Assessing the Impact of Artistic and Cultural Activities on the Health and Well-being of Forcibly Displaced People Using Participatory Action Research

"By focusing on the relationship between arts, well-being and forced displacement and in keeping with PAR, the study actively changed the narrative surrounding refugees/asylum seekers and gave an understanding of how to improve conditions for forcibly displaced people through opportunities for social connectivity, creative thinking and employment skills."

Evidence suggests that cultural participation (including music, art making, theatre, dance, and museum and heritage activities) enhances human health and well-being. Considering that asylum seekers and displaced people report high rates of pre-migration trauma and often encounter post-migration difficulties, a number of organisations engage migrants, refugees, and asylum seekers in the arts, with nearly 200 of these in the United Kingdom (UK). This study developed a participatory action research (PAR) method for assessing the impact of arts interventions on forcibly displaced people and identified themes concerning perceived benefits of such programmes. The hope is that the methodological approach and interview questions produced could be applied in the UK and international settings.

The study was conducted at the Helen Bamber Foundation (HBF), a UK charity offering support to refugees and asylum seekers as victims of torture and human rights violations. HBF adopts a holistic approach to support its clients that includes cultural activities within a 3-phase model of integrated care comprising stabilisation (medical and legal support), intervention (trauma-focused therapy and general psychological care) and integration (attending computing and English classes and interacting with other clients). Led by volunteers, their creative arts programme (CAP) includes art (painting and drawing), photography, textiles, and singing. The study took the view that arts participation would enhance the sense of well-being by allowing participants to form meaningful relationships based on trust and mutual support (improving social well-being) and enhance self-esteem and self-confidence (increasing personal well-being).

To provide voice and agency for participants, the study used a collaborative approach to explore client experiences of creative activities, with HBF clients, staff, and volunteers acting as co-researchers. The research was operationalised according to the principles of participatory action research (PAR), which "encourages an active contribution in the production of knowledge within a collaborative framework." One of the pillars of PAR, especially when community based, is ownership.

The qualitative research comprised observation, focus groups, and one-to-one semistructured interviews with clients, volunteers, and staff. Creative and cultural activities were observed over a period of 5 months. Clients participating in the activities had reached the integration stage of the model of integrated care, taking part in CAP activities for 2 plus years prior to the research. In total, 31 (6 males) participants volunteered for the study and attended focus groups; 17 (3 males) participated in interviews. (Box 1 in the article outlines focus group questions; Box 2 outlines interview questions.)

According to the researchers, HBF staff were instrumental in the application for research funding and helped determine the study's objectives; also, HBF clients were involved in the recruitment process. Also in keeping with PAR, co-researchers (HFB clients, volunteers and staff) determined the research questions and outcome measures. A core group of 7 co-researchers were involved in design of the interview guides, discussion of emerging themes, and dissemination of the research findings to other participants for verification and comments. The results of the research were fed back to everyone involved through ongoing communication with the researcher, an internal report lodged at the charity, and an end-of-project event. Specifically, the clients decided to organise a public exhibition to showcase their artwork, which "was a means for them to interact with wider society and actively rewrite the narrative around asylum seekers and refugees, often depicted in negative terms in the public sphere..."

Findings of the focus groups showed consistency in the way all HBF participants articulated their reflections on the impact of creative activities. Three main overarching themes emerged: "skills", "social aspects/friendships", and "mood-personal sphere"; the latter subdivided into "brain" (creative thought processes), "routine", "self-expression", and "confidence". Example finding: "Enhancement of mood appeared to derive from not only meeting new people, forging meaningful relationships and feeling part of a group but also connected to a growing self-confidence and self-esteem experienced as clients acquired new skills."

During interviews, clients elaborated on practical and social skills and commented on the positive effect of attendance on their mood and emotion; quotations are shared to illustrate these effects. Example finding: "The sense of self-improvement associated with learning skills was linked to the perception that by learning, clients were preparing themselves for a new life when they would be allowed to live and work in the UK, countering the perception that life for them had stopped and giving them something to look forward to. The process of skills learning was not simply a vertical one; peer learning was equally important, stressing the importance of social aspects."

As noted here: "The time spent by the researcher at the HBF was vital for familiarisation with the context, getting to know people involved in the organisation and explaining the research to recruit participants from among clients, volunteers and staff. The fact that several clients attended more than one group per week (2-4) made it possible to forge trusting relationships and recruit coresearchers, allowing them to feel comfortable in speaking their mind."

PAR was found to be particularly appropriate for refugees/asylum seekers with post-traumatic stress disorder (PTSD) and other mental health issues in that their involvement as co-researchers countered client isolation and built social capital. Furthermore, they acquired research methods skills (e.g., drafting interview guides, conducting focus groups, and discussing data) and acquired/refined organisational abilities (planning the event/exhibition). "Participating in the research and disseminating findings gave clients a sense of agency and ownership of the project that enhanced self-confidence and feelings of empowerment."

In conclusion, creative activities at HBF:

• provided opportunities for clients to socialise and develop new relationships based on respect and mutual recognition;
• countered loneliness and allowed refugees/asylum seekers to develop a sense of belonging in a safe space;
• supported freedom of expression and the possibility of developing a new identity to counter the negative stereotype of being viewed as a refugee or asylum seeker; and
• led to sustained improvements in positive mood and self-confidence, countering anxiety, depression, and other mental health issues.

"It is recommended that other refugee/asylum seeker organisations could use the interview questions generated by the study or develop their own, following PAR guidelines, to appraise and improve migrant provision particularly in terms of upskilling peer-learning. If scaled up across the UK, programmes of creative activities for migrants could reduce pressure on health and social care services and help to address the social determinants of health inequality.....Research outputs have wider implications for policy development, for example by the United Nations Refugee Agency, WHO [World Health Organization] and other government and non-government agencies."