Deborah Hayman Ehpid 2011 Dissertation

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MA Dissertation title: Healthy Heritage: The role of heritage and culture in promoting health and wellbeing

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Deborah Hayman Ehpid 2011 Dissertation

  1. 1. 1Healthy Heritage: The role of heritage and culture in promoting health and wellbeing Deborah Hayman MA Education, Health Promotion and International Development 2011 Word Count: 22, 000 This dissertation may be made available to the general public for borrowing, photocopying or consultation without prior consent of the author.
  2. 2. 2AcknowledgmentsI would like to thank all of those who participated in the interviews and myfriends and family for their support and patience and their useful insights whilecompleting this dissertation.I would also like to thank my tutor Ian Warwick for his support and listening tome work through many half ideas until they turned into coherent sentences!
  3. 3. 3Table of ContentsAcknowledgments.............................................................................................................2Table of Contents..............................................................................................................3Abstract..............................................................................................................................5Chapter One: Background and Research Questions..........................................................6 Introduction...................................................................................................................6 Background ...................................................................................................................7Chapter Two: Literature Review.....................................................................................11 What is health? ...........................................................................................................11 What is wellbeing?......................................................................................................13 What is Health Promotion? .........................................................................................15 What is heritage? ........................................................................................................19 Intangible Heritage..................................................................................................21 Tangible Heritage/Artefacts....................................................................................21 Natural Heritage......................................................................................................21 Built Heritage..........................................................................................................22 Cultural Heritage.....................................................................................................22 Connections: what do we already know about the links between heritage, wellbeing and promoting health?.................................................................................................23 Is heritage just genetics?..........................................................................................23 Globalisation and Multiculturalism ........................................................................24 Lay Concepts of Health and Cultural Heritage.......................................................27 Intangible Heritage .................................................................................................29 Tangible Heritage/ Artefacts...................................................................................33 Natural Heritage......................................................................................................37 Built Heritage..........................................................................................................40 Cultural Heritage.....................................................................................................43Chapter Three: Methodology..........................................................................................47 Preparation...................................................................................................................48 The Study Design........................................................................................................49 Sampling......................................................................................................................50 Data Collection Methods.............................................................................................52 Analysis.......................................................................................................................54 Ethical Considerations.................................................................................................55 Limitations ..................................................................................................................56Chapter Four: Findings....................................................................................................57 Group One...................................................................................................................57 Past Experience........................................................................................................59 Present Experience..................................................................................................63 Perceived Impact.....................................................................................................66 Group Two...................................................................................................................69 Past Experience........................................................................................................70 Present Experience..................................................................................................73 Perceived Impact.....................................................................................................75 Group Three.................................................................................................................77 Past Experience........................................................................................................78
  4. 4. 4 Present Experience..................................................................................................80 Perceived Impact.....................................................................................................81 Similarities between the Groups..................................................................................83 Definitions of Health, Wellbeing and Health Promotion........................................85Chapter Five: Discussion and Implications.....................................................................87 Intangible Heritage..................................................................................................91 Tangible Heritage/Artefacts....................................................................................94 Natural Heritage......................................................................................................96 Built Heritage..........................................................................................................97 Cultural Heritage.....................................................................................................98 Implications.................................................................................................................99 Policy.......................................................................................................................99 Programming.........................................................................................................100 Further Research....................................................................................................102 Conclusion.................................................................................................................103Appendices....................................................................................................................104 Appendix One ...........................................................................................................104 Consent Letter............................................................................................................104 Appendix Two .........................................................................................................106 Types of Activities.....................................................................................................106 Appendix Three .......................................................................................................108 Definitions ................................................................................................................108References.....................................................................................................................110
  5. 5. 5AbstractThere is an increasing awareness of the importance of cultural heritage inhealth care but what of the value of heritage more generally in promoting healthand wellbeing? This dissertation focuses on how health and wellbeing might bepromoted through the use of heritage-focused programmes and activities.Through individual and group semi-structured interviews, 18 respondents wereasked about their involvement in heritage-based activities, whether theyperceived these activities had an impact on their health and wellbeing and, ifso, in what ways. Analysis of interview findings highlighted that, for theserespondents at least, involvement in heritage-based activities generally had apositive impact on their perceived health and wellbeing. This study contributesto an emerging understanding of the associations between heritage and health.
  6. 6. 6 Healthy Heritage: The role of heritage in promoting wellbeingChapter One: Background and Research QuestionsIntroductionEvery day we are surrounded by heritage, be it the buildings we pass on ourway to work, the train station we travel from, the parks, museums and gallerieswe visit for leisure or the photographs and stories we pass down through thegenerations. How do these places and artefacts make us feel? What effect dothey have on our health and wellbeing? This dissertation explores thecontribution heritage might make to our perceptions of health and whether aheritage-based approach could contribute to the promotion of health andwellbeing.We live in a multicultural, globalised world in which societies, culture and ourfinancial world have become integrated through political ideals, trade and travel.Many see this as progress towards a wealthier world with fewer barriers (Fry &Hagan, 2000). However, this plurality of cultures does not always meanequality. For some, the stages in history that have led to multiculturalism andglobalisation have meant a loss of agency as cultures have become diluted,assimilated or marginalised. Policies and programmes that do not take into
  7. 7. 7account the functionings and capabilities of an individual or community maytherefore cause more harm than good. No matter the view taken, there aredefinite health and wellbeing consequences of the importance placed on whatdifferent groups value. Questions have begun to be asked regarding socialcapital and socioeconomic impacts on our health both in the UK and in theinternational development context (Stephens, 2008; Wilkinson, 1997; Marmot,2005). But how do our cultural surroundings influence the health and wellbeingof an individual and the community in which they live? In particular, how couldthe heritage that surrounds us be effectively used in promoting wellbeing?BackgroundThe idea for this dissertation began while I worked for the Heritage Lottery Fund(HLF). Thousands of funding applications came through the office, all of whichclaimed to be important to the heritage of the area for aesthetic reasons or forthe participation, inclusion and enjoyment of the local people. Some hadspecific health-related outcomes, but often these were not made explicit. Thisgave me cause to question if every such project contributed in some way to thegeneral wellbeing of the population, at least through its perceived emotional andphysical benefits. If such heritage-based projects had a wider value to theparticipants in health terms, could this be used to inform the promotion ofhealth?Heritage in its many forms is undeniably a part of our everyday lives.
