson, 2020). We now know exactly how untrue this statement was as concerned the behaviour of the Prime Minister himself, rendering all claims to national unity and togetherness viscerally objectionable.

Perhaps one outcome of the pandemic is that the duplicitous use of discourses of togetherness produced greater popular awareness of underpinning inequalities. As Ryan Nolan writes in a paper subtitled 'COVID-19 and the lie of solidarity', 'The pandemic has unmasked the hidden systems of inequality that are lost in the mundanity of everyday life […] It seems that we may all be in this together, but it is a simple fact that the most vulnerable groups will carry the burden of damage caused by the virus' (2021: 102). Rather than some early rhetoric about COVID-19 being a great leveller, the dominant understanding would now align with that asserted in a letter to the *Canadian Journal of Health* which describes the pandemic as a 'symptom of deeper societal inequalities' (Ali et al., 2020).

This disjuncture between a rhetoric of togetherness and meaningful action is something that with hindsight we can see as a recurring feature of responses to the pandemic. It is present, for example, in the tidal wave of criticism of perhaps the very first high-profile pandemic social meme – Gal Gadot's co-ordination of celebrities and musicians joining together to sing John Lennon's 'Imagine' over Instagram. Gadot captioned the original March 2020 post,

'We are in this together, we will get through it together', prompting almost immediate condemnation for its failure to recognise the very different material living conditions with which people were experiencing that first lockdown. Another and more nuanced example is the Clap for Our Carers social movement, first initiated by Annemarie Plas in the UK, which saw neighbours standing on their doorsteps on Thursday evenings in 2020 applauding, banging pans or cheering in support for health service and other key workers. Speaking of my own experience, within the moment there were elements of shared experience here, a feeling of togetherness both along individual streets and of a dispersed national collective experience. I remember calling my parents, in lockdown several hundred miles away, who had been outside their own house, banging their own pans, at the same time as me. That kind of sense of connection is real and was experienced multiple times across the country. However, the movement suffered from increasing ambivalence, alongside critiques that it was purely performative with no substantial impact (Wood and Skeggs, 2022). Sarah Spellman goes further, describing it in terms of a laudatory othering that reproduced inequalities while acting as a substitute for action (2021). A more forgiving reading of Clap for Our Carers is presented by Sam Mackay, who parallels it directly with participatory art practices and analyses it in terms of its sonic politics. Mackay recognises that for many people the movement was simultaneously both an 'inclusive act of solidarity' and an empty gesture that provided 'a smokescreen for government incompetence and underfunding'. Mackay suggests that many people maintained both these contradictory perspectives internally at the same time, with the event also oscillating between constructing an impossibly broad and therefore inevitably safe national consensus and providing multiple ways for autonomy 'through which participants could question the boundaries and possibilities of public sounding' (2021). This vital aspect of autonomy within experiences of togetherness is something that I will return to later in this chapter.

As with the governmental and corporate claiming of togetherness, the Clap for Our Carers phenomenon points to how even 'ground up' social movements can fall into a trap whereby claims of togetherness are perceived as gestural rather than enactive of real change. We might, therefore, be justifiably sceptical and cautious of rhetoric of togetherness. In particular it is necessary to consider in whose interests such claims are being made: who benefits?; what are the motivations?

This focus of this chapter, of course, is togetherness within online community arts. But this cannot be divorced from wider discourses. Nor are the community arts immune to the use of aspirational claims as a form of rhetoric. We are all aware of the manner in which complex relational concepts become reduced to formulaic or almost rote assertions – of bringing people together, of empowerment or cultural democracy, of safe spaces, of giving voice and more. The community arts are no stranger to simplifying and overclaiming impacts (see, for example, Clift, 2020). The response, and the focus of the next step of this chapter, should be the careful consideration of the relational processes by which effective and affective experiences of togetherness are produced.

# **Creative Doodle Book and experiences of togetherness**

The concept of togetherness was explicitly present within the design of the CDB project, which, as noted above, identified the centrality of togetherness to community arts practice and the challenge presented to this by the sudden shift to online delivery. It set out to explore how the community arts might produce similar experiences of togetherness while physically apart, particularly in the context of working with marginalised individuals and in an inclusive manner. Interim reflections and reports often used the title 'together while apart', unconsciously echoing the recurring public discourse. The purpose of this section is to go beyond the rhetoric and interrogate the practice and experience of togetherness. With the key frameworks for the project being community arts, online delivery and inclusive practice, the following discussion explores togetherness in terms of ideas of communitas and selfhood.

# **Communitas**

A core utility of community arts is that of people doing something that is valued and absorbing with and alongside other people – which for this chapter we are describing as an experience of togetherness.

Throughout the CDB project participants reported experiencing something productive and rewarding through their online engagement, such as comments from Dawn Hartley, of Scottish children's arts company Lyra:

We have a sense that there's a rich engagement happening with the Doodle Book. It's a rich, authentic engagement, that's not perhaps happening in the young people's lives at this time. It's being together in a group, doing something together, enjoying it. And that's a precious moment to feel online that is not always happening.

This evocation of 'doing something together' is at once commonplace and powerful. In seeking to conceptualise its significance, the community arts have frequently drawn upon the writings of Victor Turner and Edith Turner, particular the concept of communitas. While a community might primarily be defined in terms of a geographic area of common living, rooted within social space, communitas describes a modality of social relationships. It is often summarised as unstructured and liminal, at once in and out of time, in which people are engaging with each other equally (Turner, 1969).

The appeal of the concept of communitas to the community arts movement is clear, as arts encounters can similarly be described as creating liminal moments in and out of time, moments which almost by their nature cannot last but are fissures in or transformation of established ways of being and living. There is an alignment here with Nicolas Bourriaud's concept of a 'microtopia', describing how participatory arts constructs a temporary community, brought together through an intersubjective experience (2002: 13). Part of Bourriaud's objective is to assert the value of such encounters and connections, produced through participatory art, even thought they might be temporary, fleeting, liminal. There is at once an implicit lesson here about overclaiming – within the community arts there is often a desire to reach for language of the 'transformational' – and awareness of the sheer systemic stuckness of the world in which small moments of freedom and beauty are valuable neither despite nor because of their fleetingness. It is for this reason that elsewhere I've turned to Bourriaud's concept to describe the value and inherent humanness of fragile and fleeting moments of connection (Reason, 2022).

In the context of COVID-19, the Clap for Our Carers social movement discussed above can be analysed within the framework of creating a microtopia, temporarily disrupting and reshaping the public realm. However, the critiques of the Clap for Our Carers phenomenon – tokenistic, unchanging of underlying inequalities – are also the frequent critique of participatory arts. That is, they produce liminal experiences that feel good, genuinely and legitimately, but which are palliative to enduring status quo relationships rather than productive of lasting change. Perhaps similar things could be said of the idea of communitas. These questions are larger than this chapter and indeed go to the heart of any participatory practice, both in the context of the pandemic and beyond (see, for example, Bishop, 2012; Matarasso, 1997). While not productive of answers, their reflective consideration does heighten our ability to analyse the operations of togetherness and nuanced qualities of engagement.

The community and participatory arts, one could argue, have generations of experience in generating experiences of communitas within physical spaces. With the CDB we were looking to create a kind of communitas, while also learning and experimenting with how to do so operating online. One distinctive feature of the CDB was that the virtual workshops and physically dispersed participants were all working from the same tangible object that they held in their hands. Alice Linnane, of young people's learning disability arts company Square Pegs Arts, reflected on the impact of this, noting it was 'really interesting to have a mix of something that's very physical and tangible. Something in your hands that you use every week.' Hannah Thompson of York-based Accessible Arts and Media also noted how the shared physical book produced a shared experience while apart:

With the doodle book, they all had the same thing. And they were all excited. 'How did you get yours in the post? Did you get yours?' And they were actually helping each other a lot more than they would normally. Like when we got to the pages, and we held up the doodle books to the camera so that everyone could see what they've done. And that was a really, really big thing for people. So I think they were doing things differently. But actually, they were doing it together. And they really like happy showing each other and their creations.

Here it is worth noting that echo of the value of 'doing it together', and in particular doing things that are valued and which feel productive.

The CDB operated by bringing people together in two different kinds of non-traditional spaces. One of these was the virtual space of the 'Zoom room', which has its own particular affordances and limitations. However, with the CDB project this online space was always accompanied by the physical and distributed space of the page within the Doodle Book itself. As highlighted in the introduction to this chapter, the utilisation of these two spaces in parallel was a key dynamic of the project, with participants able to be together (working at the same time, on the same page) while also working apart and with agency. Several of the partner organisations noticed that this produced a different way of working together to their normal online practice, one that slowed things down and brought a kind of calmness. Imogen Barton-Wells, of Proud and Loud Arts, for example noted that:

I think you can kind of throw everything at a session sometimes if you feel it is running away from you. And I thought this had moments of stillness and quiet that were kind of the antithesis of my work.

#### Similarly, Hannah Thompson of AA Media, commented:

On our Zooms at the moment we don't have quiet time. There's always something going on. There's always me encouraging people in the background, kind of chattering away. And the fact that they got that quiet time, but were actually still with other people, I think they've really benefited from it.

The quality here – of being companionably present with other people – is a particularly powerful kind of togetherness. One that doesn't feel forced or the requirement to fill every moment with activity in order to assert its legitimacy but rather acknowledges value within the presence in and of itself. For Joshua Green of Lawnmowers a learning disability theatre company from Gateshead, the CDB allowed people to be 'Working on something online but in a spacious way' or Jo Frater of learning disability dance company Confidance 'With the Creative Doodle Book there is something about the quietness of working [that] allows people a bit more space.' The Doodle Book therefore enabled a return to that almost secret joy and benefit of calmness, and just hanging out together.

It is not accidental that the very concept of doodling aligns itself to calmness, to allowing the mind to drift in manner that is akin to daydreaming, to considering what if, to not worrying about outcomes. Doodling is about process and not product. As noted above, the books were private, physical, tangible spaces which belonged to the participants. They were a space into which the participants could drift, explore and play. Returning to ideas of togetherness as a form of communitas, this balance is key. A community or experience of togetherness in which we lose entirely our sense of ourselves is potentially as harmful as a world in which we all remain atomised individuals.

The bigger critiques of the value of such liminal experiences remain. The CDB could not permanently transform the material experiences of isolation that accompanied the pandemic. At its least it provided a respite, something positive and uplifting to look forward to. Many of the participants discussed how participating in community arts was central to their identity and their relief that online practices such as the CDB meant they could continue to feed that element of their sense of self. For example, Luke from learning disability self-advocacy group Our Lives Our Ways commented: 'It made me reflect on the past year, but it made me feel confident about the future. […] And more confident about myself as well. It brought me out of myself again. Because with isolation I found it really hard.'

It is ideas of selfhood, and the relationship between the self and the other, that will be the focus of the next section.

# **Selfhood**

The importance of considering the self – that is, the individual and their sense of selfhood – might seem counterintuitive in discussions about togetherness. Indeed, central to critiques of neoliberalism has been an over-emphasis on the individual, and specifically individualism, to the active degrading of ideas of community. Individualism and selfhood, however, are not synonymous – indeed, a strong sense of the self as having autonomy and agency seems vital to a healthy and non-coercive experience of community. Rather than being counterfactual, a sense of self emerges through engagement with others. Often this is described in terms of identity politics, of in-groups and out-groups, and of definition in opposition to the other. Here, however, I am interested in the idea of the self that can be developed through being together *with* others.

One recurring framework here is that of dialogue, which invites us to consider the ways in which people engage with people as equals and peers. Dialogue is at the heart of Mikhail Bakhtin's writings, describing how the self cannot be self-sufficient but is always formed in relation. That is, in dialogue: 'I am conscious of myself and become myself only through revealing myself for another, through another and with the help of another. The most important acts constituting self-consciousness are determined by a relationship toward another consciousness' (cited in Crang and Thrift, 2000: 27).

That the self is formed in relationship to others recurs again and again across philosophy. The nature or qualities of this of course vary: whether from the coercive societal gaze articulated in existentialism or a more neutral sense of co-being in phenomenological intersubjectivity. For Paolo Freire, dialogue is central to his proposal for a liberatory education, described in contrast to hierarchical, one-directional teacher–student relationships (Freire, 1972). Dialogue here is about people encountering each other in a particular kind of way, which Sandra Smidt writes 'relates to the fact that humans are born into and live in communities made up of other humans with whom they constantly interact' (2014: 23). As with Bakhtin, for Freire dialogue also has a function in individuals' claiming of self, or conscientisation, although now in a more political form of being able to assert meaning and consciousness upon the world around us.

A further articulation comes from Martin Buber, who describes how every human encounter can be understood in terms of relationships between the self and other, which either tend towards an I/It or I/Thou relationship. I/It relationships are instrumental or monologic, not unlike Freire's description of a uni-directional or 'banking' style of education. In contrast I/Thou relationships are dialogical, open-ended and mutual (Buber, [1923] 1999). Such I/Thou relationships occur within a community, with the following articulation from Buber appropriately enough cited by Turner:

Community is the being no longer side by side (and, one might add, above and below) but *with* one another of a multitude of persons. And this multitude, thought it moves towards one goal, yet experiences everywhere a turning to, a dynamic facing of, the others, a flowing from I to Thou. (Buber cited in Turner, 1969: 372)

In our reflections on experiences of the CDB we felt that it constructed a mode of communitas – a shared modality of being and doing together – but which also encouraged particular reflections on the individual and their role and relationship to the group.

Jo Frater of Confidance, for example, reflected on how the parallel spaces of the Doodle Book and Zoom room enabled autonomy within the collective doing: 'Everyone's got their own space, no one's comparing themselves to anyone else. You know, they're able to have their privacy and their art time and creativity in a really private way. And then they get to share it in this really nice, communal way.'

Tina Shuker of learning disability theatre company In on the Act identified a similar process, where by working online participants could be together but also 'there's space for the participants to go off and do something' on their own. This was markedly different to in-person practice, which can produce an intense form of groupness in which the individual disappears. While Alice Linnane of Square Pegs talked about the balance between 'creating a space that was collective and communal' and space 'that's just them and their book'. Joshua Green of The Lawnmowers drew this together into a broader conceptualisation of the benefits of working together online while apart: 'I guess it's people doing like, tasks more autonomously. […] people, being in their own space, going off and doing things and bringing them back. […] showing different sides of themselves.'

It is worth recognising that the manner in which online practice expands community arts into spaces of autonomy and privacy does bring its own challenges. Autonomy includes the potential for disengagement, without the at-the-shoulder support that is possible within a physical space – and indeed there were several comments about the difficulty of providing one-on-one support online in a manner that didn't disrupt the whole session. With learning disability practice, the engagement can then depend on the availability or otherwise of family or carer support (see Reason, 2023). Online workshops also raise valid questions about safeguarding structures, as they open individuals' home lives and privacy to outside view. Acknowledging these concerns, there are a number of reasons why this autonomy within the experience of communitas should be recognised and celebrated. Various practitioners working with the

CDB contrasted this way of working to experiences of in-person practice, which can be dominated by the same (particularly extrovert) individual or lead to forms of 'group-think'. Jess Robson, of inclusive youth theatre company Fuse, for example, reflected that working online they heard from different and more members of the group. Within the specific context of learning disability practice, such autonomy is vital, countering a cultural/social experience of being silenced and spoken for which was only exacerbated during COVID-19 (McCausland et al., 2021). The relationship between learning disability autonomy within supported or facilitated structures is something that Lauren Hall explores in her analysis of learning disability arts practice. Hall suggests that while a 'full' independence is often held up as a marker of aspiration and achievement, in fact relationships of interdependence more accurately describe all our experiences as humans living alongside other humans. The question for Hall, and in this discussion, is the extent of the learning disabled individual's agency and autonomy within such interdependent structures (Hall, n.d.).

This autonomy, however, was simultaneous within a process that was shared. Each individual was aware that other people were present, also engaging with their own books and in their own physical spaces with the always implicit invitation to then share and compare and take pleasure in how other people had responded very differently to the same task. Here the two spaces, virtual and book, came together. In almost every session there would be a moment when – across the series of tiled rectangles on the Zoom screen – participants would hold their books up to the camera and create an instant gallery (see Figure 2.3). As Hannah Thompson of AA Media put it: 'You could really see that they were looking and concentrating at other people's, and if somebody did something a bit different it was like Ohhh, they didn't think of doing it like that.'

This doing apart, doing together, doing with and alongside and in conviviality represents, I would argue, a form of dialogue. A dialogue that was not always verbal, but which nonetheless fulfils the descriptions of interpersonal encounter of Freire and Buber. Indeed, that dialogue has the potential to be non-verbal is an important point to note, given the context of working with people with various learning disabilities. A fundamental principle of the Doodle Book was that of the 'open task', where the same stimulus or starting

**Figure 2.3** Instant virtual gallery, Fuse Theatre

point could prompt multiple different kinds of responses regardless of skill or cognitive ability. This was central to the design of the book and the workshops and was picked up upon by many of the practitioners, including Jess McKenzie of learning disability theatre company About Face: 'I like the open endedness of it. I like that it gives you a starting point. It can lead to all sorts of things, which is quite unexpected. It feels that it's just an opportunity to be creative, therefore, it's open to anybody.'

The CDB therefore enabled the engagement with experiences of togetherness that were inclusive in a manner that represents not just a set of technical requirements (which might be better described as accessibility) but which aligns with Sailaja Chennat's description of inclusivity as an 'outlook, a conviction and a philosophy': 'Inclusion is a way of implementing the democratic principles of equality and justice with acceptance and conviction so that every individual of the group feels accepted, valued and safe' (2019: 39).

Through this ethos and practice of inclusivity the CDB constructed a kind of microtopia, a temporary space (both physical and virtual) in which participants were able to exercise a sense of self within the experience of communitas. In the context of COVID-19, during which learning disabled people were at once among the most vulnerable but simultaneously often excluded from public discourses, this inclusive togetherness that did not erase the individual felt particularly significant and empowering.

# **Conclusion**

Togetherness is an unassuming word, which became perhaps overused and certainly over-politicised during COVID-19. While the evocation of togetherness was utilised by government to support public health strategies and produced genuine grassroot responses to experiences of isolation and dislocation, it was also used to hide inequalities, shut down criticism and in tokenistic gestures that could never substitute for meaningful action.

The stakes are different in the community arts, but nonetheless it is important to interrogate what we really mean in the claims we make about applied and participatory practices. The discussion here of the CDB has sought to model a more nuanced exploration of togetherness, specifically within emerging online community arts practice. Here communitas and selfhood have been presented as concepts that allow us to think into togetherness, beyond the rhetoric and consider when it is productive of meaningful and authentic experiences. As a final thought within this conclusion I want to stress a third theme, which is that of inclusivity.

The pandemic exposed the hollowness of rhetorical togetherness in public discourse, resonating across a range of structural inequalities. It was a togetherness from which certain individuals, groups and communities were excluded. The CDB project created a space – the space on the page and the virtual space via the screen – in which inclusivity was taken as a fundamental starting point of how we should be together. Governmental, corporate, top-down assertions of togetherness result in a loss of authenticity and autonomy and the exclusion of anybody who does not fit within a homogeneous narrative. One question that we must ask after COVID-19, is how can we be together, in communitas, but without losing autonomy and inclusivity?

The CDB was a creative adaptation responding to particular circumstances, from which we can learn important lessons for the future. None of the partners involved would have moved so swiftly or with such inventiveness into online practice if not required to by COVID-19 restrictions; as we recover from COVID-19 there has been an equal rush back to in-person delivery. With resources limited, this has resulted in online delivery ending and the benefits that it provided being lost. There is a lack of inclusive and accessible online community spaces, both for learning disabled and others who might benefit from ways of being together while apart. During COVID-19 practitioners (the CDB is just one example) learned how to deliver this kind of inclusive virtual practice, but that learning is already being set aside. With appropriate support, in the form of investment, technological infrastructure and skills training, there is strong potential for the ongoing delivery of *online* community arts to provide a network that supports the social and individual resilience that a genuine sense of togetherness enables.

# **Key insights**


# **Note**

1 The Creative Doodle Book: Developing Inclusive Community Arts Engagement during Physical Distancing project was funded by the Arts and Humanities Research Council, project reference: AH/V011405/1.

# **References**


# **Part II**

Places and spaces

# Just walking: creative methods towards pedestrian equity

# *Dee Heddon, Maggie O'Neill, Clare Qualmann, Morag Rose and Harry Wilson*

'Walking Publics/Walking Arts**:** walking, wellbeing and community during COVID-19' was an Arts and Humanities Research Council-funded research project exploring how adults across the UK experienced walking during the COVID-19 pandemic and the role of creativity in walking activities. Employing a range of methods, from a large-scale survey to walking interviews and artist commissions, the research identified the potential of the arts to sustain, encourage and more equitably support walking during and recovering from a pandemic.1

The interdisciplinary research team, working across performance and visual arts, cultural geography and sociology, share an interest in creative walking practices, as scholars and practitioners. Our use of the term 'walking' does not presume bipedal mobility; walking is not just undertaken on foot and can include all sorts of technologies which help disabled people and anyone with mobility issues to move around. Walking can be undertaken indoors as well as out, and we also include imaginative walks – walks of the mind rather than the body.

Our research builds on the existing evidence base for the general benefits of both walking and art on physical health and mental wellbeing, locating this within the context of the pandemic. Quantitative research, our own included, indicated that during COVID-19 some people walked more frequently, but some people walked less (Department for Transport, 2021; Stewart and Eccleston, 2020 and 2022). Engagement with walking activity was unevenly distributed before and during the pandemic, and access to walking continues to be dependent on many variables, including opportunity, environment, health and perceptions of safety (Twohig-Bennett and Jones, 2018; Friends of the Earth, 2020). The concept of pedestrian equity – or 'just walking' – within and beyond the pandemic has yet to be fully addressed. Our use of the term 'just walking' signals its doubled meaning and the implicit tension between walking as a supposedly simple act and walking as a question of equity and justice. Through knowledge co-creation with artists, in partnership with environmental and arts organisations, we were able to better understand how walking and creativity in combination might more equitably support walking by addressing systemic barriers and subverting walking 'norms'.

# **Understanding walking and creativity during COVID-19**

There is a wealth of evidence that walking and the arts both play a role in sustaining and improving physical and mental wellbeing. The known physical benefits of engaging in walking activity include improving the performance of the heart, lungs and circulation, lowering blood pressure, reducing heart disease, improving flexibility and boosting the immune system. Walking also benefits mental health, registering positive impacts on mood, anxiety and sleep. Walking with others can help mitigate feelings of isolation (Morris and Hardman, 1997; Murphy et al., 2007; Hanson and Jones, 2015). Walking is also typically – though not exclusively – an outdoors activity and often provides a route to accessing green spaces. Spending time in green space delivers additional mental health benefits (Twohig-Bennett and Jones, 2018). Engagement with the arts – which can variously involve imaginative, emotional, and cognitive stimulation and social interaction – may produce beneficial psychological, physiological, social and behavioural responses, ranging from and including enhanced confidence, new skills and peer networks, reduced isolation, and lower stress levels and anxiety. Some arts practices, such as dance, additionally harness the health benefits of physical activity (APGA, 2017; Fancourt and Finn, 2019).

'Creative walking' sits in the generative nexus of walking and art, and often also green space, although many artists seek strategically to locate and appreciate the green in the grey, for example the wildflowers thriving in the cracks of pavements, thereby extending

our understanding of 'green space' beyond partitioned 'natural environments' such as parks, forests or nature reserves.2 By 'creative walking', we refer to activities that people or groups may undertake while walking which have an imaginative, playful, or task-based framework. These frameworks add an additional layer or lens of attention to the walking activity, giving it a particular direction and focus. Examples of creative walking include following a painted stone trail or looking out for everything that is yellow on your walk. Our research also expands the definition of 'walking' beyond the physical act to include imaginative or proxy journeys.3 For example, 'Walks to Remember During a Pandemic: with memory I was there', by artist Louise Ann Wilson, demonstrates the emotional and mental benefits to be had in imagining a favourite walk, even when not able to undertake it (Wilson, 2020). In a proxy walk, a walk is undertaken at the request of, and on behalf of, someone else, and then relayed back, for example through drawings or photos which document the work, or simultaneously using video conferencing technology.

Our digital survey, addressed to UK-based adults aged 18 and over, ran from 27 April 2021 to 21 May 2021. The purpose of the survey was to help us understand, in more depth, how people experienced and felt about walking during the pandemic and whether they created or encountered creative walking activities. Survey questions covered the period from the UK's first lockdown in March 2020, to the date the survey closed. Questions asked respondents to reflect on how often they walked, why, where, with whom and how they felt about it during the different stages of the pandemic. We circulated the survey via project researchers' and partners' networks and though we do not position it as a representative sample of UK adult residents, the 1221 responses, many of them qualitative in content, offered useful insights into people's experiences of walking during the pandemic (Rose et al., 2022).

Key findings to emerge from our survey were that most respondents walked more and walked more in their local neighbourhood, though some people walked less. The most popular reasons for walking included exercise, health, wellbeing, relaxation, to get out of the house and to visit a green space. Daily walking helped establish a routine when working from home and offered a way to engage children in outdoors activity. Lockdown prompted many people to explore their local environments in more depth and engage in creative walking.

Our findings align with other studies; one reported that 74 per cent of Britons said they had taken up some form of exercise during the first lockdown, with the most popular form being a walk (Department for Transport, 2021), while Stewart and Eccleston's report for NatureScot found that participation in outdoors activity was higher than usual and that walking was the most popular activity of those visiting the outdoors, with increased numbers of people making visits to outdoor spaces for exercise every day during lockdown (Stewart and Eccleston, 2020). That they also found increased numbers of people taking no visits at all demonstrates clearly the widely variable impact of the pandemic on individuals and the corollary need for post-pandemic resources and actions to be alert to and address this continuum.

# **Creative walking during the pandemic**

Our focus on creative walking during the pandemic is, as far as we know, the first study to explore this subject. It offers substantial new information, specifically around the potential value of creative walking as a tool of engagement with additional health and wellbeing benefits. Most of our survey respondents had engaged with some form of creative walking activity, particularly 'Following or encountering a "thing"', which might include art trails, window trails and treasure hunts. Many respondents also devised their own creative walking activity, such as composing local guidebooks, walking to create digitally tracked shapes, or 'themed' walks.

Comments by respondents demonstrated the various positive impacts of creative walking, from stimulating the imagination, to motivating people to take exercise, and offering creative ways to safely connect with others and bridge physical distances. Simple interventions such as pebble or window trails fostered a sense of community and mitigated feelings of isolation. Photographing environments provided a way to document and make sense of the pandemic but also to engage more deeply with local places and, often using social media platforms, to share individual experiences with others. Creative approaches, including geocaching and treasure hunts, also offered encouragement for children to walk.

# **Barriers to walking**

Alongside understanding why and how people walked during the pandemic, we were keen to identify barriers. The most frequently reported were the weather, work commitments, pandemic restrictions, time, physical and/or mental health, caring responsibilities and fear. Most of these barriers existed before the pandemic, but for some respondents they were exacerbated, and for a significant number – 23 per cent – the pandemic directly caused the issue that stopped them walking. This included fear of busy places, shielding and health (Rose et al., 2022: 12–15; 38–43).

I have really wanted a balcony or a garden during lockdown – somewhere I could be outside, get fresh air, and be in my own space. Instead, I have had to make do with walking to/from somewhere specific (shops, GP surgery) or very rarely hang out in a public area … because of where I live combined with how busy all the parks have been.

Over the Winter especially I found it harder to fit in walks as I did not feel safe walking alone in the dark after work.

I was paranoid about being viewed differently due to my perceived ethnicity, especially when hate acts spiked in the US, being a nonwhite person in a predominantly white market town.

(Respondents to the anonymous survey)

While our survey is not offered as a representative sample of adults across the UK, other research similarly suggested that experiences of walking and associated access to outdoor space, including green space, was inequitable during the pandemic. Sport England, for example, reported increased walking for exercise, but at the same time noted that 'those from lower socio-economic groups, older people, Black, Asian and minority ethnic (BAME) groups and women' were all less likely to be active during the first lockdown (Sport England, 2020). That many people in these socio-economic groups were more likely to be key workers and therefore also less likely to be working from home, suggests one correlation. Stewart and Ecclestone similarly note highest participation in outdoor exercise among men, younger age groups, residents of least deprived areas, higher social grades and those with good health. By contrast, 'older people, those living in the

most deprived areas and those not in good health were most likely to have taken no outdoor visits at all' (Stewart and Eccleston, 2020: 13).

# **Walking commissions: 'walking with'**

Recognising the positive impact of creative walking reported by many survey respondents, alongside the challenges they identified, we commissioned eight new walking artwork pilots to explore how creative walking practice might variously help to:


Our commissioned artists collaborated with a range of partners and explored very different methods of creative walking which responded to specific contexts, including a hospice and a dementia centre. All the works created sought to address intersectional issues of marginalisation and exclusion.4 Our commissions modelled various forms of 'walking with', which, borrowing from Springgay and Truman's work on walking as a research methodology, is a practice of walking that is 'accountable [and] is a form of solidarity, unlearning, and critical engagement with situated knowledges' (2019: 11). Such an approach places participants' experiences and expertise at the centre of the practice, allowing this to inform and shape both process and outcomes, rather than expecting people to fit into existing normative practices which then persist unchanged. Springgay and Truman critique participation as too often symbolic, framed through a logic of inclusion and rehabilitation, rather than an undoing of 'the structural logics of racism, ableism, homophobia, and settler colonialism' (2019: 13). While participatory models of inclusion may serve to bring the margins into the centre, such a move can disguise systemic structures of oppression.

