Policy context for Health Inequalities
Health inequalities can be geographic, across socio-economic gradients, in populations with specific characteristics such as ethnicity or disability, or in groups that are often excluded from accessing services.
The term can relate to disparities in health outcomes, or to differences in accessibility and experiences of care, and are strongly influenced by the wider determinants of health. As well as the impact on life expectancy and quality of life for individuals, health inequalities place a considerable burden on the NHS. Health inequalities are persistent but have been highlighted by Covid-19 as people from lower socio-economic groups and minority ethnic communities experienced significantly poorer outcomes.
There is a policy focus on reducing health inequalities as part of the levelling up agenda and healthcare reforms, which prioritise prevention and personalised care. The NHS Long Term Plan commits to the establishment of measurable targets in the reduction of health inequalities and CORE20plus5 has been developed to focus on the 20% most deprived areas of the country, groups experiencing greatest inequalities as determined at local level, and five clinical areas.
How can Creative Health approaches help?
Creative Health can help reduce inequalities through prevention and initiatives to encourage health-promoting behaviours or reduce stigma or build agency, self-efficacy, and peer support.
Creative Health approaches can facilitate co-production of appropriate and accessible services and can work at a neighbourhood or place level to tackle the social and economic conditions that can lead to poor health.
The WHO Scoping Review ‘What is the evidence on the role of the arts in improving health and wellbeing?’ provides several examples of studies where the arts have been effective in reaching groups who experience barriers in engaging with healthcare services and the APPG report Creative Health: The Arts for Health and Wellbeing discusses the arts and marginalised communities.
Key areas of focus
People experiencing homelessness
People affected by homelessness experience significant health inequalities, and often have complex needs and comorbidities, which may be a cause or consequence of homelessness.
Integration and personalised approaches to healthcare are necessary in order to improve outcomes in this population. Creative approaches have been used with people affected by homelessness to facilitate engagement with services, to improve health and wellbeing and to build skills and confidence, leading to moves into housing and employment. Co-produced artistic performances provide a voice for those affected, which can influence strategic policy change and the development of more appropriate services.
Arts and Homelessness International Activities improve wellbeing, confidence and social inclusion. The 2020/21 impact report shows 95% of participants said it made them feel healthier.
Booth Centre in Manchester provides creative activities and opportunities for people affected by homelessness in a community centre setting. They also work with local theatres to run drama and singing workshops and to co-create theatre productions.
Choir with No Name community choirs for people affected by homelessness – builds skills, confidence and social inclusion, and reduces stigma through performances.
Museum of Homelessness Educate on homelessness by working with artists and creatives to make unforgettable art, exhibitions and events.
Ethnic minorities
Inequalities exist between white and ethnic minority communities and between different ethnic groups and vary by health condition. For example, rates of infant and maternal mortality, cardiovascular disease and diabetes are higher among Black and South Asian groups. Ethnic inequalities in health outcomes were highlighted by Covid-19, where ethnic minority communities were disproportionally affected and suffered higher mortality rates.
Ethnic minority communities are disproportionately affected by deprivation, negatively impacting health. Structural racism can reinforce inequalities, and racism and discrimination have a negative impact on health. The NHS Race and Health Observatory 2022 review found longstanding ethnic inequalities in both health outcomes and access and experiences of NHS services, recommending improvements in data collection and statistics to ensure outcomes can be measured, investment in interpreting and research, and closer links between the NHS and community and VCSE groups to develop culturally appropriate services.
Although there can be barriers to arts engagement by ethnic minority communities, culturally specific creative health programmes can be successful in targeting particular populations. The WHO scoping review provides evidence that arts-based approaches can be effective in reaching groups that face barriers in accessing healthcare services. Creative approaches may also be used to co-produce culturally appropriate services with communities.
Red Earth Collective aims to support and improve the mental health and wellbeing of marginalised and racialised communities using arts, theatre, music and film.
Baring Foundation (2021) Creatively Minded and Ethnically Diverse – Increasing creative opportunities for people with mental health problems from ethnically diverse backgrounds - opinion pieces on best practices in ethnic and cultural diversity related to arts and mental health practices.
Breathe – Melodies for Mums. A singing programme for mothers at risk of postnatal depression has been shown to be a good way to engage mothers from minority communities, who are less likely to seek treatment.