  8. 8. 8 ‘{T}he cultural industries employed close to 1.4 million persons, whichrepresented five percent of the total UK workforce at the time; revenues fromthe cultural industries was in the excess of £60Bn; they contributed £7.5Bn toexport earnings (excluding intellectual property); and value added (net ofinputs) was £25Bn, which significantly was four percent of UK GDP, and inexcess of any (traditional) manufacturing industry’ (Pratt, 2004: 4).It would seem reasonable to expect an industry of such magnitude to make asignificant impression on our health and wellbeing.Over the centuries, the movement of people between borders and around theglobe has had profound consequences on the heritage of individuals and thecountries to which they have travelled and sometimes settled. As people andtherefore aspects of their cultures move around and settle in other countries,the world becomes ever more multicultural. In fact, it has been argued that inthis ‘age of globalisation’ ‘peoples’ lives are no longer predominantly shaped bywhat is decided within sets of national borders’ (Clark in Fry & O’Hagan, 2000:79).This dissertation attempts to examine the links between heritage and our healthand wellbeing, with the purpose of establishing whether and how heritage-based activities could be used in promoting health. By exploring this area, Ihope to achieve a sense of how a broad definition of health, more specifically‘wellbeing’, might relate to the heritage of the group, community or nation, andmight provide a more holistic approach to promoting health. The researchquestions below focus on definitions of health, wellbeing, health promotion and
  9. 9. 9heritage and support an exploration of the possibilities of heritage-basedprogrammes and activities to promote health and wellbeing.The dissertation is informed through the use of three overarching researchquestions: 1. What is already known about the links between health, wellbeingand heritage? 2. What perceptions do those taking part in heritage-based activitieshold regarding the links between their own health, wellbeing and heritage? 3. What are the implications of this for promoting health andwellbeing through heritage?In the following chapter, I will explore the various definitions of health, wellbeingand heritage and contextualise the study. The Methodology used is explained inChapter Three, providing insights into how the semi-structured interviews werecarried out. Chapter Four lays out the findings of the interviews, explaining theresults both positive and negative of a heritage-based approach to promotinghealth. These findings are discussed alongside literature from the fields ofeducation, health promotion and international development in order to explorethe impact heritage-based activities and programmes might have upon healthand wellbeing. The implications of a heritage-based approach to promotinghealth and wellbeing based on the findings and discussions are explored inChapter Five.The definitions used throughout this dissertation are: health promotion as anactivity that aims to strengthen individuals’ skills and capabilities in order to
  10. 10. 10obtain better health and wellbeing. Wellbeing will be defined as a holistic termlooking at health as far more than the absence of disease. Heritage is anythingfrom the past that we value and want to keep for future generations, and, for thepurpose of this study, falls under five main categories: Intangible Heritage,Tangible Heritage/Artefacts, Natural Heritage, Built Heritage and CulturalHeritage.
  11. 11. 11Chapter Two: Literature Review ‘Everyone has the right to a standard of living adequate for the healthand wellbeing of himself and of his family, including food, clothing, housing andmedical care and necessary social services, and the right to security in theevent of unemployment, sickness, disability, widowhood, old age or other lackof livelihood in circumstances beyond his control’ (Article 25, UN Declaration ofHuman Rights, 1948; webpage)As stated above, health and wellbeing are basic human rights of everyindividual, regardless of race, religion or gender. But what is ‘health’, and whatmakes ‘wellbeing’ different? If we are all aiming for good health and wellbeing,what is it that we are trying to attain?What is health?In the West, health has tended to be viewed in negative terms as the absenceof disease, adopting the scientific medical model. The belief that the body is likea machine and so each part can be treated separately has influenced medicalthought for centuries (Naidoo & Wills, 2000). However, in recent times this viewhas been widely criticised as being too narrow, ignoring the social andenvironmental factors that contribute to health. As the Commission on SocialDeterminants of Health stated, ‘Avoidable inequalities in health arise becauseof the circumstances in which people grow, live, work, and age, and the
  12. 12. 12systems put in place to deal with illness. The conditions in which we live and dieare in turn, shaped by political, social and economic factors’ (2008: 3). Thisbeing so, is it sensible to think of health as the absence of disease or illness, orshould we look at health more holistically?Although there is still much discussion about exactly what ‘health’ means, manyof those working in health promotion would now agree that health encompassesmore than the absence of disease. Aggleton and Homans (1987) and Ewlesand Simnet (1999) prefer an approach that accounts for the Environmental 1,Societal2, Physical3, Mental4, Social5, Sexual6, Spiritual7 and Emotional8dimensions of health (Naidoo & Wills, 2000). Sen (1999) agrees with theseviews and expands further that health and wellbeing is more than just about thephysical; rather, good health and wellbeing are essential to achieving ones’ fullcapabilities. Therefore, in addition to basic needs such as nutrition, shelter andadequate sanitation facilities, human beings need optimal psychologicalconditions as well, such as confidence, happiness and the political freedom tomake choices. The arguments put forward by Sen fall under the more objectivemeasures of health and wellbeing which argues that people may adapt to thecircumstances in which they find themselves and so self-evaluation in terms ofsatisfaction and happiness will become distorted. Measuring functionings andcapabilities has the advantage of helping focus policy makers’ attention topeople’s primary needs. This has been the inspiration for lists of indictors such1 physical environment in which we live2 how society is structured, infrastructure3 absence of illness4 feeling able to cope, positive sense of purpose5 having support, friends, family6 ability to express one’s sexuality7 ability to put religion, beliefs, principles into practice8 ability to express feelings