Before focusing in detail on two of our commissions (Sheffield Environmental Movement and Open Clasp Theatre Company), we offer a snapshot of the other six, demonstrating the rich range of ways in which creative walking can be used to actively address and respond to barriers to participation. 'Finding a Way', developed by Kate Green in collaboration with Leominster Meeting Centre, devised a non-linear heritage trail around the town with and for people who live with dementia. 'Plantar', by Laura Bradshaw and Steven Anderson's, offered an audio-walk created for and to be listened to in the seasonal gardens of Glasgow's Prince and Princess of Wales Hospice. 'To the Moon and Back', by Shonagh Short, explored with a small group of mums in Bolton the daily walk to school, collectively revealing it as a significant journey of care and space of transition. Henna Asikainen's creative walking was developed in collaboration with North East Solidarity and Teaching, a student-led charity based at Newcastle University which teaches English as a second language and organises community integration support for people in Newcastle who have experienced forced migration. Henna's walks, all of which ended in a communal meal, sought to challenge exclusionary cultural practices that impress a sense of homelessness and not-belonging. London-based Arts Canteen supported artist Areej Kaoud in the development of a live art piece, 'Intimate Distance', which used walking games to create imaginative and playful connections between bodies, responding to the physical isolation felt by so many during pandemic lockdowns. Museum of London Archaeology (MOLA) partnered with artist Elspeth Penfold and East Kent MENCAP to explore how creative walking can create new approaches to public archaeology, working with a range of different materials, including rope, to open landscape up to different embodied experiences and representations.

Responses from artists, organisations and participants to each of these pilot projects demonstrates the potential of creative walking approaches to support participation in both walking and creative practices, and the wide variety of potential benefits which can emerge. Importantly, models of participation push against conceptual norms attached to 'walking', including what counts, who does it, and how it is done. For example, Shonagh Short, in her collaboration with mums – who, she notes, would not identify themselves as walkers – repositioned the daily school run as a meaningful and valued site of exploration and discovery. Laura Bradshaw's and Stephen Anderson's audio-walk not only offered patients a relaxing experience, but also their visitors. Staff observed that visitors to hospices need such restorative space too, yet often feel unable to leave those they are visiting. The artwork also functioned as an act of care for staff, an invitation to spend time on their own in the garden, to slow down, observe and reflect.5 Kate Green developed a new methodology, a form of the proxy walk, for her work with Leominster Meeting Centre. Her aim was to explore Leominster guided by Centre members, in whatever way best suited their needs, 'walking with' people who had a range of mobilities, interests and experiences of dementia. Wearing a headphone with a microphone and her mobile phone on a selfie stick pointing at either herself or the environment, Kate was joined by both those who wanted to physically accompany her and those who preferred to stay at the Centre, where a Zoom screen ran on a giant whiteboard. Those at the Centre could see where Kate was and guided her by offering instructions. As Kate explained, they shouted '"go over there, or go into that shop and buy a cake, or take off your shoes and socks and run into the sea." Or I can ask them, "do you want me to cross the road here or to carry on towards the river?"' Kate recognised the walk as an improvised and fluid two-way interaction, left as open as possible to ensure participants have choice and agency in the walk's unfolding.6

# **Walking, equity and creative interventions**

Focusing in more depth on two of our commissioned art walks and the contexts within which they take place, our intention is to foreground the work that creative walking can do in addressing and challenging systemic barriers to equity and the social, structural, cultural and relational contexts in which 'walking' takes place.

# *Commission 1: Sheffield Environmental Movement (SEM)*

SEM is a charity based in Sheffield which works with Black, Asian, Minority Ethnic and Refugee communities to promote social and environmental justice. Led by Maxwell Ayamba, SEM was founded

in 2016 as a Charitable Incorporated Organisation. Prior to setting up SEM, Maxwell was also co-founder, in 2004, of the '100 Black Men Walk for Health Group'.7 In 2015, this became Walk4 Health, expanding its invitation to women and people of colour. SEM's aim is to ensure everyone has a clean, healthy environment, pushing for a 'fair green deal' for individuals to help them develop resilient and prosperous communities by ensuring the environmental sector listens to and is guided by all parts of society including people who feel 'invisible' and marginalised.8

In 2021, project researcher Maggie O'Neill joined SEM for a walk and talked with participants about their experiences of walking. Maxwell offered key insights into SEM's formation. The initial '100 Black Men Walk for Health Group' was not founded as a rights or protest movement, but it inadvertently became a political statement in response to the paradoxical experience of Black people walking in the British countryside feeling simultaneously invisible and hypervisible. Even though Black people have and do inhabit the British countryside, their persistent erasure from rural history positions them as being 'out of place'. Being made to feel out of place can be a deterrent for Black people and people of colour and covert forms of micro-aggressions and more overt racism are significant barriers. In her walk with SEM, one participant admitted to Maggie that he 'didn't walk a lot during Covid because the area where I live, there is not much black people round there'. Maxwell also reminds Maggie that Black people have been written out of the landscape and have been 'culturally severed or detached from our heritage, our roots. So, walking in England is seen as a White privilege, hobby or sport.'9 Walking in the British countryside is a racialised activity.

One organisation with substantial connections to Britain's rural environment and influence over its reception and interpretation is the National Trust. Aiming to redress historical erasures by writing Black people and people of colour *into* British history, in 2020 the National Trust published an 'Interim Report on the Connections between Colonialism and Properties now in the Care of the National Trust, Including Links with Historic Slavery'. This explicitly reveals the connections between many of the country houses and vast grounds to which they are attached and colonial practices, including the slave trade. As co-editor Sally-Anne Huxtable notes in her introduction, 'somewhere in the region of one-third of [National Trust] properties can be directly connected to colonial histories [and] the research also highlights interesting evidence about the presence of African, Asian and Chinese people working on English and Welsh estates' (Huxtable, 2020: 5). In a later chapter, Huxtable writes that 'records and portraiture provide evidence that a number of people of colour lived at properties now in the care of the National Trust from the seventeenth century (and possibly even earlier)'. Some individuals with mixed African heritage owned properties, but the majority 'were servants, or possibly enslaved individuals' (Huxtable, 2020: 10).

In his discussion with Maggie, Maxwell identified other barriers to walking, including cultural perceptions (walking perceived as a way of livelihood or mode of transport, rather than a leisure pursuit), pressure on time and competing priorities, the commodification of walking including pressure to 'have the right gear', and lack of knowledge about and therefore confidence of being in the countryside, which causes anxiety. SEM's purpose is to support Black people and people of colour to access local green spaces, to build knowledge, skills, confidence and community through group walks and to demonstrate, *through* walking, that green space is for everyone. As Maxwell puts it forcefully, 'where green becomes white, there can never be diversity', an insight which resonates with Jason Byrne's point that the cultural politics of park *making* encode and reproduce greenspaces according to 'White ideals of nature', including the notion of the urban pastoral (Byrne, 2012: 596). Though writing about Los Angeles, Byrne's findings can be extended to the UK, not least because many of the historical discourses underpinning USA environmental movements are anchored in racist European ideals which serve to recycle narratives of white goodness and innocence (Bratman and DeLince, 2022; Finney, 2014: 25–27). The cultural production of 'nature', as represented in these green spaces, perpetuates exclusionary ideas and practices 'of *what parks are*, *where* they should be built, and *who* they are intended to serve' (Byrne, 2012: 598, emphasis in original).

Inequitable access to green space is one aspect of environmental inequality and is an enduring, intersectional issue across the UK. Predictors for being an infrequent visitor to green/blue spaces for

recreation include socio-economic status and disability. The main reasons cited by people include distance from home or work, challenging topography and limited path networks, safety concerns and lack of time due to working longer hours (distributional inequity is both spatial and temporal) (Boyd et al., 2018; Nesbitt, Meitner and Sheppard, 2018). Friends of the Earth's recent mapping of the 'green space gap' in England reveals not just a marked disparity in access to green space but 'a strong correlation between green space deprivation and ethnicity' (Friends of the Earth, 2020; see also Natural England, 2017). Signalling the intersectionality attached to issues of environmental justice, the link between green space deprivation and income is noted here too. Black people in England are also four times less likely than white people to have their own outdoor space (RICS, n.d.).

Green space inequality not only persisted during the pandemic but potentially deepened. Data collected in spring 2021 show that the majority of those visiting green and open spaces the previous four weeks belonged to higher socio-economic groups, with those in lower socio-economic groups reporting lack of local green spaces and accessibility (Olsen and Mitchell, 2021; see also National Trust, 2022). The reported gap in 'green space' *provision* is important because it shifts the point of analysis and interpretation from a behavioural to a resource deficit. Where the former places responsibility on individuals and, by demographically grouping people together, risks essentialising behaviour, the focus on a deficit of resources, such as access and provision, centres systemic structures and resultant inequities.

It is within this context of systemic environmental inequality and indeed environmental racism, that our commissioned walk with Maxwell Ayamba and Sheffield-based artist Jenson Grant took place. Maxwell and Jenson collaborated with ROSHNI Asian Women's Resource Centre. Established in 1992, the aim of ROSHNI is to 'advance the welfare and education of South Asian women in Sheffield'.10 Notable in the Centre's contextualisation of their aim is reference to the women's isolation, due to cultural re-adjustment, racial prejudice and urban deprivation.

For this commission, Maxwell and Jenson developed a sci-art walking project to explore natural indicators of air pollution in and around Sheffield. Commencing while COVID-19 restrictions were still in place, Maxwell gave an online presentation about air pollution, including its potential impacts on health. This was followed by a face-to-face workshop introducing the OPAL tools which monitor air pollution,11 and in-person group walks to both inner city areas of Sheffield (Darnall and Sharrow) and to the Peak District (Longshaw Estate, purchased from the Duke of Rutland by the Sheffield Corporation in 1927 and now managed by the National Trust).

The OPAL tools offer a framework for measuring air pollution, with nitrogen-tolerant and nitrogen-sensitive lichen functioning as bioindicator systems.12 Supported by Jenson, the group used digital cameras and audio recorders to capture their experiences of walking together and being in both familiar and unfamiliar environments. (See Figures 3.1 and 3.2 below.) Jenson and Maxwell then collaborated with the women to digitally manipulate, edit and compile documentation, creating a collaborative multi-media record of their project comprising titles, audio-recordings, still photos and video. The artwork created by the women foregrounds the attentiveness of their walking, of getting to know an environment through careful looking (the artwork presents a rich collage of shadows, shapes, textures and longer views) and also walking's hapticity (hands feeling branches and cradling soft mosses). The conviviality and collaboration of the group walk is foregrounded in the work too, with a branch held by someone so that someone else can take a photo, playfulness captured in a spray of water, and an ensemble of women gathered atop a slab of granite, their stories visibly circulating among each other. The audio segments of the artwork relate the resonances of distant homes in strange(r) landscapes, bringing the latter closer and making them more familiar in the process – 'It brings back [a] memory of home', says one of the women. Words in English, such as 'plant', are given their Urdu and Punjabi equivalents, recentring and valuing the women's knowledge. We are shown the women enacting skills of scientific observation, using magnifying tools to identify lichen and determine pollution levels, with cameras and audio recorders in hand to document their experiences and, later, computers to create the collaborative artwork. Also brought into focus are their observations and insights on the different environments they

walked, with the Longshaw Estate perceived as having fresher air than the urban environments in which they live:

What's it like here? Very fresh. Enjoyable. […] More green here. Feels like when you take a breath, it feels a different, nice breath. Fresh air. Nice weather. It's very nice.

(Spoken text, transcribed from video montage)

This innovative sci-art approach addressed many of the challenges identified in our research. It used walking to create a convivial, safe space, which enhanced social connectivity between a group of women. It increased the women's knowledge of their environment and empowered them by reinforcing and extending the knowledge they already hold in new environmentally focused directions. While walking and accessing green spaces have been shown to have demonstrable health benefits, vitally important in this work was the explicit acknowledgement of health and environmental inequalities, the two often implicated. The walks in Sheffield's urban environments oriented the women to the 'nature' on their doorstep. Using the OPAL toolkit also, however, enabled those women to 'read' the signs emitted by 'nature' regarding levels of pollution in the city air – the air which they breathed daily. Walking further afield, in the Longshaw Estate, introduced the women to a new area, possibly building confidence in accessing that space through both the visit and the subsequent creation of artwork documenting it which served to explicitly write the women into that landscape. (Notably, all the signs at Longshaw are only in English, and both Maxwell and Jenson acknowledged the importance of having a translator in the project [see Byrne, 2012: 596].) At the same time, having developed the knowledge to interpret the lichen signals, the women understood that this space, further away from Sheffield and where they live, was demonstrably healthier.

Like access to green space, experience of air pollution is stratified. Largely an urban problem, neighbourhoods with the highest air pollution levels are also the most ethnically diverse (Fecht and DeLince, 2015). Placing walking, environment and health into this wider context of environmental inequity is to insist on the politics at stake in 'just walking', holding together the multiple benefits and vastly different experiences of walking. While walking is good for health, this persistent message disguises the reality that not all walks are equal, and in areas of high pollution – toxic environments – the benefits of walking are perhaps more circumspect. In this 'walking with' work, the women may become empowered not only to walk more but to be part of a wider movement which insists on healthier local environments in which everyone can walk and take pleasure. While walking delivers personal benefits, 'just walking' gestures towards the need to connect walking campaigns to wider campaigns of environmental equity, pressing for systemic and structural changes which will support more people to access the pleasures and health benefits of walking, taking us towards

**Figure 3.1** Participants from ROSHNI Asian Women's Resource Centre, standing in front of trees, with Sheffield Environmental Movement. Credit: Jenson Grant

**Figure 3.2** ROSHNI Asian Women's Resource Centre identifying moss on a tree trunk with Sheffield Environmental Movement. Credit: Jenson Grant

what Barbara Hudson calls 'beyond white man's justice' (Hudson, 2006). Here, justice is constituted by discursiveness – people can put their claims to justice in their own words and ways, in a process both relational and reflective.

# *Commission 2: Open Clasp Theatre*

Maxwell, Jenson and the women from ROSHNI Asian Women's Resource Centre used a sci-art-walking combination to make visible and share the women's existing knowledge *and* develop knowledge and agency concerning their environments. Open Clasp Theatre Company, with playwright Guen Murroni, used walking to reflect on women's experiences of walking and generate material for the creation of a new activist play addressing street harassment.

Open Clasp, based in the North East of England, collaborates with women excluded by theatre and society to create theatre for personal, social and political change.13 Like SEM, then, Open Clasp both recognises and embraces the potential for personal transformation that may result from participation, in this case in the arts, but is committed to embedding this within a wider systemic context towards social justice, by 'changing the world one play at a time'. Pressing for social and cultural change is to resist neoliberal paradigms which focus singularly on self-help and which present structural oppressions as individualised deficits requiring individualised solutions. In this commission, Open Clasp collaborated with West End Women and Girls Centre, a community centre also based in the North East of England, which aims 'to build the power of women and girls, who have been and continue to be disenfranchised'.14

As preparation, project researchers Clare Qualmann and Maggie O'Neill visited Open Clasp to share with a team of creative practitioners, different concepts and practices of creative walking, focusing on storytelling, place-responsive writing and participation. Writer Guen Murroni then worked with two Gender Equality Peer Educators from the West End Women and Girls Centre to workshop and create 'We', a new theatre piece addressing street safety.

The endemic presence of street harassment is writ large in the walking interview Maggie and Clare undertook with Lily, a representative from the Centre. Lily started the walk at the mural on the wall of the West End Women and Girls Centre. The text on the mural reads 'Misogyny is a hate crime #NotWelcomeInElswick', a response to an act of sexual harassment committed by a local councillor.15 As they walked, Lily shared her own multiple experiences of sexual harassment in public spaces, mapping them across the route on which she took Maggie and Clare, indicating the safety mechanisms she routinely builds into her walks. These included the places where she texts friends and family to tell them where she is and the locations of safe houses, inhabited by people she knows if she needs to divert her journey. Lily also reflected on some of the perceived heightened risks during the pandemic, including the quieter streets. Although Lily's walk was framed by harassment, zones of fear and safety mechanisms for managing the space, the overall impression was that she nevertheless loved to walk and that her regular pandemic long walk to work had changed her attitude and approach to her own health and wellbeing, reinforcing her motivation to work with women and girls to instigate social change. Given the demonstrable benefits of walking to physical and mental wellbeing, it is imperative, as an issue of spatial justice, that the spaces in which walking takes place are felt by all to be safe.

Lily's experiences of street harassment will resonate with most women and are reflected in a 2021 YouGov survey on sexual harassment which found that 71 per cent of women of all ages have experienced some form of sexual harassment in a public space, rising to 86 per cent among 18–24-year-olds (APPG, 2021). A subsequent survey in 2022 reported that 50 per cent of women felt unsafe walking alone after dark in a quiet street near their home and that 82 per cent of women felt unsafe walking alone after dark in a park or other open space (Home Office, 2022). As Lily's conversation with Maggie and Clare signalled, the pandemic did not improve women's experiences of public space. Plan International reported that 28 per cent of women and girls aged 14 to 21 'feel less safe now than they did before [the pandemic], with regards to going out in public' (Plan International, 2020). The most common reason reported 'was feeling that there are fewer people around to help if something happened to them (51 per cent)'.

The doubled idea of 'just walking' – simply walking and walking as a question of justice – felt particularly resonant in March 2021, following the disappearance and murder of Sarah Everard.16 Many social media comments reflected that 'She was just walking home.' Like Lily, Sarah Everard purportedly practised safety mechanisms that night, including using her phone to call her partner while walking and sticking to well-lit main streets. 'Just walking' is often a highly rehearsed and skilled routine.17

This is the context in which the collaborative theatre making of Open Clasp Theatre Company and the West End Women and Girls Centre took place, with collective and individual walking activities forming a key tool to generate material to be used in the creation of content for the play. The group worked together on ideas for the play, based on their life experiences, and the collective walking and writing workshops that they took part in. Together they built the character of Aliyah, a 20-year-old campaigner for safer streets, whose actions are inspired by her experience of harassment. Following Clare and Maggie's earlier workshop, mapping, walking and writing in and in response to specific places fed into the process, along with group and solo walks to collect images, sounds, smells and textures to inform the writing. The materials generated collectively were used by Guen in the writing of the script, which tells the story of Aliyah's campaigning journey, from responding to an incident of street harassment and culminating with the organisation of a mass protest march which blocks one of Newcastle's main bridges. Several of the play's scenes draw on the walking experiences of the young women, including a night walk in the park:

ALIYAH: I hate how we walked down the park yesterday, ten of us, and two lads were behind us and we separated – and let them through. Ten of us, two of them and still … we were the ones to move. We opened up, almost in unison and let them through. We broke our line, we broke our group and we put our head down. And we got quieter and we got smaller.

(Beat)

This rage within me though. This rage within us. It's not a shot in the dark anymore. Because ten of us then was 20. And then 30, then 50 … And now we … we are hundreds. Right here. On this bridge, on this day.

'We' was staged as a public performance at Open Clasp's Annual General Meeting in June 2022, and it issued not only a call to the ongoing and urgent need to address and end public sexual

**Figure 3.3** Two women performers on stage, fists raised. Performance by Open Clasp Theatre. Credit: Ellen Dixon

**Figure 3.4** Two women performers on stage. Performance by Open Clasp Theatre. Credit: Ellen Dixon

harassment but also offered to the young women collaborators a powerful representation and acknowledgement of their lived experiences of moving through so-called 'public space'. (See Figures 3.3 and 3.4 above.) Creative walking workshops provided the structure for collaboration and participation, which then shaped the play's content. The project's facilitators, reflecting on the use of walking as part of a creative process, stated that it would continue to inform their work going forward.18

# **Conclusion**

These two case studies support the findings of our wider research, providing detailed qualitative insight into intersectional barriers and challenges to walking experienced by different communities. They also demonstrate how walking can be both embraced for the pleasures it brings and put to work in addressing inequalities. Through the case studies, we demonstrate examples of pedestrian equity – or 'just walking' – within and beyond the pandemic. The knowledge generated by and with participants and partner organisations supports assertions that:


# **Key insights**


# **Notes**


the misconception of Black people's 'arrival' in Britain being the 1948 Windrush generation. The first Black British Roman Emperor, Septimius Severus, marched with his army on the Old Roman Road, now part of the Peak District National Park. See Marland and Stenning, 2020.


85


# **References**


National Trust, 5–6. Available at: www.nationaltrust.org.uk/whowe-are/research/addressing-our-histories-of-colonialism-and-historicslavery (accessed 12 April 2023).


# Nature's affordances: challenges and opportunities

*Qian Sun, Amy Corcoran and Anna Jorgensen*

Research into links between health and nature recognises that nature is a great source of primary prevention and health promotion for the general population and particular groups (Hampshire et al*.*, 2021; Ward Thompson et al., 2014). Spending time in nature supports mental and physical health, is associated with a sense of gratitude and self-worth, and can help people recover from stress and mental illness. This kind of experience with nature also helps build a sense of place and community and foster feelings of belonging. This has been particularly apparent during the coronavirus (COVID-19) pandemic (Poortinga et al., 2021). COVID-19 triggered a surge in social innovation to address issues ranging from food poverty to social isolation, combined with a dramatic turn to nature as a source of solace, stress relief and relaxation. In urban environments, local green space became particularly significant in this regard (Ugolini et al., 2020), with access to green space understood as a major source of resilience during the pandemic (Geng et al., 2021). Simultaneously, greater discussion of climate change gave rise to growing understandings of the need to redefine human interactions with natural ecosystems.

# **Nature-based Health Services (NbHS)**

There is growing interest in (re)connecting people with nature, either through developing green areas in people's nearby environment or encouraging and facilitating people to actively participate in nature-based activities (Van den Berg, 2017). These activities range from health promotion programmes and projects for the

**Figure 4.1** Tiers of nature-based healthcare interventions

general population, like green gyms or community gardening, to more therapeutic interventions for individuals with a defined need, like care farms or horticultural therapy. These different tiers of interventions are illustrated in Figure 4.1. Nature-based activities and programmes primarily aimed at achieving health benefits (shown at the base of Figure 4.1) are the focus of this chapter and are termed Nature-based Health Services (NbHS).1

The public's growing interest in nature echoes the shift of focus in public health thinking and practice from treatment to prevention through a more integrated approach. NbHS may be a cost-effective way to mitigate demand for medical interventions. One pathway is through Green Social Prescribing: non-medical ways of supporting wellbeing through programmes of activity involving nature. This provides great promise to change the landscape of healthcare and opportunities for stakeholders to participate in implementation. However, while nature can benefit wellbeing, opportunities need to be visible, comprehensible, possible and desirable to be fully realised. Developing and delivering these activities entails challenges and requires people to work together to negotiate the complex ecosystems involving existing green spaces and potential sites, funders, stakeholders, and legal and regulatory frameworks, as well local politics, custom and practice (McHale et al., 2020). Research into these relationships and realities is, therefore, vital to inform policy that works to address inequality and support wellbeing.

This chapter investigates the perceived affordances for NbHS to identify opportunities offered by nature for wellbeing, as well as any challenges present. 'Affordances' is used here to describe the action possibilities for people who play important roles in realising the health and wellbeing benefits of nature. In it we report on findings from the Nature's Way project.2

# **Affordances**

'Affordances' as a term was first introduced to conceptualise people's relational experience with external space (Gibson, 1979). Now it is often understood as the function(s) or possible action(s) that objects offer through interactions with users (Ditzler et al., 2018; Harwood and Hafezieh, 2017). This relationship emerges from the object's properties and the user's characteristics (Norman, 2013), and results in a range of possible interactions (Eastwood et al., 2022). Norman sees that affordances can be invisible and that 'signifiers' or signals help people discover how to access affordances and, thus, reveal possible actions. Norman distinguishes actual from perceived affordances; a range of actions might be possible but those perceived (directly or from past experience) may be more likely to occur. This interacts with the user's desires, intentions and capabilities to determine how they may ultimately decide to act. However, if no affordance exists there can be no possibility for action. Similarly, if accessing an affordance is extremely challenging, it could be considered functionally nonexistent – the ease with which different affordances can be actioned will determine how the actor is likely to act. Therefore, only when (1) the affordance exists, and (2) there is information available such that the actor perceives the affordance, and (3) can potentially act upon, and wants to act upon, the affordance, does the affordance become realised. At this time, the actor may be willing and able to act on this opportunity.

In the context of NbHS, when the awareness of nature-based activities as options for health and wellbeing is absent, or when the barriers to act upon these opportunities (e.g. accessing necessary funding, bureaucratic processes) are considered too immense to overcome, the opportunity will not be considered actionable.

Investigating the affordances of local NbHS, this chapter aims to understand whether nature-based activities for health and wellbeing are considered perceptible and desirable action opportunities by stakeholder groups who play an important part in developing, delivering, supporting or participating in local NbHS. The chapter focuses on the three stakeholder groups: the local council, local third sector,3 and local communities, particularly those operating within Walsall, England. Their early experience and perceptions of NbHS are important to help us to understand the affordances of nature-based activities as options for health and wellbeing. Green Social Prescribing, as a specialised path to NbHS, is also discussed to investigate how Green Social Prescribing is perceived by the UK's National Health Service (NHS) and social care organisations, such as those providing mental health support and how the system of Green Social Prescribing functions.

Through analysing the affordances of NbHS, the chapter aims to reveal opportunities for crisis response and recovery both in the context of COVID-19 and beyond. The following questions are investigated in relation to NbHS delivered to communities in Walsall, in order to understand their affordances:


# **Walsall as an example**

This chapter takes Walsall, a medium-sized urban area in the West Midlands, England, experiencing high levels of deprivation and health inequality, as a case study. Walsall is ethnically and culturally diverse, with around a quarter of its population drawn from minority ethnic communities (Walsall Council, 2022b). It is one of the most deprived 10 per cent of local authority areas in England,4 and overall health is poor (Walsall Council, 2022a). From this, we suggest, learning can be taken to other areas, and neighbourhoods within those areas, where deprivation is also present. These insights

hold significant potential for transferability: 61 per cent of local authority areas in England, for example, contain one neighbourhood in the most deprived decile (Ministry of Housing, Communities & Local Government, 2019). In these deprived areas, health is getting worse and health inequalities are increasing, particularly since the 2008 financial crisis and subsequent austerity measures (Marmot et al., 2020).

Walsall was one of the locations hit hardest by the pandemic in the UK (Office for National Statistics, 2021a). Even before COVID-19, about 28 per cent of Walsall's population had experienced mental health problems, and isolation during the pandemic is thought to have exacerbated existing problems (Poortinga et al., 2021). Research has shown that the health benefits of access to green space are disproportionately greater in income-deprived populations (Mitchell and Popham, 2008), including ethnically diverse populations (Roe et al., 2016). Walsall, therefore, stands to benefit by having wellbeing needs addressed through naturebased activities that can contribute to recovery after crisis and to ongoing resilience. Walsall Council considers that promoting health through nature is a strategic priority (Active Black Country, 2017; Baggott, 2018). However, little research has been conducted to understand how the top-level strategy work translates into perceivable, accessible and desirable action opportunities at the community level.

# **Research methods**

The project used a design-led research method to understand the affordance of NbHS and to reveal challenges and opportunities for implementing NbHS at a local level. The project took Walsall as a case study, considering the impact of the COVID-19 pandemic in particular.

Design-led research is a form of participatory action research. It offers an open-ended, collaborative and transdisciplinary approach for developing new, creative and actionable solutions for complex challenges. It allows researchers to incorporate their creative practice into the research design and as a part of the research outputs. Developing NbHS is a complex challenge that requires collaboration between different disciplines and stakeholders in the system; we used design-led research to achieve this. We hoped to use this approach to generate transformative knowledge, facilitate multidisciplinary and multi-stakeholder collaboration, and foster an innovation culture and practice from the bottom up.

The project started with mapping the NbHS system in Walsall to establish the local context and knowledge base. This was achieved through reviewing literature and policy documents, observing how NbHS projects in Walsall were developed and delivered, and interviewing key stakeholders to understand their perspectives. Mapping was followed with work to establish an in-depth understanding of the lived experience of individuals representing key stakeholders of NbHS in Walsall, including community organisations that provide NbHS (for example, allotments, community gardens and public green spaces). Some of the stories identified here were developed into short documentaries and played back to the community through a screening event. Workshops were delivered to validate the learning and to disseminate the findings to the community. Visual tools, such as user journey maps, stakeholder maps and storyboards, were used to facilitate the discussion and summarise what had been learned from the project.

The project generated a wealth of data in different formats including interview transcripts, video clips, reflective journals, notes and visual materials. As it was action-based, we used weekly team meetings to reflect our learning and workshops to share and validate these. The process helped to generate a good understanding of the local context, lived experience, perceived challenges and opportunities for small-scale nature-based projects, depicting the affordances of nature-based projects for these stakeholders and thus revealing the possibilities, effectiveness and scales of NbHS.

During the 18-month project, we worked with 130 people from 55 organisations ranging across third sector organisations, social housing providers, Walsall Council, volunteers, local residents, academics, policymakers and funders.

As the work was delivered during the COVID-19 pandemic, most interviews and interactive workshops were conducted digitally, but observation was conducted in person during site visits. The wider adoption of digital tools (e.g. Zoom, Miro) during the pandemic made project scheduling more flexible. This combination

of remote research activities and intensive in-person engagement proved important for understanding the situation, developing trust and ensuring genuine collaboration.