GemArts’ Cultural Threads programme works with diverse communities, using creative engagement to address isolation and loneliness and to improve health and wellbeing.
Gypsy, Roma & Traveller Communities
In the 2011 census, the Gypsy or Irish Traveller ethnic group made up 0.1% of the total population Health outcomes for Gypsy, Roma & Traveller Communities are poor. Barriers include difficulties accessing healthcare services, language difficulties, discrimination and a lack of trust, leading to non-engagement.
‘Gypsies, Roma, Travellers and Showmen unite to Give Covid the Jab’ is a film from Romany journalist and film maker Jake Bowers, backed by the NHS in Surrey, to provide Gypsy, Roma, Traveller and Showmen information on Covid-19 vaccination.
People experiencing drug and alcohol dependence
Drug and alcohol dependencies contribute to a wide range of physical and mental health conditions, and place a significant burden on the NHS, and on the wider economy. A role of the Office for Health Improvement and Disparities (OHID) will be to focus on addiction, including drugs and alcohol, from a population health perspective. Personalised approaches to alcohol and drug dependency within the NHS have demonstrated better outcomes for patients.
Creative approaches can be used to raise awareness of the dangers of drug and alcohol use, and to improve wellbeing and confidence for those in addiction recovery. Participatory arts can support people with complex needs including addiction to make positive and healthy choices, and can raise awareness and reduce stigma in wider society.
Fallen Angels Dance Theatre exists to support those in recovery from addiction to transform their lives, and to share the recovery journey with the wider public, through dance, performance and creativity.
Phoenix Futures A charity supporting recovery from drug and alcohol problems, with a recovery through the arts programme.
Portraits of Recovery Manchester-based visual arts charity supporting people and communities affected by addiction and recovery.
Outside Edge Theatre and participatory arts company improving the lives of those affected by addiction through drama workshops and theatre productions.
People in contact with the criminal justice system
People in contact with the criminal justice system experience health inequalities particularly in relation to mental health, suicide and physical disabilities, and can find it difficult to access health services. They may be affected by substance abuse, homelessness and childhood trauma, and involvement in the criminal justice system may exacerbate mental health conditions and stress.
The NHS Long Term Plan commits to improving wellbeing, reducing inequalities and addressing the drivers of criminal behaviour through the provision of services in prisons and continued support post-release from custody. The needs of children and young people at high risk of coming into contact with the system are also considered.
National Criminal Justice Arts Alliance (NCJAA), represents 900 individuals and organisations delivering creative interventions in prisons, on probation and in the community. NCJAA hosts an Evidence Library of key research and evaluation documents relating to the impact of these interventions.
Building Resilience and Overcoming Adversity through Dance & Drama (BROAD) is an innovative dance theatre pilot programme designed for vulnerable groups in prisons, secure children's centres and secure hospitals. The project was co-created by Odd Arts, who have been delivering forum theatre- based work in such settings for many years, partnered with dance Company Chameleon.
Koestler Arts is a prison arts charity encouraging people in the criminal justice system to participate in the arts. Collated research, evaluation and impact reports on the effectiveness of arts in prisons can be found here.
Helix Arts is a participatory arts organisation based in Newcastle upon Tyne that works with a range of socially excluded groups, including (ex) offenders. A case study, Participatory Arts and Young Offenders covers the issues art and desistance, working with young offenders and restorative justice.
Refugees & asylum seekers
Refugees and asylum seekers have complex needs, but may face barriers in accessing healthcare services. This group are likely to experience poor mental health, including anxiety, depression and Post Traumatic Stress Disorder (PTSD). The NHS provides guidance on the health needs of migrant populations.
The WHO Scoping review finds evidence that creativity can decrease anxiety, depression and PTSD in refugees and asylum seekers, and well as supporting the preservation of personal identity and experience, which is important for wellbeing.
Kazzum Arts' Pathways Programme provides creative opportunities for young refugees and asylum seekers with a focus on mental health needs, reducing isolation and developing skills.
Music Action International create music programmes with survivors of war, torture and persecution.
Arts Stream of Sanctuary supports arts organisations to work with refugees to tell stories of migration and bring communities together.
Platforma, Arts and Refugees Network, a project managed by Counterpoints Arts, provides a national framework for promoting and developing refugee related arts in the UK, and beyond.