  13. 13. 13as the Human Development Index and the Index of Social Health (NIACE,2009; Unterhalter, 2008).What is wellbeing?A definition that has become the most definitive, wide-ranging take on health isthat of the WHO (19489): ‘Health is a state of complete physical, mental andsocial wellbeing and not merely the absence of disease or infirmity’. Health andwellbeing appear to be interlinked but what is wellbeing and what makes itdifferent from health?The UK Department for Environment, Food and Rural Affairs (DEFRA)describes wellbeing as ‘a broad concept with many varying definitions. … a positive physical,social and mental state; it is not just the absence of pain, discomfort andincapacity. It requires that basic needs are met, that individuals have a sense ofpurpose, that they feel able to achieve important personal goals and participatein society. It is enhanced by conditions that include supportive personalrelationships, strong and inclusive communities, good health, financial andpersonal security, rewarding employment, and a healthy and attractiveenvironment. Wellbeing cannot be fully measured by a single indicator.Numerous factors influence individual wellbeing. It is only possible to identifyand measure some of them’ (2011: webpage).9 Preamble to the Constitution of the World Health Organization as adopted by the International HealthConference, New York, 19 June - 22 July 1946; signed on 22 July 1946 by the representatives of 61States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7April 1948. The definition has not been amended since 1948
  14. 14. 14UNICEF in their 2007 report ‘Child Poverty in Perspective’ listed six dimensionsof child wellbeing: Material Wellbeing, Health and Safety, EducationalWellbeing, Family and Peer Relationships, Behaviours and Risks, andSubjective Wellbeing. This more subjective approach to health would take intoaccount how people evaluate their own lives.Perhaps this is where the distinction lies between health and wellbeing. Howpeople measure their own feelings of pleasure and displeasure, happiness andsadness, satisfaction and dissatisfaction may indicate how society is structuredand how this affects the individual in a way that has an impact on wellbeing.While, perhaps harder to measure, these indicators have been found tocorrelate with actual behavior and key physiological variables (NIACE, 2009)and can be found in many countries definitions of health. For example, Canadadefines mental health as ‘the capacity of the individual, the group and the environment to interactwith one another in ways to promote subjective wellbeing, the optimaldevelopment and use of mental abilities (cognitive, affective and relational), theachievement of individual and collective goals consistent with justice and theattainment and preservation of conditions of fundamental equality’ (CanadianDepartment of National Health and Welfare, 1988, found in Sainsbury, 2000:82),This definition is a further example of the importance of how we evaluate ourown wellbeing.
  15. 15. 15Wellbeing includes health but encompasses more than the absence of disease,as it takes into account the various dimensions of health and the social, political,economic and environmental factors that often cause health inequalities as wellas how people view their own lives. Wellbeing could be seen as a social andcultural construct (Eraut & Whiting, 2008: 4) as well as having ‘positive andsustainable characteristics which enable individuals and organisations to thriveand flourish’ (Institute of Wellbeing, 2006-2008: webpage).We have now established that the term ‘health’ encompasses far more than theabsence of disease, including emotional, spiritual, social and environmentalfactors but is still measured objectively. Meanwhile, ‘wellbeing’ encompasses allof these ideas of health as well as people’s own perceptions of their health andtheir values, agency and behaviour. Wellbeing could be described as asubjective and holistic expression of functionings, capabilities and agency.What is Health Promotion?There are a number of ways of defining health promotion. Health Promotion and‘public health’ activities have taken place in many forms over the centuries. Inthe UK, the 19th century saw a huge rise in top-down health promotion throughlegislation and other government activities in response to health crises such ascholera outbreaks and poor sanitation (Naidoo & Wills, 2000). Approaches haveranged widely from exploring individual behaviour change to community actionand capacity building to policy change and inter-sectoral working (Nutbeam &Harris, 2004). Programmes have targeted individual behaviour throughinformation and mass media campaigns aimed at changing the behaviour of
  16. 16. 16individuals and groups. More recently, participatory techniques have begun togather greater momentum, particularly in the field of international development(Manandhar et al., 2008). However, before the 1978 Alma Ata Declaration onPrimary Health, very little about international cooperation on health promotionhad been formalised. The Alma Ata Declaration pointed the internationalcommunity towards partnership working and for governments to work at alllevels to promote health. At the international level, the World HealthOrganisation (WHO) has taken a leading role in health promotion. In 1984, theWHO regional Offices for Europe described health promotion as the ‘process ofenabling people to increase control over, and to improve, their health. {Moving}beyond a focus on individual behaviour towards a wide range of social andenvironmental interventions’.This concept was also captured by the Ottawa Charter for Health Promotion,1986, which saw a real move towards recognising the complex interplay offactors that contribute to health by providing a more holistic description of healthpromotion: ‘Health promotion is the process of enabling people to increase controlover, and to improve, their health. To reach a state of complete physical, mentaland social wellbeing, an individual or group must be able to identify and torealise aspirations, to satisfy needs, and to change or cope with theenvironment. Health is, therefore, seen as a resource for everyday life, not theobjective of living. Health is a positive concept emphasising social and personalresources, as well as physical capacities. Therefore, health promotion is not
