This policy brief is intended for healthcare authorities and health service organisations, producers of art, artistic activities, and art-related services, educators and students in the health and social service sector and the cultural sector, and decision-makers in all these fields.

The policy brief aims to encourage health service organisations to pay attention to the cultural contexts of health and integrate culture and art into their activities to promote health and wellbeing.

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Photo: Matti Snellman/ HUS

According to the Universal Declaration of Cultural Diversity of the United Nations Educational, Scientific and Cultural Organization (UNESCO), culture should be regarded as the "set of distinctive spiritual, material, intellectual and emotional features of society or a social group, and that it encompasses, in addition to art and literature, lifestyles, ways of living together, value systems, traditions and beliefs" (UNESCO 2001). However, health service organisations may overlook the cultural aspects of health and wellbeing as well as people's cultural wellbeing because of their strong focus on the provision of medical care and efficient operations. The international Lancet Commission has noted that the neglect of culture in the healthcare sector presents one of the most significant challenges to improving people's health (Napier et al. 2014).

The operating environments of health service organisations should become the focus of increased attention. Hospitals, for example, have developed over long periods, and the current facilities, infrastructure, and various organisational cultures bear traces of past ideals and ideologies. We know from history that 2,000 to 3,000 years ago, patients in Egypt received care in temples, while in Ancient Greece, they were treated in military hospitals. On the other hand, modern hospitals are clinical centres that bring together various medical professions and technologies. Their objective is to provide safe and secure operations with state-of-the-art diagnostic services and effective treatments and therapies. In this environment, however, the role of culture and the arts remains marginal.

Consequently, health service organisations should use all the available resources to promote the patients' recovery, health, and wellbeing. The importance of culture and the arts becomes particularly pronounced when a patient is treated in a somewhat isolated environment with no access to art or culture. Hospitalised patients suffering from a long-term illness have especially often pointed this out. Just like with any other form of treatment, the efficacy of culture and art can be measured. For example, there is compelling evidence of the beneficial effect of music on patients' recovery (Fancourt & Finn 2019; Särkämö et al. 2011). The impact of culture and the arts also becomes apparent when an individual's self-reflected experiences concerning participation in the arts and culture are examined.

Culture and the arts in health service organisations

We propose that the organisations working in the health service sector should implement the following procedures into their operations and adopt a holistic approach to improving people's health and wellbeing through culture and the arts:

Strategy planning and the development of health service organisations

1. A cultural wellbeing plan for healthcare districts. Each healthcare district needs to revisit its strategic plans and policy documents to amend them to include a list of regional objectives and procedures on cultural wellbeing based on existing domestic and international research. The goal of the cultural wellbeing plan is to make it possible for patients receiving care to enjoy and participate in cultural and artistic services, to be able to express themselves, and to reflect upon their condition by the means afforded by art and culture. The municipalities should implement cultural wellbeing principles as part of their municipal strategies, service pledges, and welfare reports. Private service providers should also formulate their goals related to cultural wellbeing and finalise an action plan based on them.
2. Cultural wellbeing needs to be adopted as one of the strategic core values of the health service organisation, and measures should be implemented throughout the organisation. The organisations should consult experts in culture and the arts in their planning and decision-making processes. A designated culture and art committee needs to be formed to promote artistic and cultural activities. An expert in cultural wellbeing should be appointed to the board of the health service organisation.

3. Hiring a Cultural Wellbeing Coordinator. Health service organisations should employ or appoint a Cultural Wellbeing Coordinator (e.g., for a fixed proportion of the total working time), who will be responsible for the everyday coordination and facilitation of the cooperation between various agents and organisations (administration, personnel, patients, family members, professionals in the fields of culture and the arts, art organisations, volunteers). The coordinator will also seek to identify members of the personnel with an interest in culture and the arts and explore opportunities to train them further to promote cultural wellbeing as part of their everyday work.

Monitoring, evaluation, and research

4. Monitoring and evaluating cultural wellbeing initiatives. Ministries should launch a project in collaboration with the healthcare districts to develop cultural wellbeing services in general healthcare by using existing international models and current research. Health service organisations should include the documentation and evaluation related to cultural wellbeing ('cultural record') as part of their documentation and registration procedures (Siponkoski 2020). Patient and customer databases should also contain information about the customers' cultural needs and wishes, their participation in cultural and artistic activities, and subsequent effects of the involvement in these activities.

