Healthier together. How arts on prescription can promote psychosocial wellbeing: a qualitative study | BMC Primary Care

The qualitative findings are presented as the following three themes: Social community & Connectedness; Self-efficacy; Routine & Structure.

Social community and connectedness

All the participants reported that social interactions and community had had a positive impact on them. By (re)connecting with the world around them, the participants found strength and support in relating to others who understood and shared their experiences. As a participant described: “to feel a sense of community and…and some friends…that is something I have not felt nor had for a long time” (KuR217).

Participants also described how they experience resonance with others “I found a lot of camaraderie with them [the group]…which I hadn’t yet found in my old circle of friends” (KuR205) indicating a special connection and an ability to resonate with others in the group.

For others, the social community in the group had helped break social isolation” I have been on sick leave for a long time and lost all my friends. I have one friend left (KuR217) and “breaking social isolation has been incredibly important to me” (KuR218) highlighting the importance of social engagement to prevent isolation and increase opportunity for social connections. In addition, the group -based engagement with the arts activities were considered meaningful: “I feel that I’ve done something meaningful during this period. I maybe had a bit of trouble with that before“(179 KuR).

Some participants commented on how they valued the diversity within the group. “It’s been a nice group, nice people. A very diverse collection, different ages, but the more you meet the more comfortable you get” (KuR179) and “…it’s fun with a wide age range because you get…many different references” (KuR181). Common grounds were found, despite diversity: “I felt we had a lot in common even though we were different” (KuR102). Other participants commented on being on how being in the same boat made bonding with others easier.

The group dynamics within the groups appeared to have significance and the participants noticed the fluctuations in attendance of other participants. A participant commented: “if there was someone missing you reflected on it” (KuR125). Suggesting that a level of concern for other group members was present.

The safe environment within the groups enabled positive feelings and a sense of belonging. As a participant stated: “You really feel that you are one of the group which I think felt good” (KuR125) and another commented: “I felt safe in this group. I could sort of open up” (KuR127). While some liked the group sizes: “I think it has been great that it has been a small group (KuR199), there were also disappointment about other group members’ level of commitment, as a participant expressed: “So we became three, four in the group…and one time it was only me. And I thought that was sad” (KuR189).

Many participants reported that they were continuing to stay in touch with one or more people from the group. Some groups had planned activities together after the AoP programme including going to an art museum, going for a walk, and having coffee together as well as setting up a Facebook group.

Providing a safe environment, the social community in the groups developed friendships and have fostered meaningful relations enabling a sense of belonging among the participants. This feeling of resonance with others has helped break the social isolation and encouraged social engagement.

Self-efficacy

Participants reflected on personal growth and self-discovery in terms adopting new behaviours that lead to specific actions e.g., connecting with others and their social environment” I think, I have become better at relating to others, actually” (KuR102). Others reported an ability to exert a level of control over their own motivation “For me it was really an opening…to cultivate my brain and to be stimulated by something else” (KuR111) and to find new interest: “It opens your eyes to different things you never thought you could be interested in” (KuR105). For another participant it was about the overall effect and regaining old interests: Yes, on the whole, uplifting… uplifting effect and that I was taken out of my isolation, temporarily anyway. But also,

that I have been inspired to resume my previous activities as well. Writing and…and painting (KuR 118).

The AoP-programme provided opportunity for participants to overcome challenges, and to train common undertakings. Some reported difficulties in perform everyday activities, such as using public transport and thereby increased self-reliance during the programme. As a participant stated: “I can ride the bus; I have learned to find my way around Malmö [the city] and I am not afraid to go out” (KuR132). Another participant considered different coping strategies for getting to the activities and that the AoP programme had provided opportunity to test new ways of coping and found that planning was helpful as she stated: “So, I planned. And then I could cope” (KuR157).

Some participants reported that they had initial anxieties and reluctance of participation in the programme. Anxiety is prevalent among patients with depression and often symptoms coexist [11] and it can be difficult to find strength and motivation to try something new, especially as many patients had already tried other care pathways. As stated by a patient: “It was a bit scary at first, it was. But afterwards if felt much easier and you realise more people are in the same situation or similar situations” (KuR105). Exposure to other peoples’ situations helped normalise feelings and emotions of participants’ own circumstances and experiences: “Here I have felt normal and not inhibited in any way.…yes, together with like-minded” (KuR217). Most patients mentioned the importance of being with people who had similar experiences and not needing to explain themselves.