  17. 17. 17just the responsibility of the health sector, but goes beyond healthy life-styles towellbeing’ (p1).The Jakarta Declaration on Leading Health Promotion into the 21st Century(1997) was signed. This Declaration reiterated what had been set out in theOttawa Charter (1986).It was not until 2005 that the Bangkok Charter for Health Promotion in aGlobalised World identified actions and commitments for the internationalcommunity to make towards health promotion. It hoped to ‘[build] upon thevalues, principles and action strategies’ (p1) of these foundations. However,many feel that the Bangkok Charter was rather a change in discourse fromOttawa. Mittlemark (2007) notes that Bangkok focuses on globalisation, macro-level factors and policy, while Ottawa focuses more on community and thesocio-ecological approach. As Mohindra (2007) states ‘[t]he need for macro-level, broad-based interventions is greatest among developing countries, wherethe burden of ill health is considerably higher than among industrialised nations’(p163). The Bangkok Charter provides a sturdy base on which to build macro-level frameworks, as it emphasises that governments and politicians at alllevels, civil society, the private sector, international organisations and the publichealth community are all critical to health promotion. These Charters takentogether show how complex health promotion is and prove the need forappropriate interventions at all levels of society, from the individual to thecommunity, to the national Government to the international level. At the nationallevel, each country has its own health promotion entities and resources. Healthpromotion has changed and evolved with the political ideologies and distribution
  18. 18. 18of power of the time. In the UK, this has meant the creation of the WelfareState, in particular the National Health Service (NHS), which has often beenseen as the best place for health promotion to take place. However, over timepreventative measures and health education have given way to the emphasisbeing on policies to reduce social inequalities in order to allow people to makehealthier choices (DoH, 2008). This has meant health promotion is no longersettled in one sphere but across government departments and the voluntarysector. Current legislation such as the Localism Bill (2010) and the Health andSocial Care Bill (2011) alongside the Personalisation agenda will further changehow and where health promotion takes place.What these international and national policies and bodies have in common isthe notion that health promotion as a shared responsibility: that action must betaken across all levels to enable people to take control over their own health.Therefore, health promotion is not something that can be forced upon or doneto an individual or a group of people. As Sen (1999) suggests strengtheningskills and capabilities so that individuals have the opportunities and ability totake action is what health promotion should aim for. It is often thought thathealth promotion must be based on a judgement of when an intervention isneeded to promote a particular area of health such as awareness of HIV/AIDSor malaria (Naidoo & Wills, 2000). However, health promotion is not simply ananswer to one particular health issue; rather it should be a continuous process,embedded in all that we do, from the classroom and workplaces, to where wesocialise and the activities we take part in.
  19. 19. 19Therefore, health promotion in its many forms and at all levels is for the purposeof aiding individuals, communities and societies in increasing their abilities toattain better health and wellbeing in order to live a fuller life. But how could aheritage-based approach help promote good health and wellbeing? And what isheritage?What is heritage?Just as health promotion, health and wellbeing are debated issues, so too isheritage. Heritage can mean many things to many people and influenceseverything we do and everywhere we go. It is a term that encompasses a hugerange of things from the past that we value and want to keep for futuregenerations, both tangible and intangible, yet is a concept that can feel veryremote from our everyday lives.The Heritage Lottery Fund website (2009) lists the following as examples ofheritage: • People’s memories and experiences10 ; • Histories of people and communities11; • Languages and dialects; • Cultural traditions such as stories, festivals, crafts, music, dance and costumes; • Histories of places and events; • Historic buildings and streets; • Archaeological sites;10 often recorded as ‘oral history’ or spoken history11 including people who have migrated to the UK
  20. 20. 20 • Collections of objects, books or documents in museums, libraries or archives; • Natural and designed landscapes and gardens; • Wildlife, including special habitats and species; and • Places and objects linked to our industrial, maritime and transport history.All of the above have an impact on our lives and how we connect to people andplaces, whether negative or positive, and therefore contribute to our overallhealth and wellbeing. Although there is no absolute definition of heritage, for thepurposes of this dissertation, I will concentrate on what I consider to be the fivemain heritage categories which encapsulate all of the areas described by HLF(some of which will appear in more than one category): Intangible Heritage,Tangible Heritage/Artefacts, Natural Heritage, Built Heritage and CulturalHeritage.These definitions are informed by professional thought as well as lay conceptsof heritage, such as those described by the interview participants. ‘Heritage is a set of values honoured/respected by a group of people,passed on from one generation to another, such as cultural traditions, buildingssuch as Tombs among others.’ (Male, user, Group One)And
  21. 21. 21 ‘Heritage is the full range of our inherited traditions, monuments, objects,and culture. Most important, it is the range of contemporary activities,meanings, and behaviours that we draw from them.’ (Female, Group Three)Intangible HeritageIntangible heritage is non-material heritage. Oral histories of people’sexperiences, spoken word, languages and dialects fall under this category. Itmay also include folk stories and legends that have been passed down throughthe generations but not written down, as well as skills such as dances orhunting that we learn from elders. Faith and beliefs may also fall under thiscategory.Tangible Heritage/ArtefactsTangible Heritage/Artefacts concerns material heritage, such as museumexhibitions, photographs, paintings, books, archives, and archaeological sites. Itcan also include family heirlooms that have been passed down through thegenerations.Natural HeritageNatural heritage includes areas of natural space such as parks, reservoirs,designed and natural landscapes as well as wildlife, flora and fauna. Gardensand allotments may also be included under this category.