# **Challenges to realising the affordances of nature**

# *Local council*

Walsall Council, like local councils across the UK, is the primary owner of land in their local authority area. Publicly accessible land in Walsall is overseen by its Healthy Spaces team, which is responsible for the maintenance of parks and other public spaces. Third sector organisations generally lease the land to run NbHS. Walsall is recognised as being particularly green, having 112 public parks and playgrounds, 34 allotments and community gardens, and many natural and semi-natural green spaces, as well as a green corridor (Baggott, 2018).

Walsall Together is a partnership of local council, NHS, social housing, voluntary and community organisations. The establishment of Walsall Together demonstrates the council's intention to collaborate with the NHS and others to take collective responsibility for managing resources, delivering NHS standards, improving physical and mental health, promoting wellbeing and reducing inequalities across the local authority area (NHS England, 2022). In particular, green spaces are considered valuable local assets to support community health (Baggott, 2018). The council also considers its local authority area to have a wealth of strong community assets, which include (but are not limited to) an active third sector, plenty of green spaces and a strong sense of local identity that celebrates the diverse backgrounds of residents (Walsall Council, 2022b).

However, we identified a range of challenges that potentially hinder the delivery of these visions and strategies. First, inequality in local blue and green spaces for health appears to be a significant challenge, particularly as these spaces are foundational in delivering NbHS. The COVID-19 pandemic exaggerated inequalities and made unequal access to green space visible. Although Walsall is a very green town, many of the green spaces are of poor quality and have limited access. Green space, especially good quality space, is not equally shared among the population (Figures 4.2 and 4.3).

**Figure 4.2** The Butts Community Garden, Walsall, 2021

**Figure 4.3** Borneo Street allotments, Walsall, 2021

People from minority ethnic groups, for example, tend to have less local green space and of a poorer quality. Considering the average combined size of parks, public gardens, or playing fields against population density, Walsall is ranked 237 among 373 local authority areas across England, Wales and Scotland. This indicates a very high population pressure on green space there, something that is normally associated with high deprivation levels (New Economics Foundation, 2020).

Revenue budget reductions have limited the council's ability to drive forward some of their plans and respond to the needs of NbHS. These reductions have significantly impacted Walsall's green space provision, losing £1m between 2013 and 2018, along with a quarter of management and development staff (Baggott, 2018). As such, the service has, as of mid-2022, not been able to deliver the objectives set out in Walsall Council's own green space strategy (Baggott, 2018). In sum, reduced investment in green space services limits the council's ability to deliver actionable opportunities for communities to benefit from nature, both in post-COVID recovery and going forward. For example, cuts to funding, maintenance and management, compounded by the pandemic (as a result, for example of increased visitors and anti-social behaviour), left many spaces in disrepair.

# **Third sector**

Third sector organisations are instrumental in delivering NbHS in Walsall. It is estimated that, as of 2019, there were 1,591 such organisations operating in Walsall, including informal or unofficial groups (One Walsall, 2019). Of these, an estimated 31 per cent base their primary service and activity around health and wellbeing (One Walsall, 2019), making this the lead reported service.

Although the benefits of nature for wellbeing are well documented in academic research and promoted from top down, we found that awareness of this approach (i.e. health through nature) among local organisations varies. Those already involved in delivering nature-based activities in Walsall, such as community gardens, demonstrated significant awareness of, and advocacy for, nature's wellbeing benefits. Their NbHS were understood by users as a sanctuary and lifeline, particularly since the onset of COVID-19. A great deal of focus was placed on activities – both physical and creative – as a means to support wellbeing, while others focused more on creating attractive, calming spaces for independent and ad hoc attendance. A couple of sites had a more direct mental health focus (such as through regular wellbeing support groups, or running projects with volunteers consisting of individuals with learning disabilities and diagnosed mental health conditions). As one service provider told us: 'we've created a real unique community here … our lads can come here and be themselves, relax, talk to themselves without feeling self-conscious because we've created this atmosphere. And it's bringing people together through gardening – that's my little catchphrase, and that's what it's about.'

Other third sector organisations primarily operating without a nature-related focus do not necessarily see nature as an important means to achieve their goals, for example those working in health and community development (One Walsall, 2019). However, while the level of awareness is inconsistent, a large proportion of third sector organisations contribute to the delivery of NbHS, including those focusing on health and wellbeing (31 per cent), environment and conservation (13 per cent), and social and community care (9 per cent) (One Walsall, 2019). Many more, for example, those operating in communities (22 per cent) and education (24 per cent) (One Walsall, 2019), have the potential to reconsider and expand their offerings to include NbHS. Prior to involvement with this research, for example, one project partner provided social care and health and wellbeing services to local communities but has since developed nature-based activities, including an urban garden and food growing project.

The way local councils operate has profound influence over their relationship with NbHS providers. Third sector organisations tend to have more positive experiences when councils are open and collaborative, both internally between departments and externally. A complex system of permissions and processes is present in Walsall. In the context of NbHS, the challenge is revealed particularly in the process of accessing land through Community Asset Transfers,5 leasing procedures, and accessing other resources and support from the council. Significant knowledge and persistence are required to navigate through these complex systems. It is often challenging to

know who to contact; NbHS providers may find themselves passed around departments. One interviewee stated, 'it's really important the care systems themselves hear what the barriers to communities are. I think an important relationship is between communities and their local care systems, and potentially through their local authorities who can help with those connections.'

Our interviews with service providers revealed that further difficulties are experienced in terms of conflicting priorities, biases and knowledge levels between council officers and the third sector. A lack of transparency and consistent communication (internal and external) were described as real barriers. Budget cuts also have a significant impact on the level of support the council provides. As such, a challenging relationship with the local council was reported by some third sector organisations, though to different degrees. In some exceptional cases, the relationship has been consistently positive, largely attributed to the proactive and committed Healthy Spaces team at Walsall Council and the leaders of the particular NbHS providers, demonstrating the unequal ways local council support can occur. These relationships take time and energy to cultivate; newcomers without such connections may face significant barriers.

All third sector interviewees reported a significant focus on financial concerns in relation to their projects and/or organisations, and often these issues were a source of anxiety. They regularly had to be creative and show significant initiative to bring in the funding required for expansion or just to sustain themselves, such as through arts grants, crowdfunding campaigns, membership schemes and small business ventures. In general, third sector organisations obtained funding from multiple sources, with grants often being awarded for individual projects or elements of the overall operation. Our observation aligns with One Walsall's report (2019), which suggests that the third sector's income in Walsall is derived from several sources; the largest over the preceding year being grants (32 per cent), charging for services (24 per cent), and contracts and commissioned services (10 per cent). National Lottery funding schemes play a significant role, and notably, were involved with all the organisations we spoke to, often as their primary source of financial support.

However, it appeared more common to receive funds for infrastructure than for staffing, meaning that many projects continued to be run in a voluntary capacity, which constrains their potential and resilience. The hidden costs of delivering NbHS are rarely acknowledged and frequently ineligible for funding; these include maintenance of green space and hosting volunteers. Additionally, investment in indoor spaces for activities is not guaranteed, even though it makes projects accessible year-round and offers more opportunities to more people (Figure 4.4). Expansion – and therefore impact – of NbHS projects can be limited by practicalities, such as access to toilets, water and electricity.

Many local third sector organisations face challenges in receiving consistent numbers of volunteers.6 During the pandemic, it was observed that some volunteers, particularly older people (a key demographic), expressed unwillingness to resume their roles due to COVID-related health concerns. However, organisations felt the increased interest in nature seen during the pandemic held the potential to draw in new volunteers as the country began opening up throughout 2021. It is imperative that projects sustain themselves through regular and sufficient volunteer engagement, and

**Figure 4.4** The Seed Hut was built as part of One Palfrey Big Local. It comprises rooms for activities, the project co-ordinator's office, a kitchen and toilets, 2021

younger participants are an important part of securing continuity. Volunteer-led projects may also be limited, not by lack of expertise or commitment, but due to volunteers' need to balance participation with other obligations. During the pandemic, many such obligations were temporarily removed, potentially leaving some with more capacity for volunteering. However, a complex situation was described by interviewees regarding closure of community gardens during lockdowns, limited opening hours and activities outside lockdown periods, restricted numbers due to social distancing rules and COVID-related health concerns. This all occurred during a time of increased demand for support, as noted by one interviewee: 'Charities have less capacity and, at the same time, many are experiencing increased demand [during COVID-19] … significantly increased in some cases: 200–400% increases in calls.'

In most cases, these organisations rely on a handful of individuals working in a voluntary capacity to operate. Walsall-based NbHS projects often pivot around these individuals; they are central to and drive the project's success through their personality, determination, specialist knowledge and lateral thinking. As well as being part of the workforce, they often provide the leadership required for projects to bid for funding through constituting formally as committee members. Those new to the roles may experience a steep learning curve and may be put off quickly by the demand. Greater support and investment in these community leaders is important in sustaining and scaling local NbHS.

Significant barriers exist for many third sector organisations wishing to scale up so their offerings can benefit more people in need. Most such organisations are small, and some are informal and not officially registered. While this can be effective, for many, it can mean competing for resources while duplicating other organisations' efforts and failing to operate efficiently. Collaboration is an important means for ensuring the variety of experience, skills and knowledge necessary for delivering NbHS are present. However, connections and collaborations among the local third sector resemble a loose patchwork, either between different NbHS providers, or between NbHS providers and other organisations. These connections tend to be informal and unevenly distributed; some people have solid connections they can mobilise to benefit their projects but it can be difficult for those without such contacts.

On the whole, these organisations make great efforts to engage local residents using a various methods, including site signage (an example can be found in Figure 4.5), social media and physical marketing materials. These are important factors to consider for organisations wanting to draw in new visitors and participants, even though they may not be seen as core elements of the service. The methods taken to engage the communities where NbHS are located are key. They can work to either compound exclusion or support inclusion. A reliance on digital communication, for example, may compound patterns of digital exclusion experienced by certain groups, such as the elderly. Additionally, this is reportedly time consuming and not always effective, so careful thought must be given to ensure the best use of what are often stretched resources.

Public events are another important means used to engage the local community, whether these be regular events throughout the year, such as open days or larger one-off events, like community festivals. They can be valuable opportunities for bringing new audiences onto green spaces and making them feel more comfortable in accessing these spaces in future.

**Figure 4.5** Welcome sign and information board at the entrance to Winterley Lane allotments, 2021

The third sector benefits from being led by locally based individuals with significant knowledge of the communities they serve. This close connection and intimate knowledge enables the project facilitators to productively engage community members and to develop their activities in line with local interests, something which enhances impact. However, operating in this way requires greater investment into staff time, knowledge and training, things which not all organisations can afford.

# **Communities**

Reportedly, a significant proportion of Walsall residents do not understand what mental wellbeing is or how they can improve their own wellbeing (Walsall Council, 2022b). It is now a key priority for Walsall Council to ensure all residents are aware of opportunities available to them to improve and maintain positive wellbeing; it appears NbHS are one type of opportunity that has not reached the wider public. However, in line with wider trends (Poortinga et al., 2021), greater interest and awareness of the wellbeing benefits of nature is noted in Walsall because of COVID-19, evidenced, for example, through growing allotment waiting lists. Additionally, over the course of the pandemic, Walsall saw an increase in engagement with green spaces, recorded by Walsall Council's Healthy Spaces team through people counters at prominent sites, as well as anecdotally. In fact, there was such an increase in some areas that the Healthy Spaces team attempted to redirect visitors away to smaller, local green spaces. Increased interest is also inspiring innovation, as one interviewee noted: 'I think COVID has taught many people that nature has some solutions. I think there is a greater realisation of that, so we are seeing more projects coming forward, which are about simply trying to connect people from all walks of life, all ages, all races, to nature.'

Inclusion is a great challenge for many NbHS and a significant consideration in Walsall given its rich cultural diversity. It is often the case that disadvantaged population groups, who have been disproportionally impacted by COVID-19 and who remain more likely to experience deprivation, are less likely to experience the wellbeing benefits of nature. Our research highlighted the need to tailor services to the cultural groups targeted; not understanding the needs of that group prevents the production of something meaningful. Additionally, even when third sector organisations are deeply embedded in their community, there can be tensions based on religious or cultural preferences. This is especially challenging for those NbHS providers who have less connection to local residents, or who only began operating just before or during the pandemic.

Accessibility for those with physical disabilities is also a common concern for NbHS providers. A number of organisations received funding to improve accessibility for wheelchair users. However, some participants from the Deaf community reported specific concerns around accessibility and safety, generally choosing to access green spaces with family or groups. This reiterates the need for ongoing consultation with those with a range of access needs. General accessibility can be significantly influenced by practical elements, for example, fences and opening hours. In Walsall, noticeable access differences were observed between green spaces: some are permanently open, others have scheduled opening hours and some are enclosed by security fences, leading to inconsistencies in levels of accessibility.

Differences in perceptions add to the complexity. For example, some allotment sites have encountered resistance and lack of interest in community-focused approaches from long-standing tenants. Tenants expressed concerns about possible anti-social behaviour and about the potential for community activities to interfere with their personal enjoyment. Such reluctance holds the potential to keep the benefits within small sections of the community and prevent new groups from becoming inspired by, and comfortable in, green spaces. However, this seems to be changing, as exemplified by an allotment manager who invested significant effort in engaging those expressing scepticism. These efforts led to greater acceptance and wider engagement with members of the local community.

As previously noted, although Walsall is particularly green, many sites are of poor quality. Site cleanliness and the immediate local environment were given as reasons why some local residents chose to access nature further afield or not at all. It can be challenging for NbHS providers to improve site quality and maintain high levels of cleanliness to achieve interest and engagement from local residents,

particularly if the site is subject to anti-social behaviour. Increases in anti-social behaviour during the pandemic, such as fly-tipping and public intoxication, were reported during our research both by local council workers and service providers. It was suggested that this may have resulted from the closure of social spaces along with disruption to council-led provisions. These behaviours in some areas leads to fewer people accessing the green spaces and may result in those who do access them not being as engaged with nature as they could be. However, conversely, it was also reported that increased numbers and engagement in green spaces can reduce such behaviour, as it may be more likely when spaces are empty. Anti-social behaviour plays a significant role in people's perceptions of whether green space/nature is safe, and therefore, whether they will choose to visit these spaces. Other constraints, such as lack of time or travel options, were identified as relating to reduced engagement in NbHS. This is largely consistent with national statistics from March 2022, where 'too busy at home' (20 per cent) and 'too busy at work / with family commitments' (16 per cent) were some of the main reasons given for not engaging in outdoor activities by respondents in a sample of 2,000 adults living in England (Natural England, 2022).

# **Green Social Prescribing**

Green Social Prescribing is a specific pathway to NbHS developed by the NHS to address the political interest in nature as a nonclinical intervention for wellbeing. In July 2020, NHS England announced £5.5 million investment for a cross-government project aimed at tackling mental health issues through Green Social Prescribing (UK Government, 2020). Public Health England, in the report 'Improving Access to Greenspace: A new review for 2020', clearly states that local green (and blue) spaces are critical assets and Green Social Prescribing is an effective approach to enable people to start and then to continue using these spaces. The establishment of link worker roles was integral to this strategic vision in the UK. The role is primarily in signposting and referring individuals towards NbHS directly (e.g. through provision of resources) and indirectly (e.g. through advocacy).

Walsall's Green Social Prescribing operates through multiple referral routes: primary care, social housing providers and the council's Healthy Spaces team which is further divided into four geographical hubs. Each of Walsall's referral routes has its own methods and networks, which can increase reach, but adds complexity and possible siloed ways of working and duplication.

A large number of link workers were recruited during COVID-19 (NHS, 2020). While this is encouraging, care must be taken in recruitment because disconnection between referrers and service providers can emerge if link workers lack understanding of the community they serve. The NHS only funds the link worker role, without integrating it into the support system as a whole; this can exacerbate disconnection. Currently, social prescribing directs patients away from the NHS towards local NbHS providers without giving those providers sufficient funding. The increased demand and escalation of needs under COVID-19 compounds the challenges for these organisations to meet varied needs and ensure inclusive and equal access – issues likely to be further accentuated should Green Social Prescribing be intensified as part of post-pandemic recovery policy without necessary investment. One interviewee framed it thus:

One of the reasons why social prescribing – I think particularly for nature-based areas – isn't taking off [is] because there's no money in social prescribing for us. If a person doesn't come with their own personal funding pot, or we've got funding from a third party, we can't offer places to people under social prescribing.

Third sector organisations in this research generally reported minimal engagement in formal social prescribing mechanisms, though there was an awareness of this process and some interest in involvement. Of note was one NbHS organisation's negative experience of participation in Green Social Prescribing. Initially offered a financial incentive for participation, the organisation was sent no referrals. The following year, continued participation was offered only if the project leader travelled off-site to provide nature-based activities elsewhere. As a result, the organisation withdrew their participation. This highlights the importance of a more mutual collaboration based on sufficient understanding of how NbHS operate, and effective communication and coordination between people involved in referral processes.

# **Opportunities for action**

Most challenges identified already existed before the onset of the coronavirus (COVID-19) pandemic. Underfunding for green spaces and the third sector, for example, has been a chronic problem in England for at least the last decade. However, this study found that, as well as exacerbating existing issues, the pandemic placed additional pressure on already stretched systems in several ways, such as an increasing need for NbHS attributable to the pressures people experienced through the pandemic, reduced volunteer capacity, and increased wear and tear on green spaces.

Walsall Council plays a significant role in supporting the delivery of NbHS to local communities and is fully committed, as evidenced in various self-published documents. However, it is constrained by a range of barriers including lack of high quality and equally distributed nature-based assets such as parks and lakes, and lack of funding and resources. There is, however, a strong third sector fully embedded in the culturally rich communities located in this local authority area. Their commitment, passion and rich local knowledge constitute important, while often-ignored, local assets. Opportunities lie in a much closer collaboration between the council and this sector. Improved communication, more streamlined and transparent processes, and greater willingness to invest in the valuable service these organisations and groups provide, will improve the relationship with and increase trust from the sector, potentially leading to greater and more equal opportunities for accessing NbHS. Opening up opportunities for access to unused green spaces allows interested and capable community groups and individuals to develop NbHS. Additional opportunities lie in the councils promoting NbHS to the general public to enable wider take-up.

Walsall-based third sector organisations are varied in foci and operation, an awareness and understanding of nature as an effective means to wellbeing is not equally shared. There is a great opportunity to raise awareness so more organisations join this approach, and more NbHS can be developed to cater to the diverse needs of local communities. Those delivering NbHS experience challenges in capacity, funding and scaling, as do many other local third sector organisations. Our research findings demonstrate that collaboration provides one avenue toward much-needed growth to tackle these challenges effectively, reducing fragmentation, duplication and inefficiency – something of particular concern in this period of post-pandemic recovery, with stretched resources and increased demand for services. Stronger sector leadership is important in facilitating this kind of collaboration. Further, cultural differences and individual needs need to be fully considered in order to tackle the challenge of inclusiveness. Rather than using a standardised approach, place-based thinking is highly relevant here to refocus on people and their local context, putting their expertise, experience, passion and interests at the centre in investing, developing and delivering NbHS. More hyper-local, specialised and tailored NbHS should be developed to offer more diverse options, thereby expanding NbHS's user base to include more vulnerable and ethnic minority communities. Our research, therefore, suggests this mode of service delivery as a potential method of enhancing crisis recovery and ongoing community resilience.

The public have experienced a greater connection to nature and greater awareness of its wellbeing benefits over the pandemic, as demonstrated in 'The People and Nature Survey' conducted by Natural England (Office for National Statistics, 2021) which looked at how people's perception of nature changed during the pandemic. Associated awareness of inequality in access has also surfaced. Our research has revealed that a range of issues contributes to the uptake of NbHS; some are practical (e.g. access, green space quality), and some are social (e.g. safety, inclusion) and emotional (e.g. relevance, motivation). The uptake of NbHS is tightly intertwined with the operations of third sector organisations and their engagement strategies. Decisions made by both local councils and third sector organisations directly affect whether NbHS provide a real opportunity for individual wellbeing.

Green Social Prescribing is one pathway for people to access NbHS. In addition to the challenges and opportunities outlined earlier, it faces extra challenges as well as great opportunities. It is challenging for the existing system to respond to the need for better governance beyond individual organisations, for improved funding pathways and for better infrastructure. Existing health infrastructure is a complex of entrenched practices patched with new concepts. Within this, new pathways, which optimise the

potential of nature for health, are hard to generate, especially when communication and coordination between stakeholders is lacking. Adding to this complexity, delivery requires collaboration beyond the health sector to include the natural environment and social infrastructure, the absence of which can be a major drawback for delivery. There needs to be a co-operative mechanism capable of working across all the organisations involved. A holistic approach to understand the complexity of local systems is required, in contrast to a narrow sectoral focus. Greater buy-in is needed from health professionals. The link worker role should be fully embedded in local networks and local knowledge to be fully functional, something which requires an investment of time, training and individual commitment. Overall, a more integrated system is a prerequisite for Green Social Prescribing to be rolled out successfully on a wider scale. Our research highlights this critical situation; future research would benefit from investigating and proposing the exact working mechanisms of such a system.

The biggest challenge for the overall affordance of NbHS for all is that they operate in complicated ecosystems of overlapping jurisdictions, multiple sectors, uncertain funding and competing interests, which are challenging to navigate. As such, we recognise the importance of a genuinely bottom-up place-based approach that considers the totality of local assets, including the realities of the physical locality and local lived experience. The richness of local knowledge held by grassroots organisations is usually undervalued and could be used more effectively to connect people with their local natural environments. This is a pressing concern given the huge potential for nature to benefit wellbeing, particularly if equal access is ensured, something that became undeniable during the pandemic. Bottom-up and bespoke approaches toward NbHS, combined with investment from local and national authorities, and significant within- and cross-sector collaboration, can support the wider need to address health inequalities and improve wellbeing, particularly in times of crisis.

COVID-19 has had a disproportionate impact on more disadvantaged population groups and has widened health inequalities (World Health Organization, 2021). NbHS can help address such inequalities, by tackling mental health difficulties in more vulnerable groups, for example, as well as supporting wellbeing in the wider population. Local service providers understand the places and communities they serve and, therefore, have the potential to develop and fine tune the outreach and services required by vulnerable groups. It is high time to give them the recognition and resourcing they need to fulfil this vitally important role. There can be no truly effective upscaling and mainstreaming of NbHS until these conditions are met.

# **Key insights**

Our research has highlighted that if the potential affordances of urban nature are to be actualised, the following four conditions must be met:


# **Notes**



# **References**



# Community resilience and recovery: the 'Restorative Museum' and responses to COVID-19

# *Breda Friel, David Farrell-Banks and Philip McDermott*

The COVID-19 pandemic and the lockdown measures implemented by governments globally are crises that have affected us at individual, community and societal levels. The impact of the disease on citizens and their families and the context of the 'new normal' is likely to have a long-lasting legacy. While museums may not necessarily be the first place that people, or indeed policymakers, might think about in the context of community recovery, the unprecedented nature of COVID-19 has provided a unique opportunity for innovative, unique interdisciplinary approaches to community resilience to emerge in museum practice. If properly funded and supported, museums can utilise new and innovative approaches which emerged during the COVID-19 pandemic to consolidate their role as sites of community wellbeing and renewal in the years ahead.

The Museums, Crisis and COVID-19 (MCC) project at Ulster University (2020–22) connected academics, heritage professionals, curators and grassroots representatives to explore how museums in Northern Ireland can contribute to community resilience and wellbeing in the light of the COVID-19 pandemic.1 Discussions during the project indicated that these institutions in Northern Ireland may become important locations for telling the story of COVID-19 in the future. Moreover, museums will become places for commemorating what has been a traumatic event for society and the communities within it, thus meeting important therapeutic needs. The multiple roles played by museums in curating the past and engaging with disparate groups make them a location in which people can reflect on the impact of COVID-19. These roles, we argue, should receive greater attention from policymakers because of their potential importance in the wider context of supporting community

health and wellbeing. Debates of this kind become especially pertinent given the ways in which the museum sector's engagement work within their wider communities was so severely impacted by the pandemic (Samaroudi et al., 2020). While much of the work we discuss in this chapter focuses on the context of Northern Ireland, many of the issues that we identify are also relevant to museums more broadly in other regions of the UK.

In this chapter, the arguments centre on a discussion of some of the findings from the MCC project. We consider emerging evidence of the role of museums as places of narrating and commemorating the psychological impact and trauma of the COVID-19 period. This was explored through a pilot study titled 'Reflective Space and Wellbeing: Mindfulness Self-Care and the Museum' that explored the use of guided mindfulness practice within museum or heritage spaces as a method of enhancing wellbeing, relaxation and reflection. During the pandemic, psychotherapist, trauma debriefing specialist and lead author for this chapter, Breda Friel, conducted a series of regional and national wellness and self-care programmes across statutory and community voluntary agencies in Northern Ireland and Ireland (2020–21). The workshops helped inform the structure of the pilot project in the museum space, drawing on the combined expertise of the authors, bridging psychotherapy (Friel), museums, identity and belonging (Farrell-Banks), and access to heritage for minority groups (McDermott). Qualitative surveys were used to collect data on participants' perceptions of mindfulness and wellness practice in the museum setting and their methods of self-care during COVID-19.

The use of this practice was led by Friel's experience in providing management and recovery services in the aftermath of crises. While the longer-term impacts of the COVID-19 pandemic may not be entirely evident for some time, the onset of the pandemic represented a crisis or severe emergency event, and it is in the nature of such events to be overwhelming, shocking and unexpected. The response capacities of those affected are unique. Individual impact is determined by several features, including previous trauma history, or if the traumatic event is an acute, one-off incident, or a chronic accumulation of events, such as bullying, domestic violence, the threat of terrorism or long-term health issues (Hodgkinson and Stewart, 1991). As in many regions, COVID-19 progressed into a chronic crisis in Northern Ireland, exacerbating already existing traumatic histories in a region affected by long-term ethnic conflict and its aftermath (Ferry et al., 2017; Khoo et al., 2021; Ulmus and Hilarski, 2003). Friel has delivered trauma debriefing and therapeutic support to first responders, eyewitnesses and survivors of human caused conflict-related and natural disasters in Northern Ireland for over twenty years. The impact of persistent terrorist threat, conflict and contested society resonates across communities, resulting in well-documented levels of mental health issues, such as anxiety, depression and increased levels of hypervigilance (Ferry et al., 2017). Such was the impact of the COVID-19 pandemic that similar symptoms and mental health presentations were emerging; it was these themes that led to the development of this pilot project aimed at exploring the role of museum spaces in wellbeing and crisis management and recovery.

Museums can fulfil a role, as identified by crisis management theory, in complementing other state services in the management of traumatic events (Federal Emergency Management Agency, 2022). Museum spaces, not only in Northern Ireland but further afield, can contribute to the social support and therapeutic needs of both individuals and communities in a time of crisis as identified during COVID-19. Moreover, the museum as an institution and a social agent can assist in the wider rebuilding of communities in the aftermath of a traumatic event (Berren, Santiago, Beigel and Timmons, cited in Hodgkinson and Stewart, 1991: 37).

# **Community, museums and resilience**

The pandemic has instigated deep reflection on the nature of society and the idea of communities. The term community is undoubtedly a complex one which captures the senses of belonging from a wider societal level through to smaller scale local networks (Tönnies, 1957). However, while sharing many values and beliefs, 'communities' are never wholly homogeneous (Delanty, 2003). A community can be a larger more geographically spread group such as those sharing the same nationality but can also be a much smaller scale collective living in a locality. It is this latter example which has permeated public policy discourse, including in the cultural

sector, where the term is often used in relation to 'peripheralised', 'marginalised' or 'hard to reach' groups (Tlili, 2008). Often in policy and government rhetoric the term is used interchangeably to refer to those who are in some way separated from wider civic life and might include so-called 'vulnerable' communities such as migrants, disabled people or those from working-class backgrounds. Public bodies have also often used the notion of the 'local community' as meaning those who live in the immediate environment of civic organisations such as museums (Crooke, 2008).

Indeed, museums and the heritage sector have, with the influence of the new museology of the 1980s (Vergo, 1989), recognised the need to alter their approaches and attract new audiences, particularly from those groups considered marginalised. 'Community engagement' in such instances can be read negatively as a problematic label imposed from those in authority to those who have been determined as vulnerable and needing assistance (Morse, 2020: 29). More recently, the idea of 'engagement' has given way to a debate about the more active notion of 'participation' where the museum becomes a place of community action and social change (Black, 2018; Sandell, 2013; Sandell and Nightingale, 2013; Simon, 2010). Such processes consider community as an overlapping notion incorporating 'symbolic,' 'civic' and 'political' elements (Crooke, 2008: 29). Therefore, successful community engagement approaches need to consider this multidimensional process and acknowledge that museum professionals, curators and policymakers are themselves also community members. In this regard, the nature of community work in a museum is a dialogue which should encapsulate the issues affecting all of us: regular visitors, museum professionals and those who live in the community environs surrounding museums but do not normally visit.