5. Monitoring and evaluating the cultural wellbeing of the patients and people living in the region. The municipalities should complement and collect indicator data acquired from a benchmarking service on how the activities that promote cultural wellbeing are realised (see TEAviisari, THL 2020). Information about the facilitation of cultural wellbeing activities can be exploited in knowledge-based management within the ecosystem of cultural wellbeing.

6. Research collaboration. National Institutes (e.g., The Finnish Institute for Health and Welfare) should promote multidisciplinary research collaboration with universities, higher education institutions, and health service organisations. The information on people's cultural wellbeing collected by the health service organisations will be made available for multidisciplinary research purposes following sustainable and ethical research principles.

Proactive measures and health promotion

7. Promoting the participation and cultural wellbeing of health service customers. Health service organisations should support the patients' participation in artistic and cultural activities through collaborative efforts that cross the established sectors and administrative branches (e.g., healthcare, social care, culture, education and early childhood education, physical education, environmental services, and parish work).

8. Supporting the patient's self-management through art and culture. Health service organisations should adopt a range of measures to introduce art to communicate and interact. They should use art that is already in place in the organisation and encourage the personnel, patients, and family members to realise their artistic and cultural potential. The patients' connection to art can be supported, for example, by social prescribing (see Dayson & Bashir 2014).

9. Promoting health and wellbeing by making use of art in communication. Health service organisations should use artistic forms of expression and cultural media in health-related communication and the distribution of popularised information to various target groups.

Treatment, management, and recovery

10. Integrating a holistic view of people into the treatment. Each patient needs to be treated as a bodily, sentient, conscious, and psychosocial individual whose prior life experiences and cultural background affect their health and wellbeing. The patient's needs and wishes about their cultural wellbeing, as well as the observed wellbeing impacts, should be registered into the patient database systems (see Siponkoski 2020).

11. Reinforcing the status of art therapies. The possibilities afforded by various art therapies should be recognised, and the therapies should play a more substantial role in the patients' treatment and recovery. This holistic approach to treatment should use the potential that exists in the multidisciplinary collaboration between art therapists, other art professionals employed in the health service sector, and healthcare professionals.

12. Establishing artist-in-residence programs in hospitals and health services. Health service organisations should allocate resources to the organisation of socially engaged, professional artists working on a long-term and wide-ranging basis (e.g., hospital musicians, artists-in-residence, dance ambassadors, literary artists, hospital clowns).

Supporting the personnel and improving occupational health

13. Reinforcing the personnel's relationship with art and culture. Health service organisations should support the personnel's relationship with art and culture as part of lifelong learning in collaboration with institutions that provide education in health and social services and art and culture. Such an approach will allow the personnel's relationship with culture and their personalities to come through in their everyday work. Health service organisations should also promote occupational health by encouraging their personnel to participate in cultural and artistic activities within the working community.

14. Recognising the role of art in health services from the perspective of occupational health and work-based learning. Health service organisations should implement contemporary culture- and art-based approaches into their activities. Doing that allows them to develop their operating culture and to promote the personnel's occupational wellbeing.

Operating environments in healthcare
 

15. Recognising the environment's relevance to wellbeing. Professionals responsible for the construction and renovation of health service organisations' facilities should carefully consider the patients, family members, and personnel's opinions in their planning and decision-making processes (e.g., architectural solutions, design, service design, and landscaping). The construction and renovation projects should pay close attention to the acoustic environment's quality, the colour scheme used in the facilities, and the amenity of the lighting and interior design, for example, and consider using the facilities from the perspective of special groups and accessibility.

16. Implementing the extended percent-for-art principle in the operating environments of health service organisations. By extending the current percent-for-art principle, a discretionary percentage of the health service organisation's budget can be allocated to art and cultural activities in patient care, customer service, and occupational wellbeing. Furthermore, the current percent-for-art principle, which pertains to the provision of funds for the purchase of art in the total project budget, should continue to be followed in construction and acquisition projects. All health service organisations should make this principle a standard policy.

17. Making use of new technologies and virtual solutions. Health service organisations should identify and pursue the possibilities afforded by modern technology to encourage people to take part in cultural and artistic activities in their units. Health service organisations should acquire cultural content from art organisations through streaming platforms and network downloads. The hospital personnel, patients, and family members should receive instruction in the use of the remote services and, more concretely, to use the necessary technology.