  22. 22. 22Built HeritageBuilt heritage includes historic places, buildings and space as well as placesand objects linked to our industrial, maritime and transport history. Thiscategory may also include urban or town regeneration projects.Cultural HeritageCultural heritage includes cultural traditions such as art, stories, festivals, crafts,music, dance and costumes as well as beliefs, religion and languages anddialect. It may also include cultural practices such as rituals, theatre, sports, artand other entertainment.All of these categories will contribute to the histories of peoples andcommunities and of place. Heritage does not necessarily have a monetaryvalue; the value is intrinsic and may change from person to person. A familyheirloom for instance may have no monetary value and no value to anybodyother than the family to whom it belongs but can still have a heritage value.I will explore throughout this dissertation whether there is a perceivedassociation between health, wellbeing and heritage and the possibilities for aheritage-based approach to promoting health and wellbeing. The next sectionlooks at what is already known about the links between heritage, wellbeing andhealth promotion.
  23. 23. 23Connections: what do we already know about the links betweenheritage, wellbeing and promoting health?Is heritage just genetics?The link between wellbeing and heritage most often cited in the literaturefocuses on the medical heritage of certain groups such as hereditary illnessesor for example the prevalence of Lupus in women of African descent. Althoughthere is little scientific evidence to support it, genetic predispositions towardsmorbidity and mortality are traditionally seen as being the reason for racial orethnic differences in health outcomes (Finch et al., 2001).We may all have some genetic predispositions, but our wellbeing is more thansimply the absence of illness or disease. Predispositions can become actualillness or not depending on the circumstances a person is put under. Forexample, Finch et al., (2001) state that higher levels of stress, anxiety,depression, paranoia and even psychosis have been linked to ethnicdiscrimination. A person may be predisposed to depression but in onecircumstance will not suffer from depression, yet in circumstances under whichhe/she is ethnically discriminated against, depression will develop.Epidemology is used to help us measure aspects of health such asenvironmental and socio-economic indicators, which may indicate the likelihoodof predispositions turning into illness. Palacios and Portillo (2009) found that tounderstand health, not only should culture, lifestyle and genetics be taken intoaccount but also ‘how intersections of poverty, geography, discrimination and
  24. 24. 24racism interplay individually and collectively on health’ (p15). Similarly, theWHO have also found that social determinants of health such as where aperson is born, grows, lives, works and ages are mostly responsible for healthinequalities. A persons’ circumstances can in fact be shaped by the distributionof money, power and resources at global, national and local levels (WHO,2008).This clearly shows that the link between heritage and wellbeing is about farmore than genetic heritage. But, in what other ways does heritage affect ourwellbeing?Globalisation and MulticulturalismThe world is currently organised into approximately 200 sovereign states, eachone ‘embodying a separate normative tradition shaped by the vagaries of itshistory and its political, ethnic, religious and other traditions’ (Preece, 2005: 4).Within these states are hundreds of group, community and individual identities,as well as the intricate web of traditions and cultures from migrant communities(Petchesky, 2003). In Europe alone, there are hundreds of languages andtraditions and many ways to view even our shared history. In the America’s forexample, the Native American population has contained between 300 and 600separate tribes, each with their own as well as shared cultures, beliefs, andexperiences and take on history (Native American Education Centre, 2005).Canada claims to have over 200 different ethnic groups (Centre for Addictionand Mental Health Policy, 2007); and Africa contains hundreds of differentethnic groups with their own dialects and cultures.
  25. 25. 25Since the 1960s, the term ‘multiculturalism’ has been used to describe theacceptance and promotion of multiple cultures within a society (McLean &McMillan, 2003). It is the view that all cultures are equal. However, for manygroups and communities around the world, multiculturalism and globalisationhave meant a loss of freedoms and of functionings. Colonialism, the slavetrade, westernisation and other political movements have forced many culturesand religions to change or disappear. While increased trade, travel andmigration in modern times have continued to spread cultures around the world,increased globalisation has also exacerbated of historical inequities and awidening gap between the rich and poor (UN, 2001; Mittlemark, 2007).Inequalities are often emphasised through an individual or group’s functionings,capabilities and agency, or lack thereof. The capability approach seesfunctionings as the activities or states of being that we value and thereforecontribute to our wellbeing. If policies focus on single functionings theninequality is more likely. However, by focusing on capabilities or a combinationof functionings, a person is more likely to have the agency to pursue what theyvalue (Human Development and Capability Association, 2005; Sugden, 1995).Most importantly for wellbeing, the capability approach emphasises freedom topursue what we value. This emphasis on participation and functionings meansthat many capabilities must be culturally specific. They will depend upon theknowledge, history and values that shape a society (Alkire, 2005; Robeyns,2005).According to Rawls (1993), people’s desire for social belonging is an essentialhuman characteristic and a prerequisite for human personalities to flourish. It is
  26. 26. 26therefore important in a multicultural society to allow individuals to findcommunities12 where they feel comfortable and can feel a sense of belonging.Multiculturalism should mean living in a society made up of many differentcultures that are linked by a common cultural thread. For instance, the Nigeriandiaspora community in London will have an identity based upon their Nigerianheritage but will have a common link of British culture with many other groups inBritain. However, there is a careful balance between a multicultural society andone in which communities are isolated and marginalised or assimilated. In fact,some such as Trevor Phillips, Chairman of the Commission for Racial Equality,have called for the term multiculturalism to be scrapped, citing that the termactually encouraged separatism (Baldwin & Rozenberg, 2004). For many, thecommon view of multiculturalism is rather negative seeing communities as livingside by side without interacting or groups of people with similar identitiesexcluding others, eventually leading to tensions or conflict (Levy, 2000).The UN Declaration of Human Rights (1948) states that ‘Everyone has the rightto freely participate in the cultural life of the community, to enjoy the arts and toshare in scientific advancement and its benefits (Article 27) as well as havingthe right to health as described in Article 25. Not only should everyone have theright to enjoy all these aspects of life but they could also be used to promoteinclusion and therefore a better sense of wellbeing. A heritage-based approachmay be able to do just this; celebrating the heritage of an area or communityand all of the different groups who live there can therefore be seen as a way ofencouraging an inclusive and participatory multicultural society.12 A community does not have to be a geographical area. I use the term to mean any group of peoplesharing a similar characteristic over which they feel a tie to each other. This could be a diaspora, a sportsteam, a geographical area, an internet based group that talks about a certain subject, a single mothersgroup etc.