Some participants reported that they had found self-acceptance and experienced personal growth. Through rediscovering a sense of identity and purpose, a participant states that “I feel a bit like I’m becoming human again and this is how life should be, to feel like a human-being” (KuR103). Another participant emphasised the significance of being part of something and to find ways to regain lost parts of oneself and to find joy after a long period of illness: “It is important for me to have an interest and identity outside my illness. Therefore, it has been important for me to engage in arts activities, creative activities, and hobbies that I find joyful” (KuR218). The programme provided a structured opportunity for participants to rediscover old interests and find new ones, which is vital for fostering a sense of purpose and fulfilment.

A participant expressed anxiety and sadness about the end of the programme– transition from the programme created uncertainty: “Yeah…well, it feels like that. So, I want to go back, but I don’t really want to go back to that [previous job]. But…I hope it will work out and some other opportunities will come” (KuR112). Others commented on AoP leaving an “empty space” and that they did not have follow-up appointments with their primary healthcare professional who referred them to the programme.

The positive experiences have increased coping mechanisms and self-efficacy. As stated by a participant: “The various cultural and creative activities have given me so much joy and have meant so much to me, both in terms of my self-confidence and my emotional wellbeing” (KuR218), linking arts participation to enhanced emotional coping.

By some level of self-accept and belief in a capacity to do things, feeling motivation anew and have control over own behaviour- the participants reported that they developed ways of relating to themselves, to others and to their community. But also, reluctance how they would cope after the programme not knowing if the newly found motivation and routines are so strongly embedded that they last.

Routine and structure

Many participants emphasised the importance of having routines and structures in their lives, particular to maintain mental health wellbeing and more often such routines and structures had become limited due to ill-health or isolation.

Participants commented on how the AoP programme had supported them in getting new routines, as a participant reflected: “I know that Tuesdays and Thursdays, I will go to different activities” (KuR 103). Being part of the programme meant participating in different activities every Tuesday and Thursday for ten weeks at the same time. However, for some, this new routine was experienced as struggle: “I’ve been struggling…it has been a battle every morning to get up and go there but I felt that I got energy from people and stuff like that. I felt that if I just go there, I’ll feel a bit better that day” (KuR206). However, engagement in the arts and culture activities also created a new context for the participants where it was possible to be free and have a break from circles of negative thought. As a participant stated: “The days at AoP, I’ve been able to let it go [negative thoughts] and kind of think about the here and now” (KuR125).

Some participants had multiple health-related difficulties and therefore found participating challenging, however, they also understood that overcoming such challenges would make them feel better, as expressed by a participant: “I slept so badly for a long time that I woke up five, six times because I was in pain and… but it was very positive that it also gave me some structure to my life” (KuR158). The participant expresses finding a balance between the pain (caused by being active) and the benefit of the structures that the AoP programme provided.

One participant commented how participation and following a scheduled programme provided a break from circles of negative moods– even if it was only momentarily: “I felt a little better when I was with the group but when I came home, I became…yes…worse again but I thought it was still better that I could get out of my house otherwise I wouldn’t get a break from my bad moods. It was very good for me to have something in a schedule” (KuR161). Participation in AoP was considered a positive activity and meant that the participant left the house. Behavioural activation encourages people to engage in antidepressant behaviour such as maintain social connections and involve themselves in meaningful activities [12]. However, uncertainty about the long-term effect of the programme was raised by a participant: “The days that I have been on AoP have been a bit happier and sometimes much happier. But in the long run, I don’t know, it’s hard to say…I would probably need to try eight weeks without AoP, then we will see if I can handle it” (KuR206). The participant found it difficult to imagine what their days would be like without the scheduled activities.

With the support structures of the AoP programme, participants overcame challenges and while the achievement that meant a lot to the participants it also helped break negative routines of staying home. Establishing routines and structures can significantly benefit individuals experiencing feelings of hopelessness, and social isolation, and completing small tasks within a routine fosters a sense of accomplishment and progress, thereby counteracting negative self-perceptions [13]. Routines also introduce predictability and stability, providing comfort in situations where ill-health and social isolation render the world overwhelming. This predictability helps individuals regain a sense of control over their lives, which is particularly empowering during periods of battling with ill-health. Additionally, routines facilitate the setting and achievement of small, manageable goals, creating a pathway towards larger, long-term objectives.