Practical examples of how health service organisations can promote cultural wellbeing

• Example 1. Supporting the patient's agency and self-management through art and culture: a) Listen together to an exciting program on the radio and discuss the thoughts it provokes. b) Help the patient reflect on their condition employing literary art.

• Example 2. Promoting health and wellbeing through artistic communication: a) Remembering to follow appropriate hand hygiene practices can be supported by composing a rhyme or a rap. b) A relatable short film can provide a more effective and multi-layered account of a peer experience than an ordinary discussion.

• Example 3. Promoting the participation and cultural wellbeing of health service customers. Models for long-term cooperation can be planned together with local art schools. Activities such as guest performances, open rehearsals, workshops, and exhibitions will be organised on the health service organisation's premises.

• Example 4. Integrating a holistic view of people into the treatment: a) The personnel becomes better acquainted with a customer or a patient and learns more about their cultural background and cultural needs. That can be accomplished, for example, by making use of an exercise, such as the 'Tree of Life,' that allows the individual to recount their life experiences to others. b) Topics in further personnel training should include the role of cultural diversity and multiplicity in people's lives ('intersectionality') and their value from the perspective of professional care. The stereotypical categorisation of people (e.g., 'the elderly') should be avoided, and people's individual preferences and self-reflection in selecting cultural services and contents emphasised.

• Example 5. Reinforcing art therapies' status: a) An art therapist, a communal artist, and a nurse can form a working group in a hospice unit. The treating physicians evaluate the art therapy's suitability to the patients' care path on a case-by-case basis. b) How various art therapies can be employed, and the health benefits related to them, are discussed in physician training. The physicians are trained to assess art therapy's help for the patient in addition to, or in place of, other treatments.

• Example 6. Establishing regular artist-in-residence programs. The health service organisation negotiates with an art service provider (e.g., hospital clowns, dance ambassadors, literary artists). It formulates an agreement concerning the collaboration's annual goals, the concrete measures related to that, and the available resources.

• Example 7. Adopting the principle of extended percent-for-art in health services: a) Patients are provided with an opportunity to engage in participatory art activities along with the regular care services. That will be accomplished by allocating a discretionary proportion of the health service organisation's budget to art and cultural activities to improve the patients' cultural wellbeing. b) Cultural and artistic activities are integrated into the organisation's daily and weekly routines.

• Example 8. Recognising the role of art in the health service organisation's operations from the perspective of occupational health and work-based learning. a) The personnel can form a choir, for example, which provides variety to their everyday tasks and reinforces their sense of solidarity. b) A forum theatre can be used as a form of experiential learning in the critical assessment of personnel and patient reports.

Cultural contexts of health and wellbeing and the ecosystem of cultural wellbeing

The Lancet Commission has emphasised the role of cultural diversity in people's behaviours and how they articulate health-related issues. Consequently, health should not be considered only in terms of measures that use standardised data related to clinical care, illness, and the patient, but also in light of local knowledge and culture-specific concepts (Napier et al. 2014). The cultural contexts of health are here understood in terms of how value systems, traditions, and beliefs can positively or negatively affect people's health and the existing clinical practices (Fietje & Stein 2017). Ignoring these perspectives can lead to a situation where questions related to the patient's health are considered and clinical practices planned, almost exclusively from the standpoint of physical wellbeing.

The perspective of cultural wellbeing should be recognised in the general development of the health service system. As a term, 'cultural wellbeing' has several meanings that pertain to how culture is part of people's lives and how it affects their health and wellbeing and clinical practices. Cultural wellbeing is often used about an individual's own experience of how "culture and art increase their wellbeing or are related to it." (Lilja-Viherlampi & Rosenlöf 2019, 21) On the other hand, the question is about a phenomenon where culture and art convey meanings related to health and wellbeing in society and thus influence both the individual and the community (id.). People's cultural wellbeing can be improved by providing everyone with opportunities to engage in artistic and cultural activities throughout their lifespan. Occasionally, cultural wellbeing can also refer to the culture and healthcare sectors: the inter-sector cooperation in the arts and cultural activities that promotes health and wellbeing (In Finnish context HYTE).