  27. 27. 27The heritage of an individual, group or society is also important whenunderstanding why they think about health and wellbeing in the way they do.Lay Concepts of Health and Cultural HeritageLay concepts of wellbeing are based upon the history and knowledge of thesociety in which we live, work and grow. These rich tapestries of humanexperience and heritage create different lay concepts of health and wellbeing,all of which are equally valid when promoting health. A heritage-basedapproach should enable these cultural beliefs to be intricately bound with theprevention methods. Even when a cultural belief leads to misunderstandingabout a health issue, surely there is still value in understanding where it camefrom in order to adjust it in a culturally sensitive way.The WHO definition of health and wellbeing (1948) may be the most used todaybut it still provides health promotion with some difficulties over conceptualclarity, particularly concerning wellbeing. As we are each influenced by ourcultural, professional or societal context, we tend to view health and wellbeingissues from the narrow confines of our own sphere, hence different countriesand different groups within countries will view health and wellbeing in differentways. This causes problems when creating appropriate public healthprogrammes. For example, ‘ in the Western world the Enlightenment in the 19 thCentury brought with it a change in how we viewed the world; traditionalreligious belief gave way to more scientific thought, rational, free thought andformal organisation replaced ideas of clan, race and kingdom’ (Chabbot, 2003:6).
  28. 28. 28However, for others this meant colonisation and a very different history.Understanding these heritages helps us to understand the wellbeing issuespeople face today.It is reported that the indigenous Maori population of New Zealand see healthas four dimensions of life; the spiritual, the intellectual, the physical and theemotional, all of which are in unity with the environment which are then reflectedin the Maori culture through song, custom, subsistence, approaches to healing,birthing and rituals associated with death (Durie, 2004). Similarly the AustralianAboriginals define health as ‘not just the physical wellbeing of an individualbut...the social, emotional and cultural wellbeing of the whole community inwhich each individual is able to achieve their full potential as a human beingthereby bringing about the total wellbeing of their community’ (NationalAboriginal Community Controlled Health Organisation, 1997 found in Sainsbury,2000: 82).Indigenous views on health and wellbeing and their intrinsic relationship with thenatural and cultural heritage are now beginning to be accepted internationally.These definitions are important as they show a long history of holisticapproaches to health and wellbeing as well as strong connections between allfive of the heritage categories. They place the responsibility of one’s healthupon the society as a whole as well as the individual and the environment.Respect for each aspect of life brings with it better wellbeing, therefore effectivehealth promotion does not always lie in the obvious areas such as the healthsector alone.
  29. 29. 29What is common sense in one culture may not be in another and lay conceptsof health will be acquired through various experiences within society solutionstherefore must also be found in various aspects of that society, as well as beingbased upon medical and scientific knowledge. The ways in which heritage canbe presented and used can provide a strong platform on which to base this mixof the scientific and lay concepts of health and wellbeing. This can be seenthrough the five types of heritage:Intangible HeritageIntangible heritage can also help explain the reasons why we believe in certainvalues and hold certain perceptions and knowledge. Some long-heldperceptions can be extremely damaging such as the belief held by many inSouth Africa that having unprotected intercourse with a virgin girl would cure orprevent HIV/AIDS. This has caused a high number of young girls to be forcedinto sexual relations with men who often carried the virus (Cameron; 2005). Thissort of misinformation, which can be passed down through the generations asfact, is a negative consequence of intangible heritage.There are some who may use intangible and other heritage as a way to inspirefear and misconceptions, especially damaging notions of ‘the other’. However,by looking deeper into such myths we can often find reasons behind them andways to help people reinterpret ‘knowledge’. More often than not, traditionalknowledge can help inform and aid understanding. In fact, there is a danger indisregarding and avoiding notions of otherness (Said, 1995). It is perhaps better
  30. 30. 30to try to understand them and critically asses these notions in order toovercome them.Over 80% of the world’s population depend upon traditional medical knowledgefor their primary care (Ross; 2007). However, traditional knowledge has in manycases been lost, especially in Britain, where according to Dr Susan Antrobus ofTees Valley Biodiversity Partnership, ‘we have lost a vast amount of our folk knowledge and plant identificationskills....The resurgence of interest has gone back to pre-First World War printedmaterial. The only thing that I find older rural people remembering is usingrosehips in the war, eating nettles and hawthorn leaves, eating clover flowersas sweets, whereas in the past we used a great deal of herbal remedies, whichis documented, although not well, as these would have been mainlyadministered by wise woman and midwifes who were often illiterate’ (Frompreparatory discussions with Dr Susan Antrobus, September 2010)Dr Antrobus believes this is what often happens when the responsibility forsomething is handed entirely over to professionals. Before the NHS peoplemanaged minor ailments themselves using knowledge passed down throughthe generations. Applying these herbal practices meant people took decisionson what to take and when they were treated. With the emergence of the NHS,we handed over the responsibility for our health to health professionals andsubsequently lost confidence in treating ourselves and our families for minorailments.