The unparalleled public health issue of COVID-19 provided a challenge for the sense of community cohesiveness at both national and local levels. Many opposing views were voiced on the political and public health response to the pandemic in relation to topics such as mask-wearing, shielding and social distancing (Morgan, 2020). These have often manifested as arguments between neighbours or the breakdown of the friendships which had been the bedrock of community togetherness (Grasso et al., 2021). Added to this has been the deep sense of grief and trauma for those who lost loved ones or who were seriously ill with the disease and are still suffering its consequences. All these tensions have caused challenges and stress for personal health and wellbeing. Participants in our research noted that these elements of the pandemic experience had been notably absent from current museum approaches. In this chapter we show how the work of museums can consider these dynamics, as it moves beyond collection approaches to and into the realm of participation work around wellbeing with staff and visitors.

This approach becomes pertinent given that increased rates of anxiety and depression are now a major societal challenge, evidenced by the increase in mental health referrals during the pandemic (McNicholas et al., 2021). Awareness of the effects of socio-economic disadvantage, educational inequalities such as digital poverty for poorer pupils and postcode differences in access to health (especially mental health support) have also become more apparent as a result of the provision of care during lockdowns (Maffly-Kipp et al., 2021). While immense strength and resilience was evident within communities during the pandemic (Malone and Morris, 2021), those who experienced complex challenges prior to this period often witnessed an exacerbation of their situation, something which reflects the pandemic's uneven impact (Daher-Nashif, 2021; Suleman et al., 2021).

An emerging body of literature on the potential utility of the museum space as a location for the promotion of better health and wellbeing influenced the approach within the MCC project (Chatterjee and Noble, 2016; Chatterjee and Camic, 2015). Morse's work on the Museum as a Space of Social Care is particularly pertinent to reframing community and engagement work. Morse critiques the idea that community engagement work in the museum is too often considered as related to what that community work 'can do' for the museum, for its contributions to collections, or enhancing visitor numbers (2020: 31). Instead, she proposes that we centralise the notion of 'care for people, care for communities, care for place and care for ideas' within the remit of what, here, we call engagement work.

Such scholarship has guided our own attempts to integrate aspects of care and wellbeing in the museums in Northern Ireland. Our interviews during the pandemic showed us that museums were 'already on a journey' in terms of embracing this aspect of outreach

and engagement activity. For example, we were told about dementia support work that had been undertaken in collaboration with care homes and mental health outreach with youth groups, with these activities taking place across local authority museums, national museums, independent museums and Northern Ireland Museums Council (NIMC) projects. Much of this continued in some form, predominantly digitally, through the pandemic, demonstrating the commitment of the sector to maintaining wellbeing focused activity (see Crooke et al., 2022 for more detail). Our research suggests that this focus on care is a critical element of the engagement work those museums will seek to continue to do as communities, in all their diversity, emerge from the pandemic. However, it may be that ongoing financial and political uncertainty brought on by the costof-living crisis and the lack of a devolved government in Northern Ireland will impact on the ability of museums to fulfil this desire.2

The consideration of health and wellbeing as a wider societal and community issue requiring holistic approaches is not new in the heritage sector (White, 2009). Such approaches have witnessed shifts from a traditional individual medical model to that of a collective community model which recognises complex determinants for wellbeing. This has led to the development of community-based health promotion initiatives across many settings and the involvement of wider professional collaboration and partnerships beyond medical settings. There is no doubting that the COVID-19 pandemic has transformed heritage practice, this being evident in the programmes of museums (Mackarell, 2021). Simultaneously, isolation, withdrawal and recovery from COVID-19 are impacting wellbeing at a societal level. Services have witnessed increased referrals across geographic areas and age ranges, an impact captured by Mughal et al. (2022) in their assessment of cultural activity and wellbeing during the pandemic. Responding to this increased and still emerging need is a priority to which museums can contribute.

The mitigation of long-term mental health issues arising from the pandemic requires a strength-based prevention strategy to ensure health and wellbeing for citizens; such approaches involve a collaborative process between the person supported and those supporting them, allowing them to work together to determine an outcome that draws on the person's strengths and assets (Duncan and Hubble, 1997). As such, it concerns itself principally with the quality of the relationship that develops between those providing and those being supported, as well as the elements that the person seeking support brings to the process. Museums and cultural organisations are well placed to offer spaces that facilitate a setting down of the traumatic narrative, in safe and reflective spaces. Museums can be considered as places of 'therapeutic holding'; we define this as the creation of a safe and structured listening space alongside mental and emotional containment, that respects, supports and validates experiences (Friel and Beavis, 2022). Within this process, telling one's story is a central component, and it starts with a link to the past, to the security of one's routine, day-to-day and ordinary lived experience. Museums can, for those who feel able to visit them, afford very grounded spaces in which artefacts and sensory experiences enable a sense of calm and history, thereby creating conducive conditions for facilitated discussion.

The MCC project afforded the development of partnerships across academia, the museum sector and community agencies in Northern Ireland. There were also partnerships within the project team, which included digital design expertise, museum professionals, trained therapists and representatives from museum funders and advocacy bodies.

Our work included an exploration of how museum spaces can facilitate programmes focused on recovery by offering reflective spaces for guided mindfulness-based meditation. Resilience as a concept has been described as the capacity to navigate through crises, a protective process instigated by the individual's system to manage stress (Ungar et al., 2013: 150). As a concept it is associated with the ability to recover from change or misfortune, through identified characteristics such as adaptability and general optimism (Pulley and Wakefield, 2011). Such individuation of coping or navigating adversity has been challenged (Coleman and Hagell, 2007: 6), a fundamental flaw being judgments about individual coping with limited recognition of the role of significant ecological adversity, such as the COVID-19 pandemic and its impact on individuals, groups and communities (Barber, 2013: 461).

Resilience, like 'community', is a term with multiple potential definitions (Wright, 2022). The resilience of a physical object, for example, can describe the ability of a material to bounce back with no 'permanent deformation after [a] stress or strain is removed'

(Dias, 2015: 69). In the context of the COVID-19 pandemic, the appeal of applying this definition to the social context is evident in discussions of a 'return to normal' once the pandemic is over, implying a pre-existing, idealised state that we wish to recapture. However, the idea of 'resilience' as a response to trauma and stress has been heavily criticised, particularly within academia, where the individual focus on resilience presents 'experiences as problems of a psychological nature […] rather than structural consequences of a system placing intolerable demands' on people (Gill and Donaghue, 2016: 97). This reflects the need to couple a social definition of resilience with a recognition of human 'vulnerability' (Wright, 2022: 28). There is a need to move beyond the individualisation of resilience and to consider community resilience as the 'collective ability of a social group' to maintain health and wellbeing while facing stresses and traumas (Wright, 2022: 1). This view of community resilience moves us away from a troublesome focus on 'bouncing back' to a previous state, instead drawing attention to an ability to support and maintain health and wellbeing while facing periods of trauma and crisis.

As an alternative, post-traumatic growth research involves the study of transformative and positive psychological development experienced due to highly challenging life events and circumstances (Tedeschi and Calhoun, 2004). Evidence of post-traumatic growth includes the individual capacity to recognise new possibilities, the development of personal strength and spiritual or religious change. In addition, growth can involve transformed relationships with others and offer an appreciation of life (Tedeschi and Calhoun, 2004: 1). The trauma perspective is compelling in its recognition of the physical, emotional, behavioural and psychological impact of external crisis experiences (Bloom and Farragher, 2011). Traumainformed and post-traumatic growth models recognise how highly stressful events challenge beliefs and assumptions regarding control, predictability and benevolence in the world. Adversity challenges the validity of hypotheses about safety in our lives, causing distress and reaction, the manifestation of exposure to previous or present adverse experiences. This chapter follows Wright's call for critical approaches to resilience and post-traumatic growth by bringing 'abstract' discussions of such themes 'into dialogue with empirical examples of how people respond to adversity' (2022: 1). We do this through a discussion of empirical data gathered during the MCC project. We also reflect on the interdisciplinary approach in the project, affording the exchange of knowledge and practice between therapeutic and heritage sectors, an intersection of innovative methods and approaches in a non-traditional context for the delivery of wellbeing and therapeutic programmes.

# **The Restorative Museum: narrating and reflecting on COVID and trauma**

Through discussion of the pilot project below we argue that facilitating narrative accounts of individual and group experiences of the trauma of COVID-19 is a therapeutic and social support process. Historical museum exhibits call on the visitor to look to the past through the stories they tell. In doing so, they engage us in memories not only of these pasts but also of our own life experiences (Doering and Pekarik, 1996). Our own memories become a scaffold to our identities (Cubitt, 2007) and by extension our engagement with the past. Within museum spaces past, present and future exist in concurrence with each other. This temporal unrest occurs alongside the structure offered by the museum visit and will be present as we move to the presentation and discussion of the COVID-19 pandemic within museum spaces.

In exhibiting stories of the pandemic or offering museums as a place of reflection on experiences of it, audiences and visitors will be drawn back to their own pandemic memories and associated traumas. Witcomb and Bounia (2019) coin the term 'restorative museum' to describe 'a museum that seeks to restore to the souls of the dead their humanity and which does so by asking present-day visitors to empathise' with the subjects of these displays. In the case of the post-COVID role of museums, we are looking not just at the restoration of the humanity of those lost, but also to the restoration of the lives of those who have survived.

Our work on MCC has given us insight into the restorative role of museum practice during the period of the pandemic. The co-creation by the Belfast-based charity EastSide Partnership and local community groups of a 'Pandemics Past and Present' exhibition at Ulster Museum provided a clear case of the value of this

practice. This exhibition, produced by a group of people who had previously worked with the charity on a heritage skills programme, focused on the impacts of the current and past pandemics on lives in East Belfast. Originally planned as an exhibition about the industrial heritage of the area, the process of designing the exhibition during the COVID-19 pandemic resulted in a change of subject. Creating the exhibition provided participants with a chance to talk productively about their experience of the COVID-19 pandemic and to find comfort in knowledge that past pandemics had come to an end. This sense of survival through pandemics was iterated in the exhibition's final title: *Atishoo, Atishoo, we don't fall down* (see Farrell-Banks and Rea Currie, 2022). Here a focus on past experiences of survival through pandemics, found in the process of exhibition creation, acted as a source of comfort for those involved. However, there has been some concern from within the sector that audiences may not be ready to visit or engage with exhibitions that discuss the pandemic. While many museums have undertaken processes of contemporary collecting, gathering items, testimonies, images and ephemera that they hope will tell the story of the pandemic, this is not necessarily with a view to displaying this content soon. A local authority museum curator articulated this view for us: 'I don't know when this collection will be on display in an exhibition. […] It's not something people want to look at now.'

The reticence to exhibit stories of COVID-19 so soon is reasonable when we are still coming to terms with the various traumas felt because of the pandemic. However, there is robust evidence for the positive role of cultural activities on individual and community wellbeing (Mughal et al., 2022). While we acknowledge the difficulty of evaluating the impact of these provisions, we have seen significant evidence of museums across Northern Ireland embracing this potential within their practice, a trend that had begun pre-pandemic. Initiatives have included NIMC's dementiafriendly museums project, National Museums Northern Ireland's (NMNI) dementia outreach work, youth-focused heritage work such as Reimagine, Remake, Replay's mental health arts festivals (Lavelle, 2021) and community focused heritage skills development programmes. Museums, therefore, are faced with the challenge of using COVID-19 collections sensitively, while also expanding upon their role as sites of community support and wellbeing.

# **Crisis management**

In exploring how museums can become restorative spaces, we suggest that theory and practice from crisis management, encompassing the phases of mitigation, recovery, preparedness and response (Tierney, 1989) can assist the development of programmes that support recovery from the impact of the pandemic, the mitigation of long-term psychological ill-health and improved wellbeing across communities.

Medical and psychological services have reported increased waiting times due to elevated levels of referrals for emotional and mental health symptoms including anxiety, fear, motivation changes, grief and anger following COVID-19 (Iacobucci, 2022). Similar themes are emerging to those recorded from previous crisis situations such a Hurricane Katrina (2005) and flooding episodes in the UK (2013/14) (Jermacane, 2018) (Williams, 1989; Alexander, 2007). Such presentations are particularly noted by those post-viral and those bereaved due to COVID-19. Those with symptoms, particularly of 'long COVID', report experiences of being discredited due to factors including lack of medical precedent, poor knowledge and public assumptions. There is evidence that marginalised and excluded groups prior to the pandemic have seen their situations worsen, a social justice theme witnessed in previous crisis situations, including Hurricane Katrina (Alexander, 2007; Sementelli, 2007). Two years on from its emergence there is additional anxiety around the economic situation. Importantly, museums can offer suitable quiet reflective spaces for the facilitation of personal, subjective experience, thereby validating the story of those affected and recovering from trauma (Lewis and Roberts, cited in Roberts and Greene, 2002). This process assists the beginning of recovery, normalising experiences that have been experienced as chaotic and stressful.

# **Restorative Museum practice: wellbeing projects in the museum space**

Considering how the museum sector can support responses to the mental health and wellbeing themes arising from COVID-19 was an aim of this project. The original empirical base of the research

was a project developed in conjunction with the Tower Museum in Derry called Reflective Space and Wellbeing: Mindfulness Self-Care and the Museum. For the MCC research, co-investigator Dr Breda Friel developed a programme aimed at professional and personal self-care in challenging times; this employed Mindfulness Based Cognitive Behaviour Therapeutic (MBCBT) approaches in creating a series of guided practices to train participants in self-care and self-regulation methodologies as a response to stress. A further aim was to enhance wellbeing through the cultivation of strengthbased, compassion and self-regard. This programme was delivered to statutory and community organisations, individuals and frontline workers throughout the period of the pandemic and draws on research conducted during the pandemic (Friel and Beavis, 2022). The research captures and articulates respondent narratives on the impact of the pandemic and on the benefits of being heard and of telling one's story. Data was collected using storytelling and artefacts, and these methods were themselves a means of facilitating clients' articulation of the individual narratives arising from the crisis of COVID-19.

The project aimed to evaluate participants' subjective accounts of self-care during the pandemic and of wellbeing in a museum environment. The rationale for the pilot project was that museum environments are suitable for delivering COVID-19 wellness and support recovery programmes, the desired outcome of which is the development of individual and community resilience and the mitigation of long-term impact on mental health and holistic wellbeing.

Respondent evaluations articulated profound experiences during the pandemic and its subsequent lockdown. In describing their selfcare efforts, some reported using a range of activities including relaxation, watching movies, gardening and walking as a means of supporting their wellbeing. There was also an acknowledgement of the impact of the lockdown rules, with one respondent saying they 'kept all rules but it was extremely difficult as I live alone and was not part of a bubble. [I] had to walk alone and I tried to do so every day (weather permitting).' This is a reminder of the isolation felt by many and the role that museums can play in combatting that isolation and opening public spaces in contained and safe ways. In describing a community outreach project, one member of curatorial staff at National Museums NI described the impact of their work

on those otherwise feeling isolated: 'One woman said if she had she not come to the meeting that night she would not have opened her mouth all day. She lives on her own, she was not going out, and stated "I wouldn't have spoken today if I hadn't come to this."'

The wellbeing sessions uncovered participant experiences of confusion and lack of knowledge in the early parts of the pandemic, due to the unprecedented nature of the pandemic and the individual's capacity for self-care and wellbeing. This is a prevalent experience during the pandemic, summed up in the following from a participant: 'I managed but retrospectively I would have done things differently. [I] did my best with the knowledge I had at the time.' It is not uncommon for hindsight to transform individual perceptions of crisis events. Those impacted by the pandemic noted their compliance with the rules at the time and their dismay at the imposition and (mis)management of such rules by governments and police departments.

Feedback on the facilitated wellbeing programme gathered through participant surveys reflected participant enjoyment and desire to acquire improved skills for the management of wellbeing at times of stress. One respondent noted: 'This activity is so simple to practise every day, and with the proper tools we can find ourselves in a calmer place.' Others expressed their desire for follow up and additional training: 'Interesting that idea to focus again back to yourself and your breath. I find with work you are pulled in many directions. I really liked the idea of the alarm once an hour to have a mindfulness moment.'

Providing these sessions in spaces like museums was viewed by a participant as valuable because museums are 'public spaces where all citizens have access'. However, feedback also showed an awareness that while museums may theoretically be open to all, there are often barriers to this access. A participant noted that 'I think it is also useful for individuals that may not visit those spaces to see this in action.' Such comments suggest that the combination of outreach activity and the use of museum spaces themselves will be at the heart of the success of programmes such as this in the future.

Participants referred in positive terms to the 'calmness' of the museum space, one noting for example that it was a 'very good idea to have museums included in activities such as this as they are traditionally calm places. This reflects the affective capacities of

the museum visit, where the expectations of a space and a perception of calmness associated with it can support wellbeing practice. This feature of these spaces extends to museums' roles as historical bridges between individual and cultural past and present at both individual and collective levels. This was summed up by another participant who suggested that 'Yes absolutely [museums should be used for this work. There] should be a connection between the past, the present and the future.' As society continues to navigate the presence of COVID-19, while also returning to more 'normal' aspects of social life, museums will have a role in navigating this past, present and future engagement with the pandemic and our experiences of it.

# **Conclusion**

As our pilot programme and the research activities connected with it have shown, museums, as facilitated spaces for reflection, can become a space of sanctuary for people and communities seeking to understand how the COVID-19 pandemic has impacted them. An understanding of the role of museums as spaces that support crisis management and recovery can contribute to the continuing development of pre-existing community wellbeing work. Interdisciplinary work, such as that undertaken by MCC, can support museums' increasingly developing community-focused role, whether that is through educational outreach or wellbeing programmes, such as those for individuals with dementia. The continued growth and interest in this form of museum work give some insight into the potential for museums to play a role in crisis preparedness, encompassing both crisis prevention and management (Reilly, 1993). Crisis preparation and prevention planning can sometimes successfully prevent crises from occurring in the first place. The MCC project falls into the latter category; it involved the development implementation of a crisis management programme aimed at containment, damage limitation, recovery and learning (Pearson and Mitroff, 1993) through wellbeing and resilience delivery in a museum setting in the aftermath of COVID. There are opportunities now to explore how this pandemic experience, in providing continued outreach through digital means, could also be applied in developing museum responses to long-term concerns such as the climate crisis and short-term fears around cost-of-living increases.

Crisis management theory and practice aims to ensure preparation for the untoward, to plan appropriate responses when critical events occur and to support recovery while mitigating the potential long-term effects on individuals and communities (Tierney, 1989). In this chapter, and through work conducted throughout the MCC project, we have reiterated the value that museums hold as places that can support wellbeing. If museums, and the cultural sector more broadly, are to be well prepared for future crises and able to support audiences and communities when these crises arrive, then the health and wellbeing role of these spaces needs to be recognised within cultural policy. The current museums policy for Northern Ireland makes only one passing reference to health and wellbeing, and this is focused on economic regeneration (Department for Culture, Arts and Leisure, 2011). This is further evidence, we argue, of the need for an updated museum policy and strategy that better reflects the direction and priorities of the sector (Crooke et al., 2022). The work described in this chapter demonstrates the value of an interconnected approach to health and cultural policy, approaches that draw on expertise across disciplines and are crossprofessional in meeting the needs of communities. There is the potential for facilitated positive psychological change, for individuals to consider new possibilities and reflect on personal strengths with resulting improvement and appreciation of life (Tedeschi and Calhoun, 2004: 1). With resources and support, the museum can emerge as a place of sanctuary and recovery both through the narratives represented and displayed in exhibition spaces and through the holistic, wellbeing-centred work being undertaken by many institutions.

# **Key insights and recommendations**



# **Recommendations**

The following are adapted from Crooke et al. (2022).


# **Notes**


# **References**



Vergo, P. (ed.) (1989), *The New Museology.* London: Reaktion.

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# 'It's OK to be closed': harnessing the power of nature, enhancing resilience and learning lessons from the literary heritage sector

# *David Rudrum and Helen Williams*

Across the UK there are over seventy museums in writers' homes and birthplaces open to the public. They include museums dedicated to globally renowned household names such as Shakespeare, Dickens, Austen and Burns, as well as to underappreciated national treasures such as Laurence Sterne, Elizabeth Gaskell and Horace Walpole. In March 2020 there was widespread concern about the future of these museums, before the announcement of the Culture Recovery Fund. Twitter pleas and donation pages emerged, many raising lifesaving sums of money for individual properties. The teams working at these properties mobilised to furlough staff and then were left to consider how to continue to meet their aims through lockdown. All were profoundly impacted by COVID-19, in ways unique to the literary heritage sector. This chapter describes the efforts of heritage practitioners from the UK's literary house sector in responding to the coronavirus pandemic and in finding new ways for the public to access English literature at a time when it was never more in demand.

The coronavirus pandemic has brought a range of challenges to UK literary heritage sites that other museums or stately homes will not have had to face. Since writers' homes are seldom much bigger than other houses, social distancing is harder than in most museums. Moreover, the visitor experience in writer's house museums, typically aiming to engage visitors with literature and to bring texts to life, was severely impacted in many ways. Writers' homes are often interpreted primarily through live guided tours, which were impossible while restrictions on gatherings of people remained

in place. In some cases, moreover, the use of touch-screen technology or object-handling as a vehicle for engaging visitors with an author's writings is more extensive than at conventional museums. These factors often necessitated urgent, large-scale reinterpretation. Furthermore, many literary heritage sites were disproportionately hit by the downturn in international tourism, because some writers with museums dedicated to them (ranging from Shakespeare to Rudyard Kipling) are of as much interest to a global readership as to the local community. Even when reopening began, many of these museums also lost out because coach trips, which account for a substantial proportion of their visitors, were not permitted.

At the same time, because these museums are valued for their connections to literature, they have had some advantages over other museums, since they are not solely dependent on their collections or on the historical value of the site. There is evidence to suggest that literary tourists are less likely to be 'incidental visitors' – i.e. passing trade – and that the sector has a more dedicated and engaged base of supporters than other heritage sites or stately homes (Frost and Laing, 2012). In order to stay connected with them, some literary heritage sites, like Chawton House, home of the brother of Jane Austen, Edward Knight, have attempted to channel resources into online festivals to appeal to virtual literary tourists and make their work accessible to those unable to attend their events in person. Other literary heritage sites attempted to keep the public engaged through online book clubs, poetry readings and creative writing initiatives. On the whole, the sector was well placed to capitalise on the rediscovery of the pleasures of reading literature that characterised lockdown for many people.

All told, then, there was every indication that the coronavirus pandemic had impacted the UK's literary heritage sector in unique ways, forcing it to change how it operates by posing particularly intractable challenges and difficulties on the one hand, while presenting opportunities to engage with the public on the other. Given this, we undertook an ambitious study to evaluate both the damage done by the pandemic and the lessons that could be learned from it in order to enhance the future resilience of this sector, which includes so many places of unique importance to our literature, heritage and culture.

Data were gathered from literary heritage sites from across the country, including all four nations of the UK and most of the regions of England. The sample included some of our best-known and most-visited literary heritage sites alongside some of our least and featured some of the most recently opened sites as well as some of the longest established. The qualitative data presented herein were gathered by interviews held with the directors/curators/managers of sixteen organisations (principally writer's house museums but not exclusively) carried out between August and December 2021.1 Quantitative data pertaining to visitor numbers, website traffic, finances and staffing levels were gathered by a questionnaire completed by eleven organisations. These organisations were paid for their input.2

Understandably, very little previous research has so far been dedicated to the impact of the pandemic on the literary heritage sector. Emma Treleaven's reflective account of curating Charles Dickens's House during lockdown is an exception. Her essay repeats accounts made by curators of Hill Top, Ted Hughes's House and Dove Cottage, who remarked on lower visitor numbers changing the atmosphere of the place:

Being in the museum in the months it was closed was a strange experience. 48 Doughty Street is dressed as a home – wallpaper, carpets, and all – but when you have up to a few hundred visitors a day exploring it, the building loses some of its intimacy. During our closure periods, it felt like the Dickens family and their staff had just stepped out of the room. It was amazingly quiet – you could hear the hall clock chime through the whole house – and I loved watching how the sun travelled around the different rooms. It made the house really feel like a home. (Treleaven, 2021)

But most reports and scholarship have indicated the shortcomings rather than the successes of the sector, warning of problems emerging in the future if new ways of working do not rise from the ashes of the pandemic. Criticising initial pandemic responses as 'medical' and 'retrofitted', comprising social distancing, hand sanitisation and the removal of tactile exhibits and activities, John David Bull has drawn from Transformational Education Theory to suggest that the pandemic crisis for the museum sector is also potentially 'a chance to embrace a role as an enabler of individual and societal change' (2020). Our research suggests that many writer's house museums have recognised and embraced this opportunity in their responses

to the pandemic. Nevertheless, the challenges they face are considerable. As the Network of European Museum Organisations (NEMO) has shown:

Until the pandemic is completely under control, museums are facing a substantial income loss, both while closed or open with security measures. Visitor levels have dropped considerably and do not only force questioning of museums' business models and measures of success, but also ask for new approaches and ideas to connect to their audiences and provide access to their collections in a meaningful way. (Network of European Museum Organisations, 2021)

This chapter contributes to recent innovations in literary tourism research which seek to put theory into practice, especially the case studies undertaken by Ian Jenkins and Katrin Anna Lund (Literary Tourism, 2019). Jenkins and Lund's practice-led approach in turn builds upon the interdisciplinary work of scholars of literature (Watson, 2006), art history (Harney, 2013), tourism (Laing and Frost, 2012), and business, sociology and cultural heritage (Robinson and Andersen, 2002). While this body of scholarship sheds light on the motivations of literary tourists and the appeal of the writer's museum, and the case studies share the practice of heritage professionals embracing the digital turn, scholars have yet to consider the continued appeal and the digital or distanced workings of literary house museums during periods of enforced closure or reduced capacity.

The digital turn certainly threw a lifeline to arts, culture and heritage organisations during the pandemic. Yet for writer's house museums, it also poses some interesting and challenging questions. Virtual tours, in particular, made it possible for visitors to see these museums without visiting them in person, which in turn meant the museums could engage with people from around the world, including many who would never have had the chance to experience them otherwise.

In some cases, the virtual tour was a standout innovation pointing towards new ways of working in the future beyond the pandemic. The virtual tour of Jane Austen's house was listed by *Forbes* magazine as one of the best virtual tours in the world, competing successfully with content curated by the likes of Google and Amazon ('Bucket list travel …' Bloom, 2021). Bespoke, intimate tours were offered to clients ranging from the British embassy in Paraguay to the PBS broadcasting service in the USA. In a ten-month period 32,000 users logged on to a tour, which is roughly comparable in scale to the 40,000 tourists who would visit the house in the average year (Interview 4, Lizzie Dunford, Jane Austen's House, 12 August 2021). Going forward into the post-pandemic future, a hybrid model could make it possible for literary heritage museums to stream live tours into classrooms in (say) Japan or the United States, outside of normal opening hours, thereby expanding the reach of these museums dramatically.

At the same time, however, the rise of the virtual tour could pose some difficult questions to the literary heritage sector. By definition, writers' houses differ from most other galleries and museums in their dependence on site specificity. As Nicola Watson has put it, a writer's house museum presents itself as 'the scene that remembers the act of writing' (Watson, 2020), which in turn frequently involves a process of 'site sacralization' (term from MacCannell's 'The Tourist: A New Theory of the Leisure Class', 1976). Might virtual tours, by rendering an in-person visit to the site unnecessary, thereby risk undermining the very *raison d'être* of literary heritage sites?

Perhaps one way of countering any such threat might be to offer in-person visitors an experience that is more immersive, more tactile and more multisensory than any virtual tour could offer. Thus, a counterpart to the digital turn emerged in the form of the sector's marked embrace of outdoor spaces such as gardens, grounds and landscapes.

# **Reading and the outdoors**

The initial lockdown imposed in March 2020 meant that many more people than ever before were working from home. When staff were able to be furloughed, suddenly a huge percentage of the working population found themselves being paid not to work. Lockdowns and furloughs brought many widely reported changes in our behavioural patterns. One of these was a reconnection with the importance of nature and the outdoors, brought about by stringent coronavirus related restrictions, which curtailed the amount of time we could spend outside. Another was an upsurge in the public's

appetite for reading – especially for reading longer, more demanding literature – which was widely discussed in the press (Boucher et al., 2020; Charlton, 2022; Hunt, 2020; Wood, 2020). Seemingly, these two trends were unrelated, since reading is often considered an indoor pursuit. However, UK literary heritage sites repeatedly found creative and innovative ways to connect them, with a view to mutually enhancing the benefits of both for health and wellbeing.

According to book sales experts Nielsen, 202 million paperbacks and hardbacks were sold in the UK in 2020, the first time sales had exceeded 200 million since 2012 ('Booksellers hope …', Bloom, 2021). In the UK and Ireland 2021 went on to be a record-breaking year for book sales (Davies, 2022). One survey showed that 31 per cent of respondents were reading more since the lockdown began, rising to almost one in two 18–24-year-olds (45 per cent) (Reading Agency, 2020). The nation also increased the amount of time it spent reading books from around 3.5 hours per week, to 6 (sample of 1,000 adults, surveyed from 29 April to 1 May) (Flood, 2020). The Scottish Book Trust surveyed readers weekly between March and August 2020, finding that daily poetry reading doubled from 3 per cent to 6 per cent and daily fiction reading rose from 55 per cent to 72 per cent over that period. Moreover, they found that of all the genres readers turned to during the pandemic, the 'classics' experienced by far the largest uptake, accounting for 37 per cent of reading before lockdown and 58 per cent five weeks later. As a study from Aston University showed, 'Many found the lockdown to be a great opportunity to explore things they didn't normally have the time or desire to read (like hefty classics that seemed too dull or heavy to bring on a commute)' (Boucher et al., 2020). Some turned to reading for escapism, and some took comfort in old books or in more predictable genres. Shared reading and remote reading emerged as popular activities (Scottish Book Trust, 2020). Having more time certainly helped.