The health service system should acknowledge at the outset that, regardless of their age, physical condition, or living environment, each individual is a cultural, creative, self-expressive, and communicative being: someone who experiences culture and actively engages in it, follows particular cultural customs and has specific needs related to that. The way these needs are met can either positively or negatively impact an individual's health and wellbeing. Reinforcing the individual's cultural wellbeing is based on their relationship with culture and art, as well as their cultural capital, which is accumulated throughout the life span. The possibility of participating in the arts and culture, developing oneself and one's community through them, and expressing oneself freely are basic rights (Lehikoinen & Rautiainen 2016). They are also essential components of a good quality of life and life-long learning. Indeed, people are grounded in their everyday lives and environment by art and culture.

According to the ecosystem of cultural wellbeing (see Figure 1), it is possible to reinforce the sense of cultural wellbeing of all population groups. It can be done by investing in the availability, accessibility, and engagement of art and cultural services and integrating these services into the practices of health and social service institutions and educational organisations. That will become possible once the information about the effects of art and culture on people's health and wellbeing starts to affect our social values, political decision-making, funding, and operating cultures in various sectors. Reinforcing cultural wellbeing will thus become an acknowledged part of the organisations and their evaluation. Similarly, the practical experiences gained in people's opportunities to participate in the arts and culture, their actual participation, and their cultural wellbeing reinforce the existing body of research and knowledge accumulation within the field. Furthermore, by engaging in well-coordinated multidisciplinary collaborations between the culture, education, and health and social service sectors, it is possible to ensure that people's relationship with culture and the arts continues to develop from early childhood to adulthood and the later years in life.

Cultural wellbeing in the HEWE ecosystem

The ecosystem of health and wellbeing (HEWE) concerns all sectors. Here, however, we will only focus on one part of the ecosystem – the dynamic network between the various agents in the health and social service sector. Such a network "produces services and distributes tasks, responsibilities, and decision-making power – [so that] all the participating agents work in cooperation, share the same goals, and carry out the required tasks according to the division of labour and responsibilities that have been agreed upon" (Vepsäläinen et al. 2017, 14). The adoption of cultural wellbeing principles can affect the HEWE ecosystem in different ways, from administration and personnel's expertise to the service organisation's operating culture, occupational health, and patient experiences (see Figure 2). Reinforcing one's connection to art and culture forms a central part of the ecosystem. The customers' (including the patients') personal connection to art and culture can be supported by making art and culture better accessible in the health and social services and reinforcing the role of art therapies. The personnel's relationship with art and culture will also be supported by paying attention to the concept of cultural wellbeing in the professional training provided by educational institutions in the health and social service sectors, leadership, operating culture, and occupational wellbeing.

The inclusion of the arts in health services and hospitals promotes the wellbeing of both the patients and the personnel

Multidisciplinary cooperation between health service organisations and art and cultural organisations will increase cultural wellbeing in society. According to the scoping review commissioned by the World Health Organization (Fancourt & Finn 2019), the arts can be used for many purposes: e.g., to influence the social factors of health, to promote children's development, to encourage behaviours that have a positive impact on health, to prevent illnesses, and to support care work. Moreover, art can benefit people recovering from mental health problems, it can support acute care, and it can help treat non-infectious diseases. Art can also support people suffering from neurological disorders and be part of palliative care (ibid.). When art and culture are taken increasingly into account in providing health services, the resulting care work will also be more ethical than before. Understanding the cultural contexts of health helps people consider patients as individuals whose lives, wellbeing, and health are substantially determined by culture. By paying attention to the patients' cultural needs, it is possible to promote their wellbeing at a time of crisis or illness. Simultaneously, an increased understanding of art and culture's opportunities in advancing people's health and wellbeing provides support to a more holistic approach to the development of people-centred care. Once the organisation-based, hierarchical operating models that health service organisations currently adopt are replaced by people-centred and increasingly equity-driven solutions, this will also increase transparency in the health service organisations' operations and communication culture. That will also diversify the value basis of the health service organisations and services to support mutual trust, making the organisations more resilient the arts and culture enjoy an autonomous status in a civilised society. Still, in the extended discourse of wellbeing, they also play a legitimate role in the health and social service sectors. As we now live in a time following the expansion of the welfare societies, all investments in the arts, art education, and culture should not only be regarded as cultural investments; instead, they are also proactive investments in people's health and social care. They are investments in a good life, wellbeing, inclusive principles, and the alleviation of cultural tensions. These ideas can even be extended to the health service organisations' innovation capital and the sustainable growth of intangible value creation.

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