  31. 31. 31Although ‘old wives tales’ have been responsible for ineffective remedies, thereasons why these came about are interesting in themselves. It may be that anindividual’s endorsement of certain heritage values could influence health fears,which in turn may affect the performance of preventative behaviours orencourage people to try ineffective remedies. Theories such as Diffusion ofInnovations (Nutbeam & Harris, 2004) that rely on messages being picked upby some and then diffused to others do not just apply to good ideas. Healthpromotion should aim to use such theories to dispel myths about traditionalremedies, for instance, and pass on the very real benefits of traditionalmedicine.Although there may be some negative perceptions of the31professionalizationof health, ‘health promotion has thrived at community level even when nationalpolicy environment has been less supportive’ (Mittlemark, 2007: 101). Theheritage-based approach to promoting health could contribute to a positiverelationship between professional and lay concepts. For example, in SouthAfrica in 2004, the traditional Health Practitioners Bill was passed to recognisethe important role of traditional healers in South African culture and medicine.The Bill set out ethical norms and standards which hoped to regulate traditionalhealers and their practices while allowing them to continue to treat people withtraditional methods (Ross; 2007). This Bill shows the importance of keepingtraditional medical practices alive as well as benefits they present particularly toindigenous populations.Heritage-based projects and activities could be a participatory and informativeway of passing on these traditional practices as well as influencing peoples’
  32. 32. 32wellbeing through social interaction and learning. The interview findings point toa level of empowerment found in being able to have control over treatmentwithout necessarily visiting the doctor. This may also be where intangibleheritage can combine with natural heritage to create projects in line with theecosystem approach put forward by Forget and Lebel (2001). They state that‘the ecosystem approach draws on science and technology to explain thecauses and effects that harm ecosystems and public health, and especially thelinkages between them’ (p4)As stated by UNESCO, the cultural importance of intangible heritage is not theonly factor to take into account. Our health and wellbeing are affected by thesocial, economic and political climate; therefore, the impact of heritage on ourhealth and wellbeing can be seen in the socioeconomic value of the wealth ofknowledge and skills passed down through the generations. Furthermore,intangible heritage is also living heritage. Celebrations such as the Mexican Dayof the Dead that are important culturally are also essential to the tourist industryand therefore the economic wealth of a community. This link between heritageand economic development may help to break down nationalist barriers whilepreserving important aspects of the past for future generations to learn from(Scher, 2011).Such celebrations and rituals are not just economically valuable but also help toencourage community cohesion and a sense of identity, both of which areimportant to our wellbeing, group and individual identity and aid our confidenceand ability to express ourselves. However, intangible heritage will also influenceour perceptions of others. Discrimination and racism often come from a lack ofunderstanding about the cultural practices of another group or individual. The
  33. 33. 33barriers such discrimination creates impact upon all aspects of life for thosebeing discriminated against, which in turn has a negative impact on theirwellbeing.Projects that aim to celebrate the intangible history of a community or area mayhelp instil a sense of cultural pride while enabling others who may not share thesame culture to participate and learn. This might spread understanding andinclusion, which are essential to wellbeing, and might also break down barriersput up through false perceptions. Of course, misconceptions and misinformationcan be spread as well, but a heritage-based approach would aim to explain thereasons behind such information and re-inform with ‘correct’ knowledge.Tangible Heritage/ ArtefactsThe way we perceive and interpret heritage may be just as important to ourwellbeing as the way we are perceived. Museum exhibitions are probably thebest known source of tangible heritage/artefacts, but how these artefacts aredisplayed and interpreted can create certain perceptions, some of which may bedamaging to a group’s wellbeing. This has become more evident in recent yearsas indigenous peoples’ voices begin to be listened to and contribute to howheritage is defined and displayed. Links have been established between thisnew voice in heritage and increased indigenous wellbeing as they ‘seek torestore cultural values and identity and renew spiritual dimensions of theircultures’ (Simpson, 2009: 122). Museums now understand that heritage is notjust about the preservation of objects from the past but also about how theseobjects can be re-socialised. In some cases this has meant returning objects to
  34. 34. 34their place of origin where the tangible heritage has an intangible meaning,perhaps through ceremonies and rituals (Simpson, 2009).Museums are just one example of tangible heritage being used to inform andeducate. However, artefacts have often been displayed in inaccessible waysand museums are now beginning to realise the need for inclusivity throughchanging the way they display artefacts, how they advertise and how specialexhibitions are run. For example, Birmingham Museum and Art Gallery ran aproject called Hair: Community Stories from Birmingham. This exhibition wasfree and included information and artefacts alongside hair related workshopsand talks, which explored the links between hair and cultural identity in the cityover the past 50 years. Tangible heritage was brought alive through the storiesof people living in Birmingham. Intangible heritage both living and from the pastwas also used throughout the workshops and talks and in the exhibition itself.The innovative methods used helped create an interactive, informative andinclusive exhibition that brought in new visitors to the museum and providedvisitors with news skills and confidence.They also developed an exhibition in the Community Gallery that addressedmental health issues and have since developed further work including an AsianWomen’s textile group to tackle mental health distress in the Asian communityand an Ability Plus training programme for people with disabilities. TheMuseum’s Audience Development Strategy 2010-13 described a need tocontribute to wellbeing by ‘developing inspiring audience developmentprogrammes that support a range of social, intellectual, emotional and spiritualneeds. {And} Developing programmes that encourage healthy living.’ Of course,
  35. 35. 35not all change will be so successful. Successful change requires money andknowledgeable staff as well as displays that create a ‘continuity betweencreation and heritage… {and} enable various publics, notably local communitiesand disadvantaged groups, to rediscover their roots and approach othercultures’ (UNESCO, 2011).As more people live longer there are many challenges to be faced by societyincluding ‘social isolation, increasing physical frailty, declining mental healthand a decline in peoples’ ability to access services and programmes’ (IDeA,2010: 2). Furthermore, participation in cultural or heritage activities could be aneffective way for older people to maintain their independence (HELM, 2006).Tangible heritage such as museum displays, art, sculptures, photographs andother artefacts can be excellent ways of engaging older people. Organisedtransport for museum visits and heritage-based groups could encourageincreased levels of physical activity, mental stimulation and social inclusion.Being able to move around and visit new places can have a positive impact onwellbeing but tangible heritage projects do not always have to rely on takingpeople to the artefacts. ‘Hospitals and other care settings that pay close attention to the overallphysical environment for patients can achieve real improvements in the healthof patients. Access and participation in the arts are an essential part of oureveryday wellbeing and quality of life’ (Speech by Secretary of State for Health,2008).