# **Outdoor interpretation**

Literary houses differ from their competitors in the historic house sector in generally being of a smaller capacity. Places like Beatrix Potter's Hill Top, a Lake District Cottage, and Laurence Sterne's Shandy Hall, a medieval parsonage, did not have the space to accommodate the social distancing measures brought in by the government in order to mitigate the spread of the coronavirus. More than ever, because of the drive to find well-ventilated spaces, and because of the way in which outdoor exercise had been permitted in some capacity throughout lockdown, more and more visitors looked to find local outdoor spaces for their leisure time. As the curators of the Shakespeare Birthplace Trust told us, 'people wanted outdoors':

They wanted spaces – that, certainly last year, impacted us when we had Shakespeare's Birthplace which is a tiny little house and our capacity is tiny really. And people didn't want – it was very difficult to be able to offer an experience of sufficient quality and depth I think in that small space in a way that when people wanted to roam around country estates and keep away from everyone else. (Interview 6, Rachel O'Connor Boyd, Shakespeare Birthplace, 1 September 2021)

This was a struggle for many literary houses, some of which had not yet made much use of the grounds in which their properties sit. Many literary heritage sites reported that public demand for outdoor space soared during lockdown: forced to 'stay local', many people discovered nearby outdoor spaces, often for the first time. Thus, the Shakespeare Birthplace Trust's Anne Hathaway's farm, the garden of Beatrix Potter's Hill Top, the extensive grounds of Gilbert White's House and Walter Scott's Abbotsford, and the gardens of Laurence Sterne's Shandy Hall and Jane Austen's House all reported unusually high visitor numbers during the pandemic, and in the case of Abbotsford, reaching record-breaking levels. This transformed the ways they make use of their gardens and grounds.

Walter Scott's extensive Abbotsford Estate saw an increase in visitor traffic of 400 per cent across the same period between 2020 and 2019. Londoners looking for green places to walk found Strawberry Hill for the first time: 'Strawberry Hill grounds was a little bit of a haven in among all the madness and it was hugely valued by the local community' (Interview 3, Derek Purnell, Strawberry Hill House and Garden, 9 August 2021). The Chelsea Flower Show garden that the Gilbert White team developed in collaboration with a local college, scheduled for May 2020, which did not then take place until August 2021, acquired new significance.

Despite having been scheduled to celebrate White's birthday, the continuing lockdowns prolonged its lifespan, thereby allowing the organisation to continue commemorating the tercentenary well beyond the date itself (Interview 15, Kimberley James, Gilbert White's House, 7 October 2021).

Many literary heritage site managers saw outdoor space in a different way due to the coronavirus pandemic, generating new interpretation for the outdoors for the first time. The team at Strawberry Hill emphasised much more than usual the fact that they have a garden and ran garden tours: 'it was perceived to be COVID secure in a good way' (Interview 3, Purnell, 2021). The staff of National Trust property Hill Top saw that 'people still wanted to come and visit the gardens', even when the property itself was closed. Perceiving this as 'a real opportunity to think about the outside offer', the garden was interpreted for the first time, with new, temporary, labels, which the following year were professionally printed and which will now continue to be used (Interview 10, Alice Sage, Hill Top, 13 October 2021). They opened a new café in the paddock to cater for their new audience and to help prolong their stay and improve visitor experience. Given that the appeal of Potter's works lies in their depictions of local wildlife, this was a logical step, yet one that, perhaps surprisingly, had not been taken before. Strawberry Hill made similar interventions in their grounds, putting up signage to inform visitors of wildlife that had recently been spotted and of the reasons behind certain plantings, tying the history of the garden to the narrative of the house which centres on Horace Walpole's time at the property, spreading the word about his garden design and changing views of the estate: 'in a way, I think it's made us appreciate that aspect of the house in a way that we probably wouldn't have done' (Interview 3, Purnell, 2021).

Seamus Heaney HomePlace, which had to close its 200-seater theatre space as well as its exhibition space during lockdown, took perhaps the biggest step in moving interpretation outdoors. Mid Ulster District Council opened an outdoor part of the visitor experience called Seamus Heaney Open Ground, developing five new sites about which Heaney specifically wrote poems, providing interpretation and a smartphone application as a guide (Interview 2, Brian McCormick, Seamus Heaney HomePlace, 9 August 2021). The app links the landscape of the area with Heaney's life and poetry, mapping the five locations that richly influenced his work. For each venue the app provides a pertinent poem, an audio file of the poem, a description of its significance, as well as a 'Go Back in Time' feature, which uses virtual reality to reimagine the place as it might have been at the time of writing, with Heaney's words magically resting in the air around it. The app includes urban and rural locations, from the Strand at Lough Beg to the Bus Station at Magherafelt.

There is some evidence to suggest, however, that the sector's turn toward nature and the outdoors might not exactly have been in reaction to the pandemic, since some initiatives of this kind predate the outbreak. For example, Ted Hughes's birthplace lacks any outdoor space, so its trustees commissioned a cartographer to produce beautifully hand-drawn maps of walks through the landscapes that inspired him, for free distribution. The research and planning for this had begun some two years earlier, and though its launch was delayed by the pandemic, the public's newfound appetite for the outdoors was of benefit to the project's popularity (Interview 5, Stephen Gould, Elmet Trust, 17 August 2021). Similarly, it transpires that the Shakespeare Birthplace Trust had begun conversations about making better use of their outdoors spaces, such as Anne Hathaway's farm and the garden at Hall's Croft, before the pandemic began. It is possible, then, that the pandemic had an accelerating effect rather than a causal one in regard to these developments.3

# **Wellbeing**

The move to outdoor space was one that prompted some predicted and some unexpected benefits for wellbeing. The People and Nature Survey for England from April to June 2020 found that 85 per cent of respondents reported that being in nature made them happy (Natural England, 2020). The Royal Society for the Protection of Birds' (RSPB) Recovering Nature report revealed that 77 per cent of those surveyed believed that visiting nature during the pandemic had been important for their general health and happiness (RSPB, 2020). Surrey's Gardens and Wellbeing Report also found that more frequent garden visits were associated with better wellbeing during

lockdown (White, 2021).4 The Organisation for Economic Cooperation and Development (OECD) found that evidence from the coronavirus pandemic corroborates the relationship between time spent in nature and general wellbeing: 'The mental health and wellbeing benefits of time spent in nature were all the more important when people were confined to their homes' (2021).

Lockdown made people want to engage with nature more. The National Trust survey suggested that most people (55 per cent) planned to spend as much time in nature as possible when restriction are lifted, with a third of respondents reporting increased interest in nature (National Trust, 2020). But there was also a social imperative to improving access to nature. Between March and May 2020, one in ten people either had no access to a garden, or found it difficult to access one, with ethnic minorities and those with a low household income more likely to find access difficult. Those under 47 years of age also struggled more than their older counterparts (White et al., 2021).5

The Laurence Sterne Trust at Shandy Hall re-opened its garden with its longstanding second-hand bookshop, which also sells antiques and souvenirs. They had over a thousand paying visitors: 'they came and they came back again, as well' (Interview 8, Patrick Wildgust, the Laurence Sterne Trust, 29 September 2021). This garden-visiting audience was a genuinely new one, coming from across Yorkshire, alerted to the Hall's beautiful grounds by the *Gardener's World* magazine, which provides its subscribers with two for one entry to select gardens across the UK. An increased interest in gardening, and subscriptions to *Gardener's World* magazine during lockdown had also dramatically increased.6 In this way, Shandy Hall Gardens were part of a major shift in reading, gardening and walking which brought widespread benefits to literary house visitors. Strawberry Hill began a gardening group for vulnerable adults. As their curator told us, 'I think it made us perhaps as an organisation more aware of that and, hopefully, a little bit more empathetic in terms of the importance with which Strawberry House is part of their wellbeing' (Interview 3, Purnell, 2021). For the house, this has improved their local reputational profile, hopefully leading to repeat visits by the local community.

Those literary heritage sites that are predominantly outdoor spaces, such as the site of St Bede, Jarrow Hall, had their own challenges. Staff had to be retrained to be able to multitask and do farm work, look after animals, as well as perform basic environmental checks on the collections.

We were lucky to have a lot of outdoor space. We're quite positive in the fact that we were able to open up those spaces and we were able to then allow visitors to come back and make use of those spaces again, which I think was such a welcomed thing, especially with so many people spending so much time in the house. People would come in order to just have that little bit of outdoor space with their families, which I think was really, really well appreciated and really important. (Interview 13, Hannah Mather, Jarrow Hall, 17 November 2021)

But literary houses also provided an important lifeline during lockdown in connecting people with beautiful places and with classic narratives. As Ellie King and colleagues have shown, 'Despite the immediate loss of up to 80 per cent of income (NEMO, 2020) and the fear of more long-term economic disruption, museums and galleries nevertheless saw themselves as community leaders, bringing people together' (King, 2021). In the case of literary house museums, they were able to do so through the turn to reading. As Jeff Cowton, curator of Wordsworth Grasmere's Dove Cottage, told us,

I think we used the words solace and help; that what people really liked was the fact that we were still there. You know, we were 200 years of history, pictures of Grasmere Dove Cottage Garden, of the house, we were just there, you know, in the time of trouble we were still here. (Interview 1, Jeff Cowton, Wordsworth Grasmere, 6 August 2020)

Cowton took the approach of sending updates about Dove Cottage with his audience, recording a video of an afternoon tea with some ginger snaps made from the Wordsworth family recipes and tweeting a photograph of Dove Cottage garden with its hawthorn in blossom. While Wordsworth Grasmere saw 55 per cent fewer visitors in the 12 months to 31 March 2021 than in the previous year (3,732 compared to 8,270), it saw an increase of 72 per cent in views of online videos (160,912 compared to 93,317), largely down to their creation of eleven new videos for families with young children to watch at home during lockdown (Wordsworth Grasmere, 2021). The team put it down to a general sense that the

house represented a kind of stability and hope. The house, and the garden, integral to the narrative of the Wordsworths and the Lakes, was still there in this time of trouble. As Cowton reflected, 'And so maybe literary heritage, you know, in our particular circumstance, anyway, offered that timelessness' (Interview 1, Cowton, 2021).

# **Outdoor education**

The literary house sector tends perhaps more than any other to make the most of major anniversaries, to help encourage repeat visits. One of the major events in the calendar for the Burns Birthplace is the annual Burns Night Supper. During lockdown, they had the supper outside in a marquee. Having acquired the marquee, they were then able to also provide a week of events for families. Crafts, bug hunts and a Scots language animal trail through the woodland brought families to the grounds to enjoy the good weather. Parents in particular were pleased, having spent months at home home-schooling.

When archaeologists at the nearby universities found themselves unable to do fieldwork, Jarrow Hall opened its doors to them. This led to their being able to deliver two weeks of summer school outdoors. Curators of the Shakespeare Birthplace Trust found that placing performers outdoors made them rethink their indoor offer:

One of the strongest parts of our visit was having our performers – having our Shakespeare Aloud actors outside, having our guides in costume – think about Mary Arden's Farm and having that depth and quality of guiding experience where people are talking you through Tudor life. All of that then drops away and then you're left with a relatively blank house setting that needed substantial work beforehand – hasn't been reinterpreted in the way we might have wanted – and then you're having to overlay Covid signage onto – keeping people walking round socially distantly – not being able to talk to guides in the same way. […] to deliver the warmth of the experience where so much of that previously did entirely rest on our guides and their ability to give a tour or a talk or a hands-on experience – all of that taken away was actually really hard and we've been exploring ways this year – not just through technology but also through trying to do some small talks and tours outside now that we're able to do that. (Interview 6, Boyd, 2021)

More than ever, literary heritage professionals are having to gather the results of the pandemic, its hits and misses, in order to engineer new ways of moving forward for the sector.

# **Conclusion**

Curators found new ways to revitalise and repurpose their engagement with the outdoors, bringing literature into nature in new ways for a public rediscovering the importance of both. These were often highly innovative: sometimes site-specific, sometimes interactive. Many were completely new departures: perhaps surprisingly, Hill Top brought Beatrix Potter's words into her own garden for the very first time. Interestingly, even writers' houses without gardens sought to connect their publics with the outdoors. If, as Elaine Heumann Gurian points out, 'museums are to be useful as they emerge from the Covid-19 pandemic era, they must be fundamentally rethought because the social, political, economic, and health environments they will re-enter are profoundly unlike the world they left' (Gurian, 2022).

In light of this, it is noteworthy that one of the common threads identifiable in these developments is a tendency to emphasise the importance of involving the local community.7 This is a significant development for a sector that, as previous researchers have found, was traditionally reliant on tourists who, in many cases, would travel long distances for the specific purpose of visiting a particular writer's house (Laing and Frost, 2012). The coronavirus pandemic obliged these museums to rethink their dependence on the traditional 'pilgrimage'-type visitor and to engage the public in their local communities in new ways. This may account for the success of the turn to the outdoors we have identified here, since those who live nearby are more likely to share a sense of identification with a writer's sense of place, space and landscape. Going forward, such developments may prove to enhance the longer-term resilience of the sector: partly by tackling, through local public engagement, the perceptions of elitism that sometimes surround literary heritage; and partly by preparing for a more sustainable future, in reducing the sector's dependence on long-distance travel.

All of the museums studied here have helped visitors reconceive how literature fits into our lives. Far from being a sedentary activity,

reading is shown to be compatible with exercise and can involve the outdoors as much as the indoors. We have long known that nature and exercise have positive impacts on health and wellbeing, and that reading literature do too, but lockdowns led many writer's house museums to seek out innovative ways of combining the benefits of both, indicating a positive direction for the literary heritage sector to take in the process of moving on from the pandemic.

Literary house museums, usually determined as such because of the significance of their indoor space, began *en masse* to project their collections and their treasures beyond the premises, mapping themselves onto the wider literary landscape of the UK and merging cultural and natural worlds in their pandemic programming. Hence, the coronavirus pandemic has taught the literary heritage sector that its next step probably lies outside the walls of the museum. For one unnamed, senior curator we interviewed, the pandemic's most important lesson was that 'it's OK [for the museum] to be closed'. In exploring the efforts of the literary house sector to cross the divide between culture and nature, this chapter has shown that engaging with a public that is increasingly environmentally aware, health conscious and wellbeing orientated is the most promising way of turning 'lockdown reading' into the 'new normal'.

# **Key insights**


• The coronavirus pandemic taught the literary heritage sector that its next step probably lies outside the walls of the museum, and that engaging with a public that is environmentally aware, health conscious and wellbeing orientated is perhaps the most promising way of turning 'lockdown reading' into the 'new normal'.

# **Notes**


adults. The figures were weighted and representative of all UK adults (aged 18+) (National Trust, 2022).


# **References**



# **Part III**

Lessons for practice

# Remote cultures: using arts activities to support staff working with people with dementia in care homes

# *Chloe Asker, Victoria Tischler and Hannah Zeilig*

People with dementia were disproportionally impacted by the pandemic. In England and Wales, 25 per cent of COVID-19 deaths were those with dementia, and in care homes in England and Wales they made up half of all COVID-19 deaths (Suárez-González et al., 2020). Lockdown measures and associated restrictions of the COVID-19 pandemic negatively affected the lives of those in care homes; this included restrictions on visits from family and friends. These were coupled with requirements for residents to remain in their rooms due to staffing shortages. Suárez-González et al. (2020) describe the effects of this situation leading to 'confinement disease', resulting from 'leaving people alone in their rooms due to staff shortages with no assistance for drinking and eating' (Suárez-González et al., 2020: 12). They argue convincingly that this may have been more deleterious than the virus itself. This is supported by figures from Alzheimer's Society UK, which showed that 80 per cent of 128 care homes reported that the lack of social contact caused a deterioration in health and wellbeing for residents with dementia (Alzheimer's Society, 2020). It was within this context that the Culture Box project was created: it sought to alleviate some of the negative impacts on people with dementia, particularly the rates of social isolation and loneliness in care homes that were heightened due to the lack of visits and confinement.

Through the project, the team designed and distributed pandemic guidance and creative activities to people with dementia and staff in care homes, with a particular focus on the inclusion of Black and racialised communities. This focus is significant since the majority of studies on the impact of COVID-19 for people with dementia have been carried out on predominantly white and female

**Figure 7.1** Screenshot of performance 'Hello Love' by Akeim Toussaint Buck

participants (Masterson-Algar et al., 2022). Culture Box addressed this issue through prioritising inclusion from Black and racialised communities (including artists and people with dementia) in the co-design phase of the project. Alongside this, we sought to provide creative activities and artist commissions that foregrounded diversity and emerging talent from under-represented communities and people from the Global Majority.

The aim of Culture Box was threefold: (1) to alleviate social isolation and loneliness; (2) to provide stimulating activities that enhance social interactions within the care home; and (3) to offer accessible public health information with a focus on reaching those with dementia from diverse communities. Over the course of a year (December 2020–December 2021), a 'culture box' was delivered to the care homes each month, containing creative and participatory activities and resources. Activities were a mixture of online (music, videos, etc.) and physical resources (colouring, painting, crafting, etc.). The project used a remote working model where most team meetings, interviews and collaborative activities were undertaken over virtual platforms alongside some in-person coordination of packaging and mailing boxes.

Drawing on the lessons learned from undertaking Culture Box during the pandemic, this chapter sets out an agenda for care staff development and future research. We offer forward-facing recommendations to others who are considering care staff training and development and those undertaking participatory virtual or hybrid projects with people with dementia. These recommendations are directed to those working in dementia research and creative activity facilitation. They are shaped around each of the lessons learned, centred around four themes: (1) creative connection, (2) wellbeing, (3) agency and (4) methodological innovation.

Culture Box was a novel project that brought about numerous benefits for the participants involved, including inspiration and support for staff and decreases in social isolation and loneliness for people with dementia. Creative connection was a core factor in these improvements and developments; creativity and creative practice was the catalyst for social interaction, relationship and community building. Creativity brought people together during a difficult time. We therefore focus on examining how creative practice in care home staff that improves the quality of social care provision can be supported and facilitated. This is urgent given that there were 165,000 vacant posts in 2021/2022 due to difficulties in recruitment and retention (Skills for Care, 2022), and that a recent report states that people with dementia want social care staff to 'deliver personalised care (and) with consistency of staffing that allows a rich, supportive, and trusting relationship to develop' (Alzheimer's Society and APPG, 2022: 6). The following sections explore these issues in more detail using qualitative findings from dialogic interviews undertaken during the Culture Box project.

# **Lessons learned from Culture Box**

# *Creative connection*

Creative connection is the use of creativity to access and feel connection and get yourself and those with you in the moment into a more connected space. (Tempest, 2020: 6)

This section focuses on artistic activity as 'creative connection': in this context referring to interactions between care staff and care home residents living with dementia. The concept of creative connection is inspired by work on co-creativity, which is understood 'as a relational practice that exists within a group' (Zeilig et al., 2019: 17), that is, it represents a non-hierarchical participatory endeavour, that promotes understanding and collaboration with people with dementia with a focus on shared ownership and process, inclusivity, reciprocity and relationality. Creative connection builds upon conceptualisations of 'being in the moment' for people with dementia who engage in creative activity. This is understood as the multi-sensory processes involved in a personal or relational interaction and embodied engagement (Keady et al., 2022).

Culture Box promoted, prompted and supported creativity during lockdown for the residents and care staff. The Methodological Innovation section below includes a description of how Boxes were developed, what they contained and how this was evaluated. However, here it is important to note how creativity acted as a *catalyst* for social interaction, 'moments' as referred to above, and relationship and community building, within the confines of a digitally delivered project. Creative activities provided a catalyst for connection for the residents and staff, supported by the regularity of the activities arriving in their virtual inboxes each week and in their letter boxes once a month. This section focuses on three dimensions of this creative connection: (1) how Culture Box supported activity provision; (2) the connective role of creativity within care homes; and (3) the routinising of creative activities through the regularity of Culture Box activity provision.

# *Supporting activity provision*

Staff indicated that the usual programme of creative activities, for example visits from artists and musicians, had been disrupted or cancelled as a result of the pandemic. One of the care staff was overwhelmingly positive about the impact of the Culture Boxes, reporting that they had filled the gap in the activities timetable which had been affected by the COVID-19 restrictions. Another care staff member told us:

I love the Culture Box first of all, I think it is very informative, lots of information, and there are different things to do which I find really useful, because at the moment obviously we can't have people come into the home for entertainment or anything like that, so the Culture Box, helps us to do an activity.

Care staff appreciated that Culture Boxes provided materials, instructions and guidance for implementation. Some did, however, need additional support to enhance their level of confidence in using the materials provided. One care worker reflected that she was experiencing a creative block and that Culture Box brought inspiration and helped to re-ignite her passion and enthusiasm for activity provision: 'I know that my creativity has just kind of stagnated and I'm not bringing the best I can to residents. So something like this has helped to lift me up and has meant that they're getting something different and I think that is really beneficial.'

Towards the end of the project, one staff member described Culture Box as a 'magic box', which contained supportive materials and ideas for creative activities:

It has supported me because it was, I can say something different for people with dementia. But with these materials [it] is not just for them, these materials can be for the others as well, it is good, because painting or music or sounds, it is a sensory feeling […] it was like magic box, it was like a magic box.

The facilitation of material outcomes through Culture Box was important – for example, completed colouring pages, sock snowman puppets and paintings. These objects acted as souvenirs from the residents' creative endeavours which could be shared with the care staff, wider care home, with family and friends via video call, and perhaps could be used to trigger empathic 'moments'. These moments were also able to facilitate future care practice through using creative outputs to support personalised and culturally sensitive care, for example including music from different cultures, as requested by those with lived experience (APPG on Dementia, 2022.). The ability of the Boxes to support activity provision is very encouraging; we argue that future projects should explore the use of virtual and hybrid creative practice to support care staff development and training. Alongside this, it would be useful to investigate how virtual and hybrid creative practice may support personalised and culturally sensitive care provision. Finally, we suggest that it would be useful to explore whether this has any impact on staff recruitment and retention.

The care staff noted that the creative activities during the pandemic provided a space for social interaction, and relationship and community building among the residents. Conversation and interaction meant that new stories and memories were shared. One care staff worker told us that:

And it is like totally changing them and it brings them out of themselves a little bit, which is nice […] It is new, and I mean something that we learn, something we can learn new thing all the time and so yeah, it is lovely, we are absolutely loving it actually.

Participants reported that the activities in the Culture Boxes provided stimulation, fun and enjoyment – effects that were urgently needed during the harrowing experience of the pandemic and its restrictions. Another care staff member noted the joy that was present during the Culture Box sessions:

A lot of laughs coming. With snowman activities like that so they have to create something. (What) they created was a bit funny because one put the eye up and one the eye down and after they were looking, oh look. And after they had to correct it so that's something good as well. What can I say, they love it.

**Figure 7.2** Residents enjoying the snowman-making activity. *Source:* Culture Box 2021

As noted above, the creative activities offered enjoyment, cognitive stimulation and distraction from the pandemic. They also provided an opportunity for residents and staff to engage socially. Some formed strong relationships through the project, so, for example, during one interview, a resident stated that she felt that the care staff worker she was partnered with was like a daughter to her.

Regular interaction through doing the creative activities together supported the dyads' relationships to develop and grow, thus enhancing personalised care practice. The context of the pandemic meant that residents' family members were unable to visit, something that would have been challenging and likely to create distress and separation anxiety. The dyads learned new things about each other, shared stories and reminisced about the past. For one resident, the colouring-in and drawing activities sparked memories. A tree-themed activity centring on a baobab tree ignited memories of growing up in rural Somalia. Another activity involving drawing a landscape led the same resident to illustrate a seascape with a ship, which provoked reminiscence of time travelling around the globe while working as a ship mechanic. These small moments need to be recognised as part of the social fabric that was keeping the care home community together during the pandemic.

# *Routinising creativity: creating moments*

Staff and residents noted the importance of the regular deliveries of Culture Boxes that arrived via post or digitally once a week for 52 weeks. However, initially, care staff spoke of the challenges they experienced in making the activities routinised and habitual. They spoke of the difficulty of building them into a busy workload that was more pressurised due to pandemic restrictions that included use of PPE and the need to promote social distancing to protect residents from COVID-19. Given this context, routinising the activities and the need to honour participation in a national research project facilitated protected time and space for the creative activities provided. The activities were reported to become embedded in the life of care homes, with boxes eagerly waited for and residents coming together regularly in groups to complete the activities. The care staff developed innovative ways of embedding activities into the routines of the care home through creating incentives and

**Figure 7.3** Resident finished his colouring activity which made him reminisce about his early years in Somalia. *Source:* Culture Box 2021

competitions. For example, one care staff member ran a colouringin competition in the home to engage residents:

So colouring competition for example I put four or five residents [together]. They do the colouring and after we show to the others and say which one is the best you think. […] We put a prize for example for the best colouring. And that gives them a motivation.

**Figure 7.4** Residents taking part in a colouring competition. *Source:* Culture Box 2021

Some, however, found the amount and range of activities provided overwhelming. Hannah, spoke about her difficulties in getting through all the material. To prioritise the activities, she began scheduling them in:

I haven't been able to interact as much with the residents with them. […] We've just got a new online system for recording everything as well. […] I've already booked out two slots a week for Culture Box, so that I can engage with them more. So we're going to go back and look at some of the digital boxes that we missed.

Scheduling allowed dedicated time and space for care staff to work on the creative activities with the residents.

This routinisation by the care staff was well received by the residents. They enjoyed the regularity of receiving the physical boxes each month; this became an 'event' within the care homes with some residents waiting eagerly to open boxes with the staff as the following extract illustrates:

It will be quite sad, won't it, when it [Culture Box project] comes to an end because we look forward to them coming every month. We get excited when we are opening them […]. They are always quite annoyed if it arrives, and I am not here because obviously they can't open it.

This description of an exchange between a resident and their care staff demonstrates how the project became a focal point in the lives of the residents and care staff during the pandemic. Each box was eagerly awaited, and there was a sense that something might be lost or missing when the project concluded, with a member of care staff in another interview suggesting to the resident that 'it is going to be weird not having it anymore, isn't it?' The resident's response to this was: 'We are going to miss it. We can carry on with it.' This indicates a desire to carry on using the Culture Boxes beyond the life of the research project and demonstrates a potential legacy for the project. Yet, looking forward to the post-pandemic context, we can imagine that the ability to integrate creative activities into care home schedules has become more challenging, as space and time for this has become squeezed. This observation has been generated from interactions with care homes

during the Culture Box Show, as many found it hard to respond to the interactive elements of the exhibition.

Culture Box was a catalyst for connection, supporting the concept of 'moment' creation and reflection (Keady et al., 2022). This was aided by the routinisation of the creative activities promoted by the regularity of activity provision from the project centrally and the organisational labour of the care staff in scheduling in weekly time to support the residents with the activities. An implication of this is that provision of frequent creative activities, including materials and clear instructions can support care staff in their work. During the pandemic, having a regular creative intervention created a point of connection for the residents and wider community involved, offering a space for social interaction each week, and promoting personalised and culturally relevant care practice. Future studies and practice should consider any longer-term impact of the project on care home practices, the utility of this approach beyond the pandemic and utilising the archive created with a wider population.

# *Care staff wellbeing*

The project's core aims were to improve the wellbeing of residents through increasing social interaction to combat social isolation and loneliness. By wellbeing, the authors refer to a variety of behaviours and approaches that support optimal physical and mental health (see NHS, 2021). The aspects of wellbeing most relevant to Culture Box are connecting with others and new learning. While not the focus of Culture Box, the team noted that there were significant challenges to care staff wellbeing during the project. This included high levels of stress, resident illness and mortality during the project. Given the lack of in-person contact, the remote and virtual nature of the research meant that ad hoc, informal conversations about these stresses and pressures facing the care staff were often revealed and discussed during the dialogic interviews. There has been research to suggest that online communication can increase instances of self-disclosure, for example, between adolescents (Davis, 2012), in online health groups (Yang et al., 2017) and with virtual reality technology (Lucas et al., 2014). This could be further explored in future studies.

In one interview, a member of care staff was very honest about the toll that the pandemic was having on the daily functioning of the care home and the pressure she was under:

I am not going to lie to you, it has been pretty stressful, there are two of us [activity] coordinators, 89 residents, so it's a lot of work to do. So I mean I always have a smile on my face no matter what, but you know, there are days when I go home and I can't even feel my feet, can't think straight. No one talk to me for an hour please.

In relation to this, Suárez-González (2020b: 28–29) argues the 'need for greater recognition of the psychological support including counselling they [care staff] may require for coping with the trauma sometimes experienced'. Staff reported that interactions with residents kept them motivated during a difficult time. Playful interactions with residents made working life bearable as was highlighted by one care worker:

I think the residents keep me going, because they make me laugh and I go and see them, they might not want to do what I want them to do, but it's just, you know, we have a laugh about it and it keeps me going.

In this context, wellbeing is relationally orientated – positive and joyful interactions between residents and care staff are reciprocated and support the wellbeing of both. The creative activities acted as a playful catalyst for these affects to be felt. Here, intrinsic motivators, the satisfaction derived from undertaking actions that benefit other people and the interest or enjoyment in the task itself (Lagarde et al., 2019), are important factors in providing high quality care. However, intrinsic motivators should not be used to exploit or underpay care workers, as identified by England (2005) who argues that they are part of the 'prisoners of love' care work framework, within which these types of motives can be used as a way for employers to justify underpayment. The emotional satisfaction from this work is the reward for the labour, leading to a commodification of emotion. This issue is particularly pernicious in an overworked and underpaid care sector, particularly during a global pandemic that exacerbated existing pressures and burdens. A call from *The Lancet* to governments to treat care workers not as 'pawns to be deployed, but as human individuals' that are 'every country's most valuable resource' (The Lancet, 2020). Postlockdowns, reports suggest that UK social care is experiencing high

rates of staff turnover, with vacancy rates being the highest since records began and issues regarding pay, contract and working conditions (e.g. zero-hour contracts and low pay) greatly affecting the sector (Skills for Care, 2022).

Some care homes struggled to keep up with the content of the project, with many staff members apologising for being behind or not being able to complete all the activities. The research team were aware that the project might place extra burden on care staff during an already precarious and challenging time and provided regular reassurance. Towards the end of one interview, a care staff participant expressed anxiety over completing all the activities:

All I am worried about is the fact that I am on my own at the moment and so I am going to have to restructure how I do things in terms of it because I have to fit in other activities as well obviously. But these are really good because some residents, even the ones that you don't see, other residents enjoy it as well. So, I will have to try and work out how I am going to fit it all into my schedule.

The research team advised staff to pick and choose the activities that seemed most appropriate for the individual resident, thus promoting personalised care. Yet, there was a clear sense that the care staff were struggling initially to integrate the activities into the routine of the care home. However, as the project progressed, routinising the activities allowed Culture Box to ease some of the burden regarding activity provision with the regular resources relieving pressure to devise new creative activities each week.

# **Creative agency**

This section focuses on the agency of the care staff involved in the project. By 'agency' the authors refer to the choice and decisionmaking concerning creative activities that Culture Box afforded to research participants and through which participatory research processes were supported. Care staff were observed shaping the creative activities to fit individual capacities and capabilities. Agency was witnessed in the ways in which staff were responsive to the fluctuating capacities of the residents, a process that involved improvisation and unpredictability. One staff member reflected that 'you can't predict creativity though can you to be fair? Some days are better than others for it.' This fluctuation was clear during another interview, where a member of care staff expressed anxiety over the abilities of the residents she was paired with: 'Sometimes it's very difficult to communicate and sometimes very difficult to do the activity in full. Sometimes I don't know what kind of result you are expecting from us […]. But I feel like we try our best you know.'

Care staff demonstrated considerable skill in improvising and working creatively to make activities bespoke to individual capacities and capabilities of residents living with dementia. They spoke about recognising the fluctuating nature of residents' capacities and worked to change the activities to meet their needs:

I think that challenged me nicely because it meant I amended things. I knew the colouring sheets weren't going to work for everybody and it meant that I could bring in things that I knew would work like doing the poetry because that's something we do quite often. And I know it plays to people's strengths and they enjoy it.

This member of staff continued to speak about the process of altering the materials, drawing on a person-centred approach to offer activities that were suitable for the residents:

It [the boxes] will contain everything you need but at the same time, you could personalise it by adding music or adding art or adding whatever works for your residents […]. You can personalise and individualise this and you can add things that you know your residents really enjoy.

However, part of this work was emotional labour: using a personcentred approach meant that additional work *was* needed to shape the expectations and confidence of the residents. Some needed extra encouragement and cajolement to continue with the activity if frustration arose from the challenges that come with living with dementia:

We can easily adapt things and I would do them at the level of that person but I would always try and push them a little bit more to see if they could do things. […] But it depends on where people are at on their journey. But mostly there's always a way to get someone to do something and stimulate.

The creative agency exercised by care staff and observed through this project indicated that this group work with considerable skill, and in some cases intuitively, drawing on their experience, training

and communication skills to work effectively with people with dementia. This complex skillset is not fully (if at all) acknowledged in a staff group who receive poor renumeration, where there is high attrition and a workforce crisis. Yet, such person-centred and institutive skills are essential to enable those living with dementia to thrive (APPG/Alzheimer's Society, 2022). Future work could consider how to harness this skill and expertise in developing training and career pathways that have the potential to lead to improved recruitment and retention of excellent care staff.

# **Methodological innovation**

The project used a Participatory Action Research (PAR) framework which involved a mixture of surveys and dialogic interviews at four time points during the study. PAR has been described as 'collaborative co-governance of research, involving researchers and those affected by issues under study or who are in positions to act on the knowledge generated by research (e.g. end-users including participants of an intervention, clinicians, health managers, and policymakers)' (Kowe et al., 2022: 1013). This methodological approach was chosen primarily to effect change, in that the project aimed to reduce social isolation and loneliness in care homes during the pandemic. This core intention was strengthened by working with dyads (residents and care staff), allowing them to be involved throughout the research process. Previous research attests to the merits of a participatory approach when working with people with dementia, allowing researchers 'to understand and address some of the complex and social problems faced', while 'contributing to individual and community capacity building' (Blair and Minkler, 2009: 651). Agency is a key aspect of a participatory approach, meaning that participants are included in all phases of the research process. During the Culture Box study, PAR involved: (1) Planning, (2) Action, (3) Evaluation and (4) Reflection. At each stage, participants were included and consulted.

During the planning stage, the dyads were consulted about their activity preferences via an online survey disseminated via email which informed the content of the boxes. Stage 2, action, involved

*Source:* Culture Box 2021

the production and delivery of the boxes every week (one via post, followed by three digital boxes each month) for 12 months. These included a range of materials (subject to co-design). Digital boxes included downloadable and printable materials suitable for oneon-one interaction between staff and residents with dementia who were isolating and subject to social distancing. The evaluation stage included a series of three dialogic interviews at three points throughout the project. Interviews were shaped by a participatory approach that was collaborative, relational and responsive (Wiesner, 2021), eliciting conversation, laughter and storytelling. A dialogic approach was chosen to facilitate a responsive and flexible interview style. All the interviews with residents and care staff were undertaken on virtual video conferencing software such as Zoom or Teams. Evaluation was iterative. The cyclical approach of PAR meant that data were collected and analysed periodically during the study. This included the perspectives of all participants,

especially care home residents living with dementia, to foreground their experiences. Reflection by the researchers and care staff involved ongoing teamwork and discussion throughout the project using remote and digital methods of communication. A final online survey was commissioned and disseminated via email to residents and staff to capture overall responses from the project and the effects the boxes had on social isolation and responsive behaviours. This stage of the project also included the Culture Box Show which involved a virtual exhibition of work from four new artists (Helena Tomlin, Polly Townsend, Iirumva Isaac and Kate Munro) commissioned to create work in response to the project. This aimed to facilitate further reflection on the project and engagement with the materials created, in keeping with the reflexive stage of PAR.

The virtual, remote and digital nature of the project shaped the way the research was conducted, allowing for the inclusion of a larger geographic area than was previously feasible and enhanced accessibility for the participants. Receiving regular boxes through the post and via email facilitated participation from the care homes, allowing them to integrate the arrival of a box into their activity schedule and routine. Conducting interviews online allowed for ease of participation, alongside reducing the costs and energy spent travelling to different locations. Although the researchers and production team were at a physical distance from the residents and care staff, the act of sending post and emails brought a sense of community and solidarity during the isolating and challenging time of the global pandemic.

However, the digital nature of the project also posed some challenges, including implications for the way PAR was conducted, ethical procedures and the participation of the care homes. PAR normally relies on face-to-face interactions to build trust, community and an inclusive atmosphere to enable participation across stakeholders and participants. The virtual nature of work during the pandemic meant that creating lasting, sustainable and close relations with care homes was more challenging, as ad hoc conversations over tea and biscuits in break rooms with care staff, and in communal rooms with residents, were not possible. Instead, all discussions were formalised through organised and scheduled video calls, which inevitably made it more challenging to access these more hidden knowledges or experiences that would be discussed in informal settings.

The research team reflected regularly on the pressures being experienced by care staff. Many discussions about the problematic nature of undertaking research during a global pandemic took place. These included consideration of how the care staff may have been stretched in unforeseen ways through taking part in the research, recognising that it might perhaps have been providing them with yet another task to complete. The extra pressures and burdens faced by care staff during the pandemic, where non-essential tasks were quickly abandoned, meant that additional research activities including collection of reflections and photos from care homes were scaled down considerably. The moral dilemma of undertaking extractive and transactional research during a global pandemic was considered by the research team. This was unresolved and is worthy of consideration by other researchers in future, particular in times of crisis or when working with populations who may be deemed vulnerable.

Another challenge faced was how to gain informed consent from the participants via online platforms from people with dementia in care homes. The team drew on a wide range of literature including insights from anthropological literature to overcome this challenge; specifically a paper about working ethically with the Indigenous non-literate population of Papua New Guinea (Benitez et al., 2002). This resulted in the project team devising a form of process consent that relied on working closely with care staff. This was particularly important as the capacity for participation for people with dementia can fluctuate during a study. The research team collaborated closely with care home managers to ensure that staff understood fully what they were consenting to and what was involved, for example: leading webinars, using specifically designed consent scripts and ensuring that the research team maintained ongoing regular contact to check that consent processes were adhered to.

The digital and virtual methodology shaped and mediated the ways that care homes participated in the research, as poor Wi-Fi and low levels of digital literacy meant that accessing the online resources, responding to emails and taking part in the interviews posed challenges for the research team and the care staff. Interviews

were disrupted by poor audio and video along with low signal strength and a high frequency of calls dropping midway through an interview. Additionally, some staff found it difficult to access the online resources due to a general lack of, or access to, technological equipment. One care staff worker described the challenges she was facing: 'I don't get those emails. This laptop isn't mine, so clicking on links isn't very easy for me. I am having to do everything on my phone.' Others reported having to buy new equipment due to the change in working cultures prompted by the pandemic: 'I didn't even have an iPhone when COVID started. And basically, I had to go out and buy one. I just wouldn't have been able to cope really in the job that I do without it.'

Digital literacy was challenging for some of the staff members, as a perceived lack in competency meant that they were not able to access all the materials provided. One noted:

I haven't managed to access the digital stuff. With the box being there and physical, that's been great. […] I have to set up a projector [in the lounge] and a trolley and a speaker and then I have to hope the WI-FI's playing ball. I haven't used the digital stuff and I regret that because I think you would have enjoyed [it]. So I think that's me letting you down in some ways.

This situation was common among care homes, along with the trepidation that the care staff felt in having to change their habitual ways of working: 'you can do FaceTime and stuff like that but sometimes, even my age, technology, you just don't get it do you?'. However, those that persevered and immersed themselves in the digital technologies were afforded new skills and competencies. Both the research team and the care staff acquired new digital expertise and resources through the experience:

We have learned quite a lot from the experience of COVID really, especially where technology is concerned. Like, the different things that you have sent us as well and, you know, being able to do FaceTime and Zoom. I am doing things that I would have never ever considered doing. I mean, we Zoom people, well, face-time people, relatives in New Zealand. […] We have made quite a lot of different connections. That we would have never made.

The project was able to purchase iPads for the care homes in need of digital equipment, allowing them the chance to access the digital resources, gain new competencies and participate in the interviews in a more mobile fashion.

In this section we have sought to demonstrate the ways in which the digital nature of remote working during the pandemic shaped the methodological approach taken in the Culture Box project. This mode of working brought many challenges to the research team and care staff, but they also enabled reciprocal growth and learning through the uptake of digital technologies and competencies. Here, the participatory nature of the research was exemplified by the shared engagement with new technologies, methodological approaches and forms of interaction.

# **Recommendations**

In this final section, the authors offer recommendations for future work for researchers in dementia care and those involved in creative activity facilitation in health and social care settings.

# **Creative activity facilitation**


NAPA website: https://napa-activities.co.uk/services/projects/ the-culture-box-study).

6 Build flexibility into activities, acknowledging diversity of experiences and interests, and demands on busy care staff time.

# **Research and dementia care**


# **Key insights**


# **References**



# Communicating through COVID: arts-based approaches to supporting healthcare workers through a pandemic

*Suzy Willson, Graham Easton, Sandra Nicholson, Bella Eacott, Eliz Hassan, Pedro Rothstein and Paul Heritage*

Clod Ensemble is a multi-disciplinary performance company. They present their productions in theatres, galleries and public spaces, as well as creating projects outside of traditional arts settings. Their Performing Medicine initiative has involved creating arts-based professional development and learning opportunities for healthcare practitioners – co-designed with people working in medical education, NHS trusts and health policy. The embodied pedagogic techniques developed by Suzy Willson, Director of Performing Medicine, and a team of Associate Artists have proven to be valuable in supporting healthcare students and staff to develop skills and strategies in verbal and non-verbal communication, teamwork, leadership, spatial awareness and self-care (Osman et al*.*, 2017; Perry et al*.*, 2011; Willson and Jaye, 2017). Underpinning this approach is an acknowledgement that, even in a perfect system, healthcare is an emotionally and physically demanding profession, one in which there is fundamental relationship between how healthcare professionals care for themselves with the care that their patients subsequently receive.

This chapter will explore how Performing Medicine (PM) responded to the outbreak of COVID-19 and share findings from *Communicating through Covid* – a collaborative research project undertaken during the subsequent pandemic.1 We share the findings of interviews with healthcare professionals and creative workshops with artists, which aimed to understand the challenges faced by these groups as a result of COVID-19 and to discover if there were lessons from creative practice that could address the challenges. The research undertaken by a combined team of academic, artistic and

healthcare professionals shows that arts-based strategies can play an integral role in recovery from the pandemic for those working in healthcare settings. The findings offer viable strategies to address critical issues and bring teams together who have been fragmented by the demands of the response to COVID-19.

# **Communicating through Covid**

Communicating through Covid was an eighteen-month collaborative research project proposed by a multidisciplinary research team of Queen Mary University of London (QMUL) academics (from Drama and Medicine), healthcare professionals and artists. Its primary aim was to investigate how both virtual barriers – such as video conferencing software – and physical barriers – such as personal protective equipment (PPE) – impacted healthcare practitioners' verbal and non-verbal communication during the pandemic, to then identify what support they may need to cope effectively. To strengthen the practice-based research methodologies and build connections with other COVID-19 research projects in the UK and Latin America, the PM team was joined by colleagues from People's Palace Projects (a research centre on arts and social justice based in the School of English and Drama at QMUL). Further collaborators came from QMUL's Faculty of Medicine and Dentistry, with whom Performing Medicine had been delivering an innovative arts-based component of the undergraduate medical school for many years. Four partner sites were brought on board to provide the healthcare staff and students forming the participants in this study: three NHS hospitals across London and South Wales (St Thomas' Hospital Emergency Department, University College Hospital and a number of sites within Swansea Bay University Health Board), and one medical school (the QMUL Faculty of Medicine).

Prior to the implementation of the profound changes that COVID-19 brought to healthcare practices and settings, there had been a growing understanding of how non-verbal communication and spatial awareness profoundly shape experiences of healthcare. But medical education had generally focused on eye contact, head nods and gestures, rather than broader, whole body non-verbal languages as it is conceptualised within the arts (Kelly et al., 2019; Silverman and Kinnersley, 2010). While role-play and video were used to address non-verbal communication, there was space for more exploratory workshops that facilitate experiential learning. The safety and infection control restrictions brought in during the pandemic – such as social distancing, wearing of PPE, restrictions on touch – immediately highlighted the importance of physical, non-verbal aspects of care, and in so doing also raised the need for new learning methods to develop these areas (Díaz-Agea et al., 2022; Hampton et al., 2020; Schlögel et al., 2021). The skills that theatre makers, dancers and visual artists can bring to healthcare are not the basis for conventional medical and healthcare training but it was those skills that became the basis for the research.

The project was organised into three phases. Phase 1 consisted of interviews with healthcare professionals and a review of the literature to understand the challenges faced by healthcare professionals during this period. Required to wear PPE, implement social distancing measures and communicate with patients and colleagues over video conferencing technology, healthcare professionals reported how anxiety, morale and their own wellbeing and self-care was affected, as well as facing barriers to their communication. Phase 2 brought together poets, theatre makers, musicians, digital artists and dancers/choreographers in creative workshops, to reflect on the themes that emerged from these interviews and to consider how the pandemic impacted on their own practice, to undertaken an audit of their own creative skills to consider how they improvised and adapted, and to discover if there were lessons from creative practice that could address the challenges highlighted by the healthcare professionals. Phase 3 piloted a range of creative interventions aimed at the healthcare professionals, accessing artistic resources such as metaphor, movement, language, voice and breathing, transformation of objects and spaces, and creating opportunities for critical reflection, to address the challenges identified by healthcare professionals during Phase 1.

# **Phase 1: Understanding the challenges**

In the first phase of the research the research team conducted thirteen online semi-structured interviews with hospital staff across four partner sites about their experiences of working since the

pandemic began. We asked participants to reflect on changes to their working life or experiences resulting from the pandemic generally, the impact of wearing PPE on their verbal and nonverbal communication, of online and telephone consultations and meetings, of social distancing and limitations on touch, on their own self-care, wellbeing and morale, and on any training they had received during the pandemic.

The interviewees included four medical students, two nurses, two General Practitioners (primary care doctors), four hospital doctors (anaesthetists, emergency medicine paediatrician and a junior doctor) and one clinical specialist physiotherapist. They worked in settings ranging from Accident and Emergency departments to their own homes, with patient groups that included both children and adults. Interviews were audio recorded, transcribed and qualitatively coded using thematic analysis, by three of the researchers (working through the following stages: (1) familiarisation with the data, (2) generating initial codes, (3) searching for themes, (4) reviewing themes, (5) defining and naming themes, (6) writing up the analysis of data. Short excerpts from these transcripts are quoted within the text below.

In March 2020 the working lives of healthcare workers like our interviewees changed drastically (Billings et al., 2021; Gordon et al., 2022; Rimmer, 2021). While some of the staff we interviewed had their services completely stopped and were taken off wards, others were asked to take on additional responsibilities or were redeployed to work in Intensive Care Units or specialist wards. Medical students left their clinical placements as their curriculum moved online. All our interview participants reported feeling unprepared for the pandemic and experienced the first wave as a period of rapid change with little clarity on regulations. Despite speaking to staff working in a diverse range of professions and settings, the challenges our interview participants described were strikingly consistent.

# *Communication barriers*

All our interview participants spoke about new barriers to communication and interpersonal connection that the pandemic brought. These barriers were felt to have negative impacts on quality of communication and their own, and their patients' wellbeing.

Hospitals fitted Perspex screens at reception areas and in staff rooms during the pandemic. While this did increase protection, it also led to staff feeling the need to shout or repeat themselves to be heard, which in turn increased feelings of frustration and led to vocal fatigue and sore throats. Similarly, staff increased their vocal volume to be heard through masks but were then concerned about misinterpretations of their change in tone, and they were worried about the negative impact on quality of care for the hard of hearing. These worries were amplified by certain settings such as waiting rooms where the atmosphere was already chaotic, but the need to relay messages in these environments concisely was also stressed. However, the pressure to do this and not be misunderstood left some feeling as if the quality of conversation had been lost.

You might hear the quality of the conversation is so much worse because you restrict yourself to simple, short sentences where you're more confident that people can understand you and you lose a lot of the humanity of the conversation because you're not able to come across in the same way that you would be if you could speak freely. (Participant, 2021)

Social distancing and PPE also created physical barriers to touching patients, which staff regarded as an important aspect of care, not only in the ways that it is required for examination, but as a tool for comfort and reassurance. The lack of face-to-face interaction minimised the social aspect of care that is particularly important for certain groups of patients, such as with children, or the elderly. Staff described feeling distant from their patients, experiencing a 'depersonalising' of care which was difficult to overcome:

They're coming into hospital, they're alone and frightened. There's only so much as a nurse that you can give them. It's not the same, and especially when you haven't even got a face to look at. You've just got a set of eyes, you know, it's just not human nature, is it? (Participant, 2021)

Staff also struggled with the new requirement to have online conversations with colleagues, patients and their carers or relatives. Some of the hospitals were underprepared to deal with a switch to online work, with limited spaces in the hospital to conduct Microsoft Teams calls, poor Wi-Fi connections and no support in how to prepare an environment for an effective video call beyond software

advice. Virtual consultations were also felt to reduce the quality of non-verbal information – body language, facial expressions, quality of touch – that staff could use when assessing patients. This left staff feeling like they were missing the bigger picture and less confident in their interpretation of patients and their problems, finding themselves having to interpret new, less familiar cues such as tone of voice and pauses in speech. Our scoping review, completed at the start of the project collaboratively by the research team, did highlight resources with advice for staff about engaging in digital consultations, in terms of both navigating the technology and the technologies impact on relational interactions (GMC, 2020; Greenhalgh, 2020; Londonwide LMC, 2020; Neighbour, 2020; NHS England and NHS Improvement, 2020). However, none of the staff interviewed were aware of these guides.

# *Physical and natural environments*

Interviewees reflected that although adaptability was key to problem solving during the pandemic, the physical environments within hospitals – for instance, the ways that reception areas were arranged, with fastened down chairs and tables – remained mainly static and inflexible. Social distancing was difficult in these settings, and when enacted it often unintentionally removed crucial social support between colleagues – with staff no longer able to offer a cup of tea or a supportive hug in a staff room, which had impacts on wellbeing.

Normally with colleagues we'd just pop into the room next door or downstairs to ask a question or speak to someone and we found ourselves using screen messaging a bit more or other forms of messaging to ask questions … in the height of the pandemic that was a little bit lonely in that we didn't have a feeling of being able to talk to our colleagues at any point which I definitely missed. (Participant, 2021)

Equally, participants described a newly anxious relationship with the physical spaces they inhabited:

I think some of my colleagues and my friends around here have been really distressed by it, have not really gone outside, been quite frightened, have to spend their days kind of watching telly or whatever and have been really freaked out and really kind of agoraphobic. (Participant, 2021)

As well as changed interactions with buildings, some staff described a heightened awareness of the natural environment, particularly with expressions of concern and sadness about the increase in single use plastic: 'the biggest thing I think about is "jeez" the amount of plastic we're wasting, you know' (Participant, 2021). Others expressed frustration with the perceived wastefulness of certain protocols: 'We don't really know why we're going from one side room to another, putting this plastic on and throwing it to landfill' (Participant, 2021).

# *Pressure, morale and wellbeing*

Participants reflected on the two years since UK lockdowns at the start of the pandemic in March 2020 as being characterised by fatigue and low staff morale. Using phrases such as 'pushed to the brink', our interviewees described facing pressures which left them feeling short-tempered and underappreciated. Some of this pressure came from the new responsibilities they'd had to take on, such as enforcing stricter visitor policies, resulting in having to deal with understandably upset families who were unable to visit unwell loved ones. Additionally, with patients more isolated on wards, staff felt obliged to make up for the lack of family interaction but were limited in doing this by their increased workloads: 'People don't have their families coming to see them. They have no one and you're one of the few people that can actually talk to them, but within that there's so many limitations thrown upon you' (Participant, 2021). Staff had to act as facilitators between patients and families, commonly through setting up video calls, which were sometimes the last time families would see their loved ones and a final opportunity to say goodbye.

Participants described their fears in working through the pandemic: worrying about contracting COVID-19 and passing it on to their families, or being in settings where disregard of rules by staff members or patients put them at risk. Adherence to mask-wearing varied across sites and roles, with medical students, for instance, feeling much more obliged to comply than more experienced doctors. Staff also were aware of how much more anxious patients were about being in hospital than compared with pre-pandemic.

Staff described managing their own wellbeing as being more difficult in this period. PPE itself was found to be uncomfortable,

causing overheating and glasses to steam up, as well as making it more difficult to take breaks or drink water, due to the effort of taking it off, having negative impacts on stress-management.

It also just made working in what was already a challenging situation much, much more uncomfortable and difficult. Just so dehydrated all the time because you couldn't have a glass of water without getting out of it all and then changing back into again, which you didn't really have time for. (Participant, 2021)

Feelings of fatigue were commonly reported across the board from those wearing full PPE in Intensive Care Units, to medical students who spent the majority of their days online and GPs who found a day of phone consultations more exhausting than face-to-face consultations*:* 'I've just realised that is because I find talking on the telephone much more intense and I have to put much more into it, and I get really tired after a few hours' (Participant 4, 2021).

The low morale within staff groups was also described as being exacerbated by staff who felt that the weekly Clap for our Carers tradition that emerged during the pandemic – for people to stand outside their homes and clap once a week as a sign of appreciation – began to feel insulting and failed to reflect their experiences within the hospitals and amidst pay cuts to the sector.

Loads of my colleagues in other departments just got to a stage where they just feel like they had enough and actually found the clapping on Thursday was actually really insulting … I do think the general morale in the whole of the NHS is probably as low as it ever has been but I think it was tumbling that way anyway because of waiting lists. I think it was the straw that broke the camel's back. (Participant 2, 2021)

Staff felt uncomfortable with the label of 'hero' with some pointing out the problems of romanticising healthcare jobs leading to an increase in unrealistic expectations and being incongruous with the lack of respect they were often shown by patients, managers, the government and wider society, removing the need to properly protect, reimburse and respect the healthcare workers time or quality of life. As a result of these feelings, staff saw an increase in colleagues leaving or desiring to leave their profession (Kings Fund, 2022).

Although there was an attempt to provide support for staff through the creation of respite areas in hospitals, many of these areas closed within one year after the initial outbreak of COVID-19. In some hospitals, support from clinical psychologists was offered to staff but there was a feeling that this was for people who were experiencing trauma, and many staff did not consider themselves as requiring this level of support. This echoed Performing Medicine's previous experience of a culture within healthcare with an emphasis on resilience, with phrases like 'man up' being common. A focus on self-care and wellbeing of healthcare workers is a relatively new phenomenon, and certainly an awareness of its importance became clear through the pandemic (Health Education England, 2019; Søvold et al., 2021). While some of the people we talked to had found ways to look after themselves – spending time with family and friends, playing sports, taking work breaks, making art and walking in nature, not all staff had these support systems in place.

Perhaps surprisingly given the scale of new demands facing healthcare staff, our interviewees described barely any training designed to address these. They received training in putting on and taking off PPE correctly, but none received any that focused specifically on communication or acknowledged the pressure, fear and stress that was being experienced along with the emotional impact of this work, which they felt would have been helpful. The scale of the demand and impacts of the pandemic on staff cannot be understated, as one medical student told us:

People would say during [pre-pandemic] training 'oh you won't forget your first death that you see, you won't forget your first patient death' but when your first placement is filled with nearly all your patients dying, I think it really does change everything. It changes your perspective on life itself. (Participant, 2021)

Although Performing Medicine's work has long been about acknowledging the embodied – physical, emotional, subjective – elements of healthcare practice, it was only in the pandemic when spatial, physical, non-verbal restrictions were implemented that acknowledging these embodied elements of healthcare became unavoidable for the healthcare professionals themselves, as highlighted in these interviews. While non-verbal communication may be mentioned in medical school curricula, in the main this is focused on codified professional behaviour, such as leaning forward when breaking bad news or nodding to show attentive listening. Staff do receive mandatory training around handling and lifting but this is not conceptualised

as 'non-verbal training' within healthcare education while, from an embodied arts perspective such activities would be. There is little time to explore one's own physicality or to develop creative expression. In many ways the themes that emerged from the interviews were underlying issues and challenges within the NHS that COVID-19 has exacerbated rather than created. The pandemic has illuminated health inequalities and work conditions of NHS staff which were there prepandemic as well as revealing gaps in training and professional development which left staff unprepared to cope with such a catastrophic public health crisis, even though many had been predicting it for years.

# **Phase 2: Creative reflections**

In the second phase of the study, we invited twenty-four artists with backgrounds and practices in visual arts, puppetry, dance, theatre, voice, architecture, literature and poetry to take part in one of four workshops which ran between January and March 2022. Two additional artists had telephone conversations with the Principal Investigator. Several of the artists had worked with the Performing Medicine team previously, and they recommended other individuals whose practice might speak to the themes of the research. These three-hour long workshops were held in a large studio and consisted of a variety of spoken, visual, written, reflective, embodied and discussion based exercises: participants were invited to look deeply at their own experiences of the impacts of the pandemic on their own practice and communication; to reflect on the themes which emerged from the healthcare interviews from the perspectives of their own artistic discipline; to identify the daily, core activities and skills they use as part of their practice; and share some exercises or approaches they might use in their practice. All conversations were audio recorded and transcribed, and photographs were taken of various images, collages or words created during the workshops.

# *'I'll teach you differences' (*King Lear*)*

What lessons might healthcare professionals learn from artists? We were interested in finding out how the artists professional lives had been impacted by the pandemic and any similarities or differences to those described by the healthcare professionals. Two of the artists also led arts organisations, and they experienced a hugely increased workload with high levels of adrenaline and responsibility as they tried to secure jobs for their employees and adapt to new systems. Most of the artists attending our workshops were freelance artists, who described their anxiety as arts venues closed, cutting them off from their main sources of income. How they felt subsequently then dependent on factors such as where they lived, their levels of financial security, health anxiety, or care responsibilities for children or parents. Where some experienced panic, others found pleasure or relief in the interruption: a time to stop, rest and develop their practice.

Like healthcare professionals, the artists described elements of normal life that had been lost during the pandemic, such as human connection or chance encounters; and things that had changed, such as the language we use or modes of communication. Unlike the healthcare professionals, many of the artists also described new perspectives they had gained as a result of the pandemic, such as observing a wider cultural appreciation of the value of the arts, their own improved spatial awareness, understanding of health inequalities and societal inequalities generally, and space for reflection.

There were two key differences that emerged from the workshops with artists and the interviews with healthcare workers:


and found there was a new openness and recognition of the urgent need for this work. There was an acknowledgement that lower socio-economic groups had disproportionate access to computers and the internet, that many elderly people were at risk from social isolation and that young people had faced a large part of the burden with impacts on their education, work and social lives. The artists who participated in the research were keen to provide equitable and inclusive services: reducing isolation and polarisation.

# *Artists' daily skills and practices*

During the workshops the artists undertook what we called a 'skills audit', where they reflected on and listed the daily activities or habits which they employed in their work or practice. It was hard for many to pin down in language what were often non-verbal methods reliant on sensation and experience, but as we shared ideas, placing pieces of paper with words written on them on the studio floor, this stimulated ideas in others, so the groups ended up in building a kind of map of these action words (Figure 8.1). These active words – move, breathe, process, facilitate, dream, walk – pointed to the centrality of an embodied practice within these artists' work.

The workshops revealed ways that artists became a kind of unacknowledged 'key worker' by creating forums that helped people to overcome anxiety and isolation, offering their services for free to support their communities as people across the UK turned to arts during lockdown to occupy their time. Many of the artists described their role during the pandemic as facilitating connection, bringing people together through online platforms, providing ways to process what was happening globally as well as individually and creating spaces in which to manage stress and acknowledge loss. They adapted to online platforms quickly and creatively, many becoming skilled broadcasters or film directors with time spent on the aesthetics of this new format of delivery – the lighting, the background, how the picture was framed – ensuring that participants in online workshops felt safe and included. Their ability to 'improvise' within ethical, secure frameworks was identified as a key skill, important if working in fast moving healthcare settings.

#### **Figure 8.1** List of creative skills

During the final part of the workshops, we facilitated group discussions about how the skills, practices and approaches already discussed could be applied to the particular challenges which emerged from the healthcare interviewees. The artists were also invited to send us any further written reflections after the

workshops via surveys. Responses from both the surveys and inperson workshops are discussed below, in the context of the final curated programme.

# **Phase 3: Curating creative interventions**

Using knowledge gathered through the interviews with healthcare professionals and workshops with artists, the research team then explored ways to circulate it in healthcare settings at the partner sites.

# *Finding the right format*

We knew through our interviews and conversations with our contacts at each partner site, that any creative learning opportunities would need to fit within a context of high workloads, time pressures and continued social distancing restrictions on staff. Staff had also described an antagonism towards conventional online learning which was often aimed at technical 'how to' skills rather than improving communication and team building. They were interested in arts as a potential counterbalance to an overbureaucratic and target-based culture of mandatory training which characterised much healthcare education, especially during the pandemic, worrying that this had limited professional autonomy and creative thinking and leading them to feel over-managed.

Furthermore, staff were fatigued by offers of training and the politics of resilience within the NHS, feeling like the promotion by healthcare institutions and political organisations of 'personal or individual resilience' in healthcare staff shifts the blame and responsibility for burnout and mental health problems onto the individual and away from the major source of the problem: underfunding, poor organisation, ineffective governance by the institutions (Oliver, 2017). Given this context, our intervention would need to be framed in such a way to not place a burden on staff who already feel under pressure to 'cope' but instead provide ways for staff to reconnect with each other, their patients and their environment.

Therefore, though initially we had imagined that our offer would take the form of day-long or half-day professional development sessions with staff and students, we soon realised that to engage with staff we needed to test new models of learning. There was a desire from our partners for something innovative, different to usual training and education offers, to reinvigorate staff. Our key partners at the healthcare sites communicated a feeling that staff would welcome the opportunity to connect with creative people and would appreciate that something was being offered to support them.

We had learned through the creative workshops that chance encounters and spontaneous interaction with others are important to much creative practice enabling a spirit of play and improvisation which enables good group dynamics. The enforced rules, social distancing and long days of scheduled video calls made this difficult for healthcare workers and artists alike, leading to increased feelings of isolation and restrictiveness. Re-establishing these chance encounters – the conversations around the edges of things – was seen as key to improved communication during a search for a pathway to recovery.

As a result we invited a small group of artists drawn from the artists who attended the creative workshops, to develop a programme comprised of light touch in-situ training, workshops, oneto-one coaching, film screenings and micro residencies, creating opportunities for unexpected encounters for healthcare staff to come across during their working day. The activities varied across each partner site, dependent on resources, spaces and interest, the needs of the people participating and at the same time aligning with the priorities of the trusts. The activities – described in detail below – developed vocal and movement skills of the staff they are working with, deepened awareness of the built and natural environment and provided opportunities to acknowledge and express some of their experiences through quiet reflection. The in-situ training was light touch and fleet of foot – flexible enough to disappear if staff were called away. The artists delivering the activities became pivots and messengers, communicators and connectors, sharing the findings of our research as they gathered with staff both online and in real life.

Feedback from artists and healthcare professionals was collected through post-event debriefs and surveys, as well as informal feedback and observations given in person or via email.

# *Metaphor and language*

In the interviews and the workshops there was an acknowledgement by both the healthcare staff and artists that the words we use to describe the world shape our experience of it. The pandemic restricted speech – by limiting social interactions and enforcing mask wearing, for instance – demanding a more focused, functional type of discourse, in order for important messages to be understood urgently, which often mean sacrificing the normal breadth and richness of language. During the workshops, we explored the ways that creative writing and storytelling give people opportunities to tell their story to themselves and others; the artists suggesting that creative writing might reinvigorate communication to move beyond three sound bites that had proliferated during COVID: 'build back better', 'hands face space' or the rhetoric of heroes and angels. There was an acknowledgment of the need to use language in sensitive ways, to unlearn language imbued with micro aggressions and to be aware of the shifts in the way people choose to identify and define their needs.

This was built into the programme we delivered to NHS trusts by feeding into the language we used when introducing the programme to staff, being mindful that words that are common parlance in the arts have a different set of understandings within a healthcare setting. The term 'reflection', for example, can have negative connotations for healthcare staff, being associated with writing lengthy passages with no obvious purpose for work appraisals. Instead, introductions to the programme highlighted that the activities were developed through conversations with their colleagues with the hope that connections forged between artists and participants will have a ripple effect, helping to share understanding across sectors.

# *Objects, spaces and tactility*

The creative workshops highlighted the ways that performance and visual art practices are reliant on physical touch between people, objects and materials, seen as potential ways to reawaken sensory awareness, to feel something. Healthcare professionals had described the impact of loss of touch on their work and on their wellbeing, and sense of support between their colleagues; the artists responded with ideas about the importance of re-establishing touch beyond the pandemic, a rediscovery of an altered sense.

Playful interaction with objects, for instance, through animation and puppetry might bring attention to the meaning of objects around them and what they might signify for others: the fear of a needle or the comfort of a tea cup. Artist Tim Spooner, for instance, who works in performance, drawing, painting, sculpture and design, led a drop-in session for staff who were invited to explore objects within their hospitals create mini sculptures or monuments, reflecting on touch and the environment. A chance to contemplate the nature of touch, care and intimacy in healthcare was also foregrounded in curated series of artists' short films, by British-born Southern African performer and choreographer Nandi Bhebhe and Welsh artist Phoebe Davies (Bhebhe and Davies). Makiko Aoyama, led origami workshops, where participants could find a moment to rest through making a paper crane, a Japanese symbol of health and longevity.

Lockdowns and isolation shrank spaces, and rooms were forced to become multipurpose as bedrooms became offices. The participating artists described the way they could bring heightened spatial awareness, helping people to organise their working spaces and transform them from personal to professional spaces and back again. A guided audio tour, created by theatre maker and artist Silvia Mercuriali through dialogue with staff at each site, invited staff to rediscover the familiar environment of their hospital workplace and see it from a new point of view.

# *Movement, communication and purposeful action*

As evidenced by the list of daily practices in the 'skills audit' described above, different kinds of movement form an essential part of many artists' practices, helping to filter, process and integrate life experiences through positive action, pouring it into dance, song, painting, building, gardening, cooking, thus opening the possibility of transformation and recovery. The artists spoke about the value of learning to move freely, of ways to uncover new possibilities and relationships with regulated spaces, and how this can support wellbeing and self-care in a multitude of situations from a busy

**Figure 8.2** *A Monument to the Hospital* (micro residency with Tim Spooner)

ward to sitting in Zoom rooms all day. Thinking about everyday movement as choreography, can – in rendering motion visible and intelligible – offer a way to examine the order and disorder of particular spaces, as well as bringing a sense of play and lightness to everyday movements, working as a mobilising force that can help to transform systems which may feel particularly rigid or stagnant, such as within hospitals during COVID-19. A team of dancers, led by the principal investigator on the project – Suzy Willson – designed a session in which they helped staff to navigate the hospital environment by creating a series of micro choreographies.

Equally, the participating artists felt they could offer support in the interpretation of gestures and visible cues online and in person. Drawing on techniques from dance and physical theatre, they articulated practices that could bring awareness to the different levels of tension we can hold in our body at any time, our rhythms, ways of entering and exiting rooms or video calls, how we position ourselves in space and the impact of all of these on power dynamics which can help to develop nuanced non-verbal communication skills. In giving detailed feedback on these areas, individuals can understand better their own habitual movements and the messages they might be sending out, their congruence or incongruence with other elements of their communication, and through this awareness create the agency to make changes and have choices. Martial artist, writer and movement teacher Victoria Worsley designed a session working with staff in situ on the wards to guide them to becoming more aware of their own movement patterns and habits, and how these affect their non-verbal interactions with others around them. Equally, a session led by the PM core team explored experiences of respectful communication with colleagues and patients over video and telephone, considering how this success could be built on.

A range of voice and breath exercises were identified with the artists that could help staff to use their voices more effectively to be heard and not strain, or to improve their vocal range to calm distressed relatives over the phone. One doctor had said he had been clenching his jaw tightly in order not to scream at the magnitude of it all and that this was affecting his voice. The barriers to communication that our interviews highlighted were addressed directly through the individual and group sessions led by voice coach, actor, singer and theatre maker Hazel Holder, to help staff to avoid fatigue and strain and help them feel more grounded and able to communicate.

# *Nature, ritual and reflection*

For both the artists and the healthcare professionals, the pandemic brought about a greater appreciation for nature and the outside world. During the creative workshops with artists we explored

ways to bring the outside in, to rejuvenate healthcare settings which may have no natural light and an abundance of plastic, man-made materials. Visual artist Amy Shelton's work acknowledges the innate human need to connect with the natural world, through artistic encounters that focus on bringing the outside inside. For this programme, Amy's project exhibited her illuminated Florilegium lightboxes made for healthcare settings and invited staff to dedicate a flower to a loved one, colleague or a team at a temporary flower pressing station, creating a card with a mounted specimen of a plant associated with healing.

Across the conversations with artists, healthcare professionals and our partners, there was a sense that, coming out of the pandemic, the enormity of what was happening was not really being acknowledged or honoured. At various points of the research, we heard about a kind of numbness, a disconnect, an absence that was often expressed as a question. How do we process a global pandemic at an individual level as well as a collective one? What kind of spaces and languages are needed to acknowledge and understand our experiences outside of a medicalised therapy session which many do not want nor feel they need? Our co-investigator Graham Easton, who attended one of the creative workshops, described sitting in his garden shed during the first wave, issuing death certificates for the relatives of people who had died of COVID-19 at home. It was a stressful and sorrowful experience that he had had no time to reflect on. He felt that the reflective space that the creative workshop itself provided was uniquely useful for him. This was echoed by a writer at the same session who also happened to work as a nurse. She described the benefit of a creative open format where there was no fixed agenda, other than to reflect, to let the mind wander.

Addressing this need space for ritual and ceremony was Sheila Ghelani's project, an artist crossing performance, social art works, installations, text and videos which seek to illuminate and make visible the connections between race, ecology, science, history and the present day. Sheila invited staff to do a tiny, one-to-one ritual – contemplating time, love and hopes for the future.

While COVID-19 created an intense sense of a collective experience, the Communicating through Covid research valued the sharing and learning from differences. The artists saw the workshops as a unique opportunity to understand their own experiences in relation

**Figure 8.3** *The Exeter Florilegium* by Amy Shelton (2021). Commissioned by the Royal Albert Memorial Museum & Art Gallery, Exeter. All rights reserved.

to other artists from different disciplines and contexts, but they also found value in the way the research methods connected them with experiences of the healthcare professionals. What was most in common was the need to feel something in a room with other people.

# **The arts as a way to compassionate and sustainable healthcare**

Participants gave very positive feedback about the programme, with all describing how they felt they might be able to make use of the ideas or techniques encountered through the session in their work and finding the programme easily accessible. Feedback from our partners at each site also suggests that these arts-based strategies can play an integral role in healthcare professionals' recovery from the pandemic, offering managers viable strategies to build understanding and bring teams together who have been fragmented by the demands of the response to COVID-19. At a time where staff turnover across the NHS is high and there is a pressure to return to pre-pandemic care with limited resources and little reparation to staff for their services over the past two years, we were pleased to hear from our partners at each site say that they felt their own wellbeing and ability to manage complex systems has been strengthened by their cultural engagement, offering them new strategies to empower staff and provide ways to improve their wellbeing, awareness and ability to communicate with each other.

Towards the end of the research project, a series of public engagement workshops at Clod Ensemble studios welcomed artists, students and healthcare professionals to take part in the activities and to hear Michael Rosen read from his book *Many Different Kinds of Love: A Story of Life, Death and the NHS*, which recounts his experiences of months in hospital with COVID-19. These events reaffirmed the important role that arts and cultural spaces can play in helping people to understand and process the impact of the pandemic on our communities, to acknowledge and honour what has been lost and to ready ourselves for the challenges that lie ahead.

Despite trends towards interdisciplinarity in academia, as ways to solve complex problems, the reality of working across arts and health in practice is that they are still two very different cultures. Survey after survey confirms that – despite being about care – the world of healthcare for the staff working in it is still often so hard and inhumane at times. Rather than seeing self-care as an optional add on, in response to challenging situations and high levels of burnout, a better solution is to nurture a proper partnership between arts and health with a focus on the value of arts in promoting self-care and giving healthcare professionals the space and skills and guidance to tap into different arts-based ways to look after themselves, redressing the balance. In the same way that Schwartz rounds have become mainstream spaces for discussion the emotional labour of healthcare, it is our hope that projects such as this one lead to NHS trusts buying into this on a regular basis. COVID-19 has acted as a catalyst for demonstrating the value of re-introducing the arts and humanities to the sector, perhaps to create a healthier balance. This project has begun to show that even beyond the pandemic there is an urgent need for an multi-disciplinary cross-sector approach to improving the working conditions of the millions of people who work within our health and social care systems, so that they are well equipped to support us and the ones we love when we are at our most vulnerable and frightened.

# **Key insights**



**Figure 8.4** *Hope and Optimism* by Peggy Shaw and Suzy Willson

# **Note**

1 The Communicating through Covid (Supporting Healthcare Professionals Through Covid-19: Understanding How Arts-based Methods Can Support Non-verbal Communication) project was funded through the Arts and Humanities Research Council. Project reference: AH/V015877/1.

# **References**



# Arts for health's sake: mapping innovation in arts provision in the Liverpool City Region

*Josie Billington, Ekaterina Balabanova, Joanne Worsley, Antonina Anisimovich and Melissa Chapple*

What COVID gave us was a real opportunity to shine a light on the value of the arts. Moving forward, we've got to continue to find ways to get that message across. (Liverpool Museum)

This chapter charts the rapid innovations achieved by arts and cultural organisations, from civic institutions to grassroots enterprises, in response to the COVID-19 crisis in the Liverpool City Region (LCR).1 Research conducted during the pandemic revealed that the immediate closure of public spaces, galleries, museums, arts venues and other cultural assets when the COVID-19 crisis started had a significant impact on mental health and wellbeing (Niedzwiedz et al., 2021). A number of studies also demonstrated the impact of arts engagement on people's ability to cope with adverse situations (Keisari, 2021), as well as with symptoms of anxiety and depression (Bu et al., 2022). The distinctive aim of the COVID-19 CARE project was to map, within a specific city region, the impact on mental health of restricted access to arts and culture, as well as the success of innovative provision in making the arts available during lockdown. This chapter explores the lessons to be learned for practice and policy from the ways in which these novel solutions have stimulated a re-imagining of arts in mental health care in the aftermath of the COVID-19 crisis.

# **Why Liverpool City Region?**

Liverpool, a port city in North-West England with a population of approximately half a million people, has one of the richest concentrations of culture in the UK with the largest clustering of

museums and galleries outside of the capital (Visit Liverpool, n.d.). Culture and creativity, including (popular and classical, grassroots and elite) music, theatre, dance, museums, visual arts, events and festivals are central to the city's identity (Belchem, 2006). Cultural capital is also critical to the city region's economy, contributing circa 10 per cent (Culture Liverpool, 2019). In addition, LCR has a pioneering history of harnessing arts for mental health care through partnerships between culture and health providers (Burns, 2017; Davis, 2006). Such partnerships have been nurtured in a region which had some of the poorest mental health outcomes in the UK observed prior to the start of the global pandemic (Public Health Institute LJMU, 2021).

Research on the impact of COVID-19 has highlighted the increased mental health risks among the general UK population (Pierce et al., 2020). In total, 29 per cent of UK adults have developed a common mental health condition (Chandola et al., 2022), and the Centre for Mental Health estimates an extra 10 million people are in need of mental health support in England (Centre for Mental Health, 2020). Research also suggests that the pandemic has exacerbated pre-existing health disparities. Vulnerable groups whose mental health risks were disproportionately affected by the pandemic include those with pre-existing mental health conditions (Burton et al., 2021; Iob et al., 2020); young adults and women (Niedzwiedz et al., 2021; O'Connor et al., 2021) and people from racialised minorities **(**Iob et al., 2020; Katikireddi et al., 2021). While the effects of the COVID-19 crisis on those already vulnerable to mental health issues and disparities in mental healthcare is projected to be long-lasting across the UK (Holmes et al., 2020), the national picture is at its most intense in the region covered by this study. The pandemic amplified pre-existing regional inequalities between the North and the rest of the country in a significant decrease in mental and financial wellbeing in the North-West (Northern Health Science Association, 2021). Mental health problems in areas of the LCR are among the highest in the North-West. Figures at the peak of the pandemic (December 2020) showed that 19 per cent of adults had a common mental health problem, exacerbated by some of the highest deprivation indicators in England (8 per cent of adults claim benefits, 22 per cent of children live in poverty, 21 per cent of adults over 60 are income-deprived) (Public Health Institute LJMU, 2021). In May 2020, the LCR Mayor's 'Case for the Liverpool City Region' (LCR Combined Authority, 2020) cited 'a high prevalence of mental health disorders' as one of the complex health challenges the region faced as a result of coronavirus.

# **The study: summary of aims and methods**

Our study, undertaken by an interdisciplinary team of experts from Arts and Psychology, sought to capture changes in access to arts and culture because of COVID-19, especially for those experiencing or at risk of mental health problems, and the effect of restriction on the psychological wellbeing of public beneficiaries. We also gathered evidence and examples of innovation in respect of arts provision, investigated the accessibility of alternative modes and their impact on public mental health and wellbeing.

We conducted two complementary surveys in three-monthly waves, covering two time periods: full lockdown (winter/spring 2020–21) and immediate post-lockdown (summer 2021). Survey One consisted of online/telephone interviews with administrators, programme managers, coordinators and creative practitioners at fifteen arts organisations, including civic institutions and community arts programmes, representing both 'elite' and 'popular' arts. (In fact, most organisations had weekly participatory programmes for beneficiaries experiencing, or at risk of, mental health difficulties, often in collaboration with health and/or social care providers.) Twenty-four participants took part in Wave One and fourteen participants took part in Wave Two. The interviews gathered the views of these arts providers and practitioners on the impact of COVID-19 on public access to arts provision (including those who usually access the arts through formal healthcare routes) and on the success of alternative (online/digital) modes of provision in reaching and communicating with established and/or new audiences. Survey Two had twin strands. First, it ran an online questionnaire (in Qualtrics), developed and piloted in consultation with an advisory group of mental health experts and incorporating standard mental health and wellbeing assessments (e.g. Patient Health Questionnaire 9, Kroenke 2001) as well as questions on the frequency and mode of arts engagement before, during and after lockdown. The survey was

advertised through social media and circulated through the communication channels of the fifteen organisations which participated in the study. There were eighty-three respondents at Wave One, twenty-seven at Wave Two and twenty at Wave Three. (Respondents at Waves Two and Three were from the same participant group as at Wave One in order to trace longitudinal change.) Second, supplementary online/telephone interviews were conducted with questionnaire respondents, who included regular arts' audiences (concert- and theatre-goers, museum and exhibition visitors) and beneficiaries of participatory community arts provision (including dance, music, drama, writing, group-reading). Twelve participants were interviewed at Wave One, and eight at Waves Two and Three. Together, these methods gathered views on the impact on mental health of restricted or non-existent access to usual provision and the perceived value and accessibility of alternative arts provision.

Our study found that arts and cultural organisations in LCR responded rapidly and creatively to the pandemic, offering new, online programmes to reach vulnerable and isolated people and adding an innovative dimension to their own services for the future. We found that those who engaged in arts and culture frequently during lockdown had significantly higher wellbeing scores than those who engaged in arts and culture 'never' or 'rarely'. While the work of arts and cultural organisations in reaching those experiencing or at risk of mental ill health was significant across the board, they were most effective when working in close collaboration with social and mental health care providers. Formal and detailed presentation of our findings have been published separately (Anisimovich et al., 2022; Balabanova et al., 2022; Worsley et al., 2022a; 2022b). Here we offer a series of (single and composite) case studies in order to highlight the learning generated by the innovations spawned by the COVID-19 crisis for the future of arts in mental health care, regionally and nationally. The chapter divides into two main sections. First, it considers the lessons learned from the experience of the pandemic, focusing particularly on partnerships. Second, it outlines the implications for future practice, taking into account the digital turn across the arts sector engendered by COVID-19 and developments in health policy at both local and national level.

# *'Liverpool has been commended for the way that we collaborate': working in partnership*

Just prior to the onset of the pandemic, Arts Council England's (ACE) ten-year strategy, Let's Create, set out objectives and investment principles for 2020–30, including a pledge to develop deeper partnerships with the Department of Health and Social Care and NHS England for the prescription of creative and cultural activities for mental health (ACE, 2020). Following the publication of the 'Creative Health' report by the All Party Parliamentary Group on Arts, Health and Wellbeing, which envisioned 'symbiosis between the arts … diffused across the complex systems of health and social care and the arts' (APPG, 2017: 6), the National Centre for Creative Health (NCCH) was launched in March 2021 with a key priority of 'promoting collaboration' to 'foster the conditions for creative health to be integral to health and social care and wider systems' (NCCH, 2021). Our study shows the degree to which COVID-19 has given impetus to the implementation of these policy initiatives in LCR. As well as showcasing the manifold forms of partnership which the COVID-19 crisis helped to spawn, this first section also highlights how the pandemic brought into sharp focus hitherto relatively overlooked aspects of arts organisations' contribution to the health of the populations they serve.

# *'Picking up the pieces', 'filling the gaps': arts in action*

What was striking about the response to COVID-19 of arts organisations in LCR was its immediate, practical and hands-on quality. While the digitisation of arts provision was national headline news, some of the support offered by arts organisations at the local level was anything but remote. On the contrary, as statutory services were shutting down or struggling to adapt, arts providers were literally going the extra mile, pro-actively seeking out those whom they knew to be lonely or in need and offering the very basics for survival where usual care was falling short. 'Getting to those people who are suddenly completely off our radar was the priority. I was phoning, asking have you got food, did you get your prescription sorted?' Many of these organisations were serving the needs of some of the city's most vulnerable people. A charity running a choir for people affected by homelessness was starkly aware from

the very beginning of lockdown that people who were typically in the 'middle ground' of need were largely left to fend for themselves. Those who were street homeless (and given hotel rooms) and those in hostels (with support staff) had better provision of care than people in bedsits, who were largely abandoned. 'There were so many people who lost the ability to get food from anywhere,' the choir manager reported. 'One member's housing provider left them with no water for four days because they didn't understand how to communicate with somebody who was vulnerable, so we had to step in.' This was social prescription in full-on action, delivered by both grassroots arts organisations primarily dedicated to providing a community service, as well as established civic institutions for whom outreach functions had hitherto been secondary. A flagship city centre theatre which, prior to the first lockdown, had just embarked on an initiative serving the mental health needs of asylum seekers, service veterans and sex-workers through a weekly community creative programme, found the key challenge was overcoming the 'terrifying' isolation which their beneficiaries suddenly faced when lockdown was imposed. 'We partnered with a small grass-roots organisation who focused their energy on drops (sanitary wear, food, clothing) to wherever our members were staying. This was an important intervention in lives which were already very chaotic and which had lost all continuity with support services.' Several organisations recognised that there was something unique about their position in the socio-cultural structure which enabled them to step in and fill the gap. 'An organisation like ours works in an unofficial way. We're not the social worker or housing association. We're left with a lot more freedom to support people in the way they actually need to be supported, instead of ticking the boxes that statutory services have to tick.' On the one hand, arts providers are fulfilling roles that are customarily occupied by church and social (poverty, refugee, homeless) charities. On the other hand, arts charities, especially when arts organisations work in partnership with other charitable agencies, bring something in addition to basic relief, providing 'meaningful' activity or (as beneficiaries variously put it) 'life', 'light', 'joy' 'connection'. A reading outreach programme, for example, struck up a partnership with a homeless charity to share reading over the phone with people temporarily housed in hotels. 'It was a highlight of my week getting a call … it has been a salvation during this time,' said one beneficiary. This common pivot towards community action promises to be a lasting one, as we shall see, helping to transform the quiet and slow revolution of arts prescribing locally into a loud and accelerated one driven, in part, by the arts sector.

But this phenomenon raises questions as well as challenges, particularly for the organisations working on the ground. As one organisation we interviewed pointed out, COVID-19 exposed the disadvantages of cascading responsibility for social care and wellbeing needs to voluntary organisations.

We've seen benefit from that. It has helped those that have closest links in communities to do good work with people, get them what they need. But if you haven't got anything that holds together the local efforts, it can feel like we're all running after the same thing, and making up our own way of doing it.

This lack of 'holding together' has several consequences which potentially weaken the value of the localism agenda. On the one hand, the lack of regulation and systematic evaluation of the services provided by arts charities and organisations, makes it impossible to ascertain how effective they are in meeting the needs of those they are supporting and, indeed, in accurately identifying those most in need. On the other hand, arts organisations, who were acutely conscious of the 'patchy' nature of their contact with usual beneficiaries during lockdowns ('Where are they? How is life for them?') were strained beyond capacity to fulfil responsibilities traditionally provided by statutory services without the latter's access to official resources, often duplicating one another's efforts and energy. These issues were the driver for one key policy recommendation emerging from our study, namely: the importance, particularly with the emergence of the integrated care systems, 'for co-ordination of arts and cultural organisations' services, in order to pull together the talents, experience and good will of local initiatives in meeting essential needs so that they can be scaled up and targeted more efficiently' (Billington et al., 2021).

# *Out of crisis comes innovation: connecting digitally*

The agility on the part of the arts sector in meeting community needs was replicated, simultaneously, in the rapid pivot to online provision. While some organisations were already considering

the implementation of a digital element to their offer and found COVID-19 a catalyst for accelerated growth, for some providers of live, performative art, the use of online technology had simply never been considered. Indeed, such provision seemed wholly counter-intuitive, when the very *raison d'être* of the activity was the close community and personally felt connection between the art, the individual and the group. But innovation was entirely and urgently driven by the impossibility of abandoning the people who had come to rely on this weekly connection. 'If asked the week before the theatre closed', said a city centre theatre's creativity director, 'whether our creative programme for mental health could translate into something digital, I'd have been really sceptical. But so enormous was the impact of lockdown on our group members, we started the drama Zooms the following week.' Again, the organisation's relative freedom from bureaucratic constraints was critical. 'Because we weren't the massive organisation that the NHS is, we were able to be really responsive, and react quickly.' This included increasing the regularity of the interactive Zoom sessions to meet demand. 'We created a wellbeing programme – writing, singing, drama, comedy – and ended up with between eight and fifteen sessions a week.' The response of a reading charity was likewise speedy and imaginative. 'Within three weeks, we were delivering Zoom Shared Reading internationally, increasing provision to twice a week to address social isolation, and had launched a new online public service as well as a series of programmes for national prison radio, reaching 120 prisons daily.' One dance organisation working with under-represented communities, when forced to abandon a final performance of a project using dance to address violence and gang crime, switched to 'a TikTok challenge and competition, with a winner, runner-up and prizes'.

At the onset of lockdown, organisations across the sector assiduously sought funds to ensure connectivity among their members, recognising that this was as basic a requirement in overcoming social isolation as food was for survival, especially in cases of digital poverty.