  36. 36. 36Heritage-based projects and activities may be a good way to use peereducation and provide positive role models (Turner & Shepherd, 1999). Peereducators in a heritage-based setting can help reinforce behaviours particularlyin young people, who may be more willing to get involved in heritage-basedprojects if they see other young people taking leading roles in the activity.Furthermore, the skills gained by being a peer educator could increaseemployment opportunities (UNICEF, 2004).There is also potential for concepts to be reinforced and for participants to feelempowered through heritage-based projects. One such project was ‘There BeMonsters’ which was inspired by the Map and Atlas collection within TheNational Archives. Sarah Griffiths, a project leader explained that the projectused expert conservators, map specialists and artists, alongside participantsfrom an outreach programme to ‘use devices and imaginary creatures inscribedon some of the oldest maps to inspire adults with experience of mental illhealth. They would create a sculpture that was to be placed within the groundsof The National Archives’ (From preparatory discussions with Sarah Griffiths;2010).The participants were from Workshop and Company, which is an organisationthat forms part of the Central and North West London Mental Health Trust. Theorganisation found throughout the project that participant self-esteem andconfidence grew while the profile and reputation of the organisation was greatlyimproved. The National Archives staff also found that the project helped themovercome their own preconceptions and prejudices about mental health.
  37. 37. 37Natural HeritageIn 2011, the Government White Paper ‘The Natural Choice: securing the valueof nature’ stated that ‘over 500 scientists from around the world have nowdeveloped a tool by which we can assess more accurately the value of thenatural world around us. The National Ecosystem Assessment has given us theevidence to inform our decisions’ (p2)The National Ecosystem Assessment put the value of living close to a greenspace at £300 per person per year in savings to the NHS. This is the first time amonetary value has been put on the significance of green space to our healthand wellbeing. Although, previous studies have shown that contact with naturalheritage including plants and animals has ‘significant positive psychological andphysiological effects on human health and wellbeing’ and children in particular‘function better cognitively and emotionally in green environments’ (Maller &Townsend, 2006: 1).The research carried out by Maller and Townsend (2006) on the impact ofhands-on contact with nature on children’s health and wellbeing recommendednature-based activities in schools and lessons on sustainability. The basis forthis was that by identifying ways to improve wellbeing from a young age,children ‘…would be more likely to reach their full potential both academic andpersonal...’ (p2). A report by the Royal Society for the Protection of Birds(RSPB; 2010) added to this by stating that spending time in natural space couldbe instrumental in the ‘development of a positive self-image, confidence in onesabilities and experience of dealing with uncertainty {which} can be important inhelping young people face the wider world and develop enhanced social skills’(Ward et al., 2006 in RSPB, 2010: 4).
  38. 38. 38In fact, Drurie (2004) suggests that the alienation of people from theirenvironment can be closely linked to the host of health problems that plaguemany indigenous populations. This is not just a phenomena experienced byindigenous peoples. It has been found that a lack of natural heritage in urbancommunities can contribute to higher rates of violence and crime, less socialinteraction and a lower level of community integration and support (Spedding,2008; Bjork et al., 2008).Parkes and Horwitz (2009) believe that ecosystems are an intuitive vehicle forexplaining and promoting health and wellbeing and that the ‘failure to embedhealthy settings within ecosystems is also a missed opportunity to enable moreintegrated approaches to promoting the commonalities between healthpromotion and sustainable development’ (Dorris, 1999 in Parkes & Horwitz,2009: 95).They use water as an example of an ecosystem, which is highly meaningful toall human beings, has fundamental features that can be understood by all andhas huge importance to security, climate change and many other aspects ofpolitical, economic and social life. The fact that it can also be geographicallyplaced allows for participation among communities including indigenous peopleand place-based cultures. Ecosystems provide ‘tangible contexts within whichto fulfil overlapping objectives across fields with a preventative and pro-activeorientation’ (Parkes & Horwitz, 2009: 100)
  39. 39. 39Of course, there are also many gaps in research that must be explored in orderto improve the accessibility of natural heritage for all. For instance, the impact ofbad experiences while outdoors or participating in a heritage activity maynegatively impact wellbeing. At the local government level better planning,design and management of natural spaces can help keep them accessible, safeand attractive. The Countryside Recreation Network recommended that‘planners and developers should take green space into account especially aspart of economic regeneration strategies in