Alongside not having a smartphone or a device, people had no data. Or if they had a smartphone, they didn't have Wi-Fi. We were really grateful to the Arts Council for emergency funding so that we could purchase iPads and data for our weekly participants. Through training and support for our members, their parents and carers, everybody who needed a device got a device and got data, to the point where we were having four Zooms a week. (Contemporary Arts Centre, running a programme for learning disabled people)

As with the provision of food and warmth, buying hardware for their membership helped organisations sustain contact with existing beneficiaries, including the very hardest to reach – asylum seekers, refugees and vulnerable migrants – when support organisations closed. Time and again, beneficiaries described alternative provision as 'a lifeline' and as their 'life blood'. Online arts activities 'opened a locked door, letting in some light into what was a very dark time for me. I personally wouldn't have made it through lockdown without this activity' (theatre group beneficiary). Digital arts provided a sense of routine – 'When lockdown started, my life stopped and normality stopped. The digital programme has given me structure and purpose' (theatre beneficiary) – as well as a crucial buffer against loneliness. 'One of the women said to me that the week before she hadn't spoken to anybody for a whole week. She found herself talking to the wheelie bin' (photographer).

Statistics from our survey of regular audiences and beneficiaries during the first lockdown in spring and summer 2020 confirm these findings, showing that those who engaged in arts and cultural activities often and all of the time during full lockdown had lower anxiety and depression scores and higher wellbeing scores than those who engaged never or rarely. Key to this impact was the sense of community and connection generated by engagement with meaningful activity. 'They were using photography as a way to document what was going on for them, and it became quite a cathartic process' (photographer). 'It's giving me a chance to let go of everything in my head,' said one beneficiary. Interestingly, these benefits were found to intensify over time. 'At first the online activities were very light-touch activities, fun. That slowly changed as people got more used to that space, the possibilities within it, the creative tools they had to hand, and were able to drill a little deeper' (theatre for social change).

These examples demonstrate the indefatigable activism – sustained to the point of near 'burnout' across multiple organisations – that is often not captured by standard research studies which tend to focus on the arts 'interventions' and on formal health outcomes. This

emphasis is understandable, given the importance of research evidence gaining traction with health services and policymakers. What can be missed by efforts to shoe-horn arts provision into conventional NHS models, however, is the value to beneficiaries of informal and often hidden care (as well as the indirect gain to NHS and statutory services as was starkly apparent during the pandemic when they themselves were stretched to the limit). These organisations were in a position to offer emergency help because they were accustomed to meeting the needs of people with long-term mental health issues beyond the point at which they exhausted their entitlement to statutory social care. As the manager of the choir supporting homeless people put it: 'Many services are time-limited. Once you've had your thirteen weeks of support, you've got to move on. We don't have a cut-off date. We don't care if you're doing really well or if years later, you're still really struggling; you're permanently part of the family.' 'I'd been in recovery for three years before coming into the choir,' said one choir member, 'but I was still empty and the choir fills me.' Significantly, the unique yet intangible enrichments which the arts sector gives were made more perceptible and appreciable, as well as being more directly articulated, through what was lost in online provision, in particular the 'wraparound support' that goes with in-person experience. 'It's harder to catch the things happening to people in an ad hoc, more organic way. People might not say, I'm really struggling but you can see it in them' (theatre for social change). 'It's that unconscious thing that we do naturally. You read an environment, you read the energy. Through the twenty years of delivering dance, you might have a plan for a class, but it always alters dependent on the people in the room' (dance organisation). The conditions of the pandemic were an indirect reminder of the degree to which personalised care is a staple of the way in which arts organisations engage with participants for health and wellbeing.

# *Responsive partnerships*

While policy guidelines from Arts Council England (ACE, 2020) and the National Centre for Creative Health (NCCH, 2021) rightly emphasise the critical importance of partnerships between arts and health providers, one salutary lesson from our study is the degree to which emergency provision at the onset of the first lockdown relied heavily on arts organisations collaborating with the voluntary sector. Where homeless charities were demonstrably crucial, one city centre gallery's distribution of a creative pack for young people missing out on education through digital poverty, depended wholly on youth associations, advisory services and the city council to distribute these to families, through food banks and community centres. Cooperation between arts organisations themselves was strengthened, especially in relation to staff and volunteer digital training, online safeguarding and risk assessment. Informal collaborations impelled by the pandemic were replicated at a structural level. The two chief arts and cultural consortia in LCR – of civic/national portfolio organisations, on the one hand, and of grassroots arts enterprises, on the other – moved towards formally combining their approaches, by recruiting a project manager to consider blended commercial activities such as joint commissioning and ticketing.

There was also a clear trend towards arts providers newly connecting with activist groups around social and topical issues, enabled by new working conditions and modes of provision. 'We started a new collaboration with an LGBTQIA group on a youth outreach project because groups and events are much more accessible online' (theatre group). 'At events, we had representation from black dance artists, and from senior managers or directors, to talk about how we can move forward with a plan to ensure that the black voice is heard' (dance organisation). Some organisations experienced a shift in their thinking and practice around co-operative working. 'Before lockdown, volunteers worked on projects within the gallery, shaped by us. Now the focus is on all of our lives, and our volunteers are driving our work.'

The various kinds of collaborative responsiveness of the LCR arts sector to the rapidly changing needs of the community – at physical, personal, social levels – is a form of what Kenneth Gergen calls (in his social-relational construction of healthy being) the 'improvised reaction' which occurs when 'discontent with the capacities of large-scale organisations to improve conditions … and a sense of urgency concerning the problems at hand, [stimulates] various groups to forge new practices' (Gergen, 2011: 193). The case studies offered here emphasise the need to preserve the capacity

of the arts and cultural sector to be flexibly extempore in their response, and fluidly porous to individual and community need, in any model of integrated arts and healthcare. Indeed, there is a need to identify models of integrated care which retain the integrity of organisational cultures and put them to use in strategic and complementary ways.

# *Arts and health partnerships*

One such model of partnership in the LCR as it evolved during the pandemic – between arts organisations and a healthcare provider – is particularly illuminating. The NHS trust in question has nurtured cultural partnerships as part of its social approach to mental health care and its commitment to engaging community assets in reducing health inequalities. The trust's social model of health is housed in local settings across the region and, in partnership with over 100 public and voluntary sector organisations, works 'side by side' with stakeholders and service users, who create their own social prescription, from support with debt and employment to digital learning and arts-based activities. One civic arts provider – a concert hall – had been working with this trust for over a decade when COVID-19 struck. Its successful Music and Mental Health Programme, which had reached more than 10,000 beneficiaries, was suspended when the concert hall closed, hospitals were unable to accept visitors and 90 per cent of the concert hall's staff were furloughed. The organisation aligned its planning with that of the trust as the latter developed its online platform and, during lockdown, reached its vulnerable beneficiaries exclusively through the healthcare provider.

We ran weekly Zoom music sessions, and transferred our interactive 'living music' session to digital. Usually, wards from the Trust would come to the concert hall monthly. We hosted fortnightly Zoom sessions instead, reaching far more wards than would come to the hall and reaching them more frequently. We set up 'music mums and little ones' sessions on Zoom, in collaboration with the Trust's perinatal mental health service and held Zoom sessions in the secure hospitals for people sectioned under the Mental Health Act. (Concert Hall)

The experience of a city centre theatre is equally instructive, albeit by contrast, of the potential of such partnerships to adapt productively in unison. Just two months before the onset of lockdown, this civic landmark had begun working with the same NHS trust, as one of the centres hosting the trust's community programme.

At the start of lockdown, the Trust wasn't allowed to use Zoom because of governance issues. So we changed our partnership so that we were the lead, with the Trust as a supporting partner, signposting service users to us. The theatre continued using the Trust's inclusive and participatory ethos, though officially we couldn't use the NHS badge. When, months later, the Trust began to pilot its own digital platform and live interactive Zoom sessions, we were able to partner them to support this process. So it's just flipped, the Trust is responsible for the platform and we are providing creative wellbeing sessions. (City Centre Theatre)

The two partnership models described here are really flipped versions of each other. But both show two sectors under considerable strain imaginatively and maximally pooling their resources to address the needs of the local population. This specific LCR trust's innovative model of arts and health alliance was cited immediately prior to the COVID-19 emergency, as offering 'a blueprint for similar collaborations in other regions of the UK' (Worsley et al., 2021). The pandemic effectively tested the robustness and efficacy of this model as an exemplar for the ways in which creative organisations can work with the NHS to support the needs of local individuals and communities. But, as our study recommends, there is a need to support sustainable partnerships between health and arts providers, building on existing successful cross-sectoral cooperation, in order to facilitate wider provision and maximise the reach of these services, as well as producing new opportunities for training care staff to deliver interventions (Worsley et al., 2022b).

# *'It will change the way we work forever': arts and health, the future*

Two principal (and inter-related) legacies emerged for arts organisations from the experience of lockdown: a continuation of hybrid delivery and a commitment to community outreach and social prescribing.

# *Hybrid / blended provision: beyond digital as 'second fiddle'*

At the top of organisations' agendas as they emerged from lockdown restrictions was sustaining the widened reach enabled by digital provision and ensuring offers were 'fully accessible' and that 'no one was left behind'. 'The pandemic highlighted the diversity of reach and ways of working through digital engagement. Some people actually feel safer online' (concert hall). 'Switching to digital is bringing important voices and conversations into a community that's really beginning to blossom online' (charity supporting writing). 'It felt like doing digital was second fiddle, but what we hadn't thought about was the impact it has for people that are lonely or isolated' (city centre theatre). As well as increasing levels of participation, and reaching an expanded range of beneficiaries, arts organisations were also able to draw on a wider pool of resources and broader scope of arts and cultural provision nationally and internationally. 'We now have people from all over the world doing classes when normally we're based in Liverpool. It was a really exciting opportunity to share cultures, share practice, share styles' (dance organisation).

There was unanimity that digital provision would never replace the place-based offer: 'Nothing beats that in-person connection.' As a theatre practitioner told us: 'When you're in a room with people, bodies align, we take emotional and physical cues from each other without even recognising that there is a way of syncing our bodies not by physically touching, just by being together.' There was an awareness of the well-documented impact of digital poverty and the risk of excluding beneficiaries (Bu et al., 2022), as well as recognition that there was no one-size-fits-all solution and that alternative modes of delivery might suit different people at different times. The consensus was that cultural providers needed 'to keep all options open', offering a blend of in-person and online activity with 'a range of points of access for people to participate on their own terms, at their own choice' (concert hall). 'The hybrid option is probably our biggest success story, because it gives people the option to feel like they are in the in-person class and allows the in-person people to still connect with the people who can't come as well' (dance organisation). Nonetheless, navigating hybrid work was highlighted as 'challenging', with the uncertainty of the financial future of arts organisations and staff burnout cited as key issues. 'We're expected to be this blended hybrid sector of working online and physical, being everything to everybody. How sustainable is it with not just the funding available, but also the staff that you have?' Our study concluded by endorsing the recommendation for continued hybrid provision of arts and cultural activity, as a means of rebuilding capacity in the creative industries and for the mental health of the region's population, enabling inclusiveness alongside in-person experiences that boost community connectedness. But arts organisations need expertise and support in order to retain the advantages of digital services for the future and to ensure that recovery happens at a pace they can realistically manage and is sustainable.

The advantages of digital provision exceeded considerations of access. A contemporary arts centre offering a programme for learning disabled people reported how:

parents and carers used to drop off and pick up people without seeing how in that space you can be a creative individual, an artist, and develop an identity at odds with how parents and carers might see you. We really want to build on these digital relationships with families to share experiences as well as resources.

In a possible model for the hybrid future, moreover, some postlockdown initiatives have innovatively built on their digital successes to design hybrid activities which reach into local communities. The House of Memories app was created by a Liverpool museum, using museum-based artefacts and activities to support carers and families of people with dementia in exploring the past and sharing memories with loved ones. Launched pre-pandemic, the number of users increased to tens of thousands during the first lockdown. An example of a pre-pandemic project which gained traction during the lockdown periods, the app engaged people from a wider, culturally diverse society of elders (not only those living with dementia). This led the museum to adapt the app using dual language content to involve broader, more inclusive audiences within and beyond Liverpool. In addition to the post-lockdown launch in Wales of House of Memories Cymru/Tŷ Atgofion Cymru, the museum is involving young people in the Yemeni community in Liverpool in digitising traditional community stories from their grandparents' cultural heritage in both English and Yemeni-Arabic (House of Memories, n.d.). The success of the app inspired *House of Memories On the Road*, a mobile version of the digital experience

created during the pandemic. This took the form of a thirty square metre immersive cinema and activity exhibition space, taking digital arts, music and heritage experiences into local communities, offering walks through local landmarks and a trip on Liverpool's overhead railway, complete with smells and objects to touch, so as to stimulate elders' sensory responses and memory. Working with community partners to identify those neighbourhoods or groups of elders who are the most socially isolated and experiencing loneliness, 'we can drive,' said House of Memories' founder, 'into local spaces, hospital trust settings, a GP car park or a supermarket. The idea is that we bring the museum to you, where you are.' This is a prime example of what can be achieved by an organisation with existing investment, thereby able to capitalise on work that came into its own during a period of crisis.

The arts sector in general was enthused and energised by the new skills they learned and the novel opportunities which rapid digital transformation of their provision made available. There was disquiet among arts providers, nonetheless, that aspects of the digital offer had been very time and resource intensive. Adequate training in respect of IT and safeguarding in digital spaces, and not least in ensuring quality provision, remained a significant area of concern across the sector: 'Things work well if they're designed for the platform that they're on. If you design a project for digital, it works well online. If you design a project to be in a gallery, it works well in a gallery.' While, therefore, COVID-19 has catalysed evolution of digital provision, and the response in the LCR has been highly creative and collaborative, resources need to be directed towards ensuring that technology develops apace with innovation. (Notably, for example, arts organisations are currently delivering their provision via software designed for businesses, such as Zoom.) Our study highlighted the importance of training all stakeholders in digital knowhow. Skilling-up both workforce and beneficiaries is at least as essential as the provision of equipment and internet access.

# *Social prescribing*

A world without arts and culture would be a very dark and cold place. Living fulfilled lives is about having access to things that make you happy when you're well, not just clinical interventions when you're unwell. (Museum)

The achievements outlined above attest to how cultural organisations can support their local community, not as a stopgap emergency measure merely but as an integral aspect of future provision. The will and energy to consolidate the revitalised spirit of partnership exists in abundance and in acknowledgement that 'we all felt something during this time, and there's really a lot of work to do to support people': 'I think everyone realised the importance of putting mental health first' (dance organisation). A sense of unique 'opportunity', and the responsibility of using it, was echoed across the arts organisations who took part in this study. 'There's a lot of potential for developing and really prioritising how we can work better with the health sector especially in areas of high social deprivation. There is going to be a huge increased need for wellbeing services, which are already overstretched' (city centre theatre). 'If you start to embed the capacity for people working in direct healthcare to join up with the voluntary and charitable sector for better outcomes, and if it's properly resourced, and there's opportunities built in to communicate well, to have shared platforms, to reflect and learn and change, it's radical' (reading charity).

These arts practitioners and providers have learned, and verified, from the ground up the lessons of research and of policy recommendations, published before the COVID-19 pandemic, on the value of community assets in supporting mental health and wellbeing. The Five Year Forward View for Mental Health 2014, the NHS Long Term Plan 2019 and the Community Mental Health Framework 2019 emphasised the need for the NHS to work across sectors in addressing the wider determinants of health and to build strong partnerships with community, voluntary and third sector organisations. The recent creation of integrated care systems is an endorsement of recent research on the value of integration of care and community assets to deliver improved health outcomes.

The arts and cultural organisations who participated in our study welcome the impetus given to the social prescribing agenda by COVID-19. A prominent concern of our participants, however, was around investment in a future which embeds the lessons of the pandemic. The key emergent message was the need for a

supportive and 'properly resourced' infrastructure. 'It can feel very much like you and one health partner just make things happen. There is a need for something at a much higher level that embeds the work long term' (photography gallery). 'We're very projectled, it feels like a world of feast or famine. We've got to look for more sustainable models of development, by aligning with other health and wellbeing initiatives. Social prescribing is an important one now evolving. Arts and culture needs to be informing that' (museum). Our partners spoke with one voice in the conviction that comprehensive financial and infrastructural support for arts and cultural provision will be as vital for people's recovery in the aftermath of the pandemic as the sector has been 'a lifeline' during the COVID-19 crisis.

# **Key insights**

Our study concluded that arts and cultural organisations can play a major role in improving mental health outcomes across the city region, if adequately resourced and properly integrated into public health strategy. Key recommendations and implications for the future include the necessity to:


The advent of integrated care systems is an occasion to support partnerships between arts and health providers and co-ordinate local initiatives. Implementation is as urgent as it is opportune, given the UK's mental health crisis. Arising from our findings, we developed a digital resource of best practice in arts and mental health: 'Liverpool Art of Care' (LivCare). Co-created with arts organisations involved in the study, LivCare is designed to connect arts providers with one another, and with health and social prescribing link workers.2

# **Notes**


# **References**



COVID-19 Mental Health & Wellbeing study', *British Journal of Psychiatry*, 218(6), 326–333.


accessibility 58, 104, 171 ACE *see* Arts Council England affordances 91 and Nature-based Health Services (NbHS) 92, 94, 109–110 Zoom 53 agency 54, 59, 157, 167–169 AHRC *see* Arts and Humanities Research Council air pollution 75–78 allotments 94–96, 104 All-Party Parliamentary Group: Arts, Health and Wellbeing 1 anti-social behaviour 97, 104–105 artists 'everybody is an artist' 43 and healthcare professionals 179–180, 187–199 key workers 189 learning disabled 44 natural world 197 and research 66, 187, 192, 199 self-care 188 skills and practices 189–191, 194 arts and health 2, 215–216 hybrid delivery 216–219 partnerships 200, 205, 213, 216, 221 *see also* creative health

arts and humanities 9, 200 Arts and Humanities Research Council (AHRC) 65 Arts Council England (ACE) 2, 3, 208, 212, 214

Bakhtin, Mikhail 55 Belfast 123, 124 Black Lives Matter 189 Bourriaud, Nicolas 51 Buber, Martin 55, 57 burnout 191, 200, 213, 217

calls *see* video conferencing care homes *or* settings 120, 155–156, 158–161, 164, 166, 167, 169, 171–175 residents 8, 155, 158–168, 170–171, 174–176 staff 157–176 care workers 29, 36, 166 choirs 5, 16, 27, 213 Clap for our Carers 49, 52, 185 climate 89, 129 Clod Ensemble 178, 199 co-creativity 158 co-presence 18 communitas 42, 43, 50–60 Community Asset Transfers 98, 111n.5

community action 118, 210 arts 6, 22, 25, 43, 45, 50–51, 54, 59, 206, 207 *see also* online, community arts assets 5, 6, 15–16, 19, 27, 28, 35, 38, 95, 215, 220 engagement 37–8, 118, 119 connection 1, 5, 16, 29, 44, 46, 49, 51, 108, 128, 157–158, 165, 175, 181, 188, 189, 211–212, 217 conversation 160, 165, 170–171, 182, 192, 193, 217 coping 3–4, 21, 24, 121, 166 creative health 2, 35, 208 creative health partnerships 35 *see also* arts and health, partnerships Creative Health: The Arts for Health and Wellbeing (report) 1, 208 creative walking 65–68, 70–72, 83–84 creative writing 136, 193 crisis management 117, 125, 128–129 cultural capital 205 cultural policy 129 Culture Recovery Fund 135 Culture Health and Wellbeing Alliance 2, 39 dance 27, 53, 66, 196, 205, 207, 211, 213 dementia 8, 22, 71, 72, 120, 155–158, 168–172, 174–175, 218 depersonalising of care 182 dialogue 22, 55, 57, 118 digital arts 212, 219 communication 102, 171, 176 consultations 183

exclusion 102 literacy 25, 35, 172, 173 poverty 38, 119, 211, 214, 217 skills 173, 175, 219 turn 138–139, 149, 20 *see also* hybrid; online; remote working; videoconferencing; Zoom doodling 53–54

embodied practices 71, 158, 178, 186–187, 189 emotional labour 168, 200 environmental inequality 74–75, 77, 78 justice 72–73, 75 movement 74 evaluation 21, 22–23, 36–37, 170, 210 Everard, Sarah 81, 85n.16 everyday creativity 3 exclusion 59, 70, 102 *see also* digital, exclusion

Floyd, George (murder of) 188 Freire, Paolo 55, 57 frontline 9, 10, 126 funding 2, 31, 91, 99–101, 104, 106, 107, 109 cuts 97 emergency 211 National Lottery 99 furlough 13, 17, 14, 135, 139, 215

gardening 21, 90, 98, 126, 144, 194 gardens 7, 69, 71, 72, 94–95, 97, 98, 101, 139, 141–148 green gyms 90 green space 3, 6, 16, 27, 66–67, 69, 74–75, 89, 90, 94, 95, 97, 100, 102–105, 107 access to 3, 7, 66, 74–75, 77, 89, 93, 95, 104, 105

health inequalities 9, 93, 109, 187–188, 215 health promotion 89, 120 healthcare 17, 18, 35, 90, 178–179, 180, 186, 187, 193, 197, 200, 205, 215, 220 healthcare professionals 8, 16, 178–80, 185–6, 188, 191, 193, 199, 200–1 impacts of COVID-19 181, 186, 192, 197 training 180, 186, 187, 191 heritage 6, 7, 71, 73, 74, 116, 118, 120, 123, 124, 130, 136, 138, 149, 218, 219 *see also* literary heritage, sector homelessness 71, 208, 209, 213, 214 horticulture therapy 90 hospital 17, 179, 181, 182, 183, 184, 185, 194, 196, 199, 215 House of Memories 218, 219 hybrid 139, 157, 159, 175–176, 216, 217, 218, 221

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identity politics 54 'in the moment' 30, 46, 158 inclusion 6, 70, 102, 103, 108, 130, 155, 156 inclusive practice 43, 50, 58, 59, 60, 106, 171, 189, 216, 218 infection control 8, 20, 180 integrated care 210, 215, 220, 221 Intensive Care 181, 185 interdisciplinary 1, 65, 115, 123, 128, 130, 138, 206

Johnson, Boris 48 key workers 49, 69, 189 learning disability 6, 44, 53, 54 arts 45, 52, 57 dance 53 theatre 56, 58 Let's Create 2, 208 Levelling Up 19 link workers 15, 16, 20, 25, 26, 27, 35, 106, 221 literary heritage museums 139 sector 7, 8, 135, 136, 137, 139, 148, 149 sites 135, 136, 137, 139, 140, 141, 144, 148, 149 Liverpool 9, 204, 217, 218, 221 local authority 93, 95, 97, 107 budgets 97, 99 museums 120 lockdown 4, 15, 16, 17, 23, 29, 48, 49, 67–8, 101, 115, 126, 129, 135, 136, 137, 139–142, 144, 145, 148, 155, 158, 189, 204, 207, 209, 211, 212, 216, 218 loneliness 2, 5, 15, 17, 21, 47, 155, 156, 157, 165, 169, 212, 219 long COVID 125

Marmot review 15 masks 30, 182 mask-making 30 mask-wearing 118, 184, 193 *see also* Personal Protective Equipment (PPE) Meeting Centres 71, 72 medical students 181, 184, 185 memory 8, 67, 219 mental health 25, 34, 98, 191, 220 arts for mental health care 205, 207, 215, 221 benefits of time spent in nature 144 benefits of walking 66 evaluation 37, 206

impacts of pandemic on 9, 17, 93, 117, 119, 120, 125, 126, 204, 205–206, 207 stigma 23 *see also* resilience microtopia 51, 52, 59 Mind the Gap (theatre company) 44, 45 mindfulness 116, 121, 127 Mindfulness Based Cognitive Behaviour Therapeutic (MBCBT) approaches 126 museums 7, 19, 35, 115–130, 137, 138, 147, 148, 204, 218–219 community role 15, 116, 118, 145 COVID-19 collections 124 virtual tours, 138, 139 and wellbeing 119, 125–126, 128, 129, 130 writer's house 135–136, 137, 138, 139, 148 *see also* Restorative Museum music 18, 27, 43, 159, 215, 219 National Centre for Creative Health (NCCH) 2, 208, 213 National Health Service (NHS) 23, 92, 95, 105, 106, 178, 185, 187, 191, 199, 211, 213, 216, 220 National Lottery 99 National Trust 73, 74, 76, 142, 144, 149 nature 74, 77, 89–91, 98, 100, 103, 105, 108, 109, 139, 143–144, 147, 148, mental health (*continued*)

186, 196–7 nature-based activities 89–90, 91, 92, 97, 98, 106 *see also* green space NHS *see* National Health

Service

non-verbal 56, 57, 178–180, 183, 186, 189, 196, 200 Northern Ireland 7, 115, 116, 117, 119, 120, 121, 124, 129

older people 69–70, 100 online 21, 25, 53, 57, 136, 156, 165, 181, 189, 196, 207, 211, 212, 214, 217, 219 community arts 6, 42–44, 46, 50, 56, 59, 60 interviews 171, 180, 206, 207 provision 35, 38, 210, 213 survey 20, 169, 171, 206 workshops 6, 20, 28, 56 work 25, 36, 173, 182, 185 *see also* digital; hybrid; remote working Open Clasp Theatre Company 79–83 outdoor education 146–147 outdoor space 7, 68, 69, 75, 139, 141, 142, 143, 144–145

Participatory Action Research (PAR) 93, 169 ethical challenges 171 pedestrian equity 66, 70, 83 People's Palace Projects 179 Performing Medicine 178, 179, 186, 187 Personal Protective Equipment (PPE) 17, 179, 180, 181, 182, 185, 186 person-centred practices 168, 169 photography 28, 175, 212 physical theatre 196 post-traumatic growth 4, 122 'prisoners of love' care work framework 166 public health 18, 38, 48, 59, 90, 118, 156, 221 crisis 187 restrictions 17, 34, 188

racism 70, 73, 75 reading 8, 21, 136, 140, 144, 145, 147–149, 207, 209, 211 recovery 1, 93, 97, 106, 108, 117, 121, 125, 128–130, 179, 192, 194, 199, 218, 221 relational 6, 46, 50, 72, 79, 91, 158, 170, 183 relationships 22, 51, 52, 57, 122, 161 I/It or I/Thou 55 teacher-student 55 therapeutic 20 remote working 156, 174 research methods arts-based or creative methods 20, 28–31, 37, 175, 180, 193 design-led research 93–94 storytelling 80, 126, 170, 193 walking as a research methodology 70 walking interviews 65 *see also* Participatory Action Research (PAR) resilience 1, 5, 42, 60, 93, 108, 119, 130, 186 community 4, 108, 115, 122, 126 concept of 4, 122–122 politics of 191, 200 restorative space 7, 72, 125 Restorative Museum 123 Rosen, Michael 199 ROSHNI Asian Women's Resource Centre 75, 78, 79 routine 23, 67, 81, 121, 167, 171, 212

#### safe

229

feeling 25, 46, 58, 69, 80, 81, 105, 189 space 50, 77, 121 safeguarding 16, 35, 56, 214, 219 sci-art 75, 77, 79 self-care 116, 126–127, 178, 180, 186, 188, 194, 200

selfhood 43, 50, 54, 59 Sheffield 72, 75, 76, 77 Sheffield Environmental Movement (SEM) 72–73 shielding xiv, 15, 17, 20, 28, 35, 60, 69, 118 social capital 19 care 92, 98, 157, 166, 174, 200, 206, 208, 210, 213 determinants of health 38 distancing 47, 101, 118, 135, 137, 141, 161, 170, 180–3, 191, 192 isolation 3, 5, 17, 47, 89, 155, 156, 157, 165, 169, 171, 189, 211 justice 80, 125, 179 social prescribing 2, 5, 16, 18, 24, 27, 34, 35, 106, 216, 219, 220, 221 Green Social Prescribing 90, 92, 105–106, 108, 109 National Academy for Social Prescribing 2 *see also* link workers solidarity 48, 49, 70, 171 street harassment 79–81 strengths-based 120

tele-health 19–20 theatre 43, 45, 56, 58, 79–83, 187, 196, 209, 211, 216, 217 'therapeutic holding' 120 third sector 21, 110n.3 adapting 24 budgets and funding 27, 110 evaluating benefits of provision to community members 22–23, 36 involvement in Nature-based Health Services 95, 97, 103, 107–108, 110 partnerships 35, 220 *see also* voluntary sector TikTok 211

togetherness and COVID-19 47–50, 59–60, 118 conceptual framework for understanding 42 rhetoric of 48 *see also* communitas; online, community arts; selfhood; 'we're all in this together' touch 180, 181, 183, 193, 194, 219, 217 tourism 136, 138, 139, 147 trauma 3, 4, 116–118, 122, 123, 125, 130, 166, 175, 186 video conferencing 19, 24, 67, 159,

170, 171, 179, 180, 182, 184, 192, 196 *see also* Zoom voluntary sector 214, 215 *see also* third sector volunteers 94, 98, 100, 101, 107, 214 *see also* volunteering volunteering 21, 27, 101 vulnerabilities 16, 21 vulnerable 5, 17, 18, 19, 20, 21, 23, 27, 28, 35, 38, 48, 59, 110, 118, 172, 175, 205, 209 adults 144 definition of 15–16

walking artwork commissions 70, 72, 75, 79 barriers to 69–70 benefits of 65, 66, 78, 80 Black people 73 creative walking 65, 66–67, 68, 71, 84 during COVID-19 64, 67–68, 126 'just walking' 66, 81, 83, 84 *see also* pedestrian equity proxy walk 67, 72, 84n.3 unsafe 81 Walsall 92–93, 95, 97, 103, 107 'we're all in this together' 6, 42, 47 working from home 67, 69, 139 *see also* remote working

young people 6, 9, 43, 51, 52, 189, 214, 218

Zoom 25, 45, 46, 53, 56, 57, 72, 94, 170, 173, 195, 211, 215, 216, 219 *see also* video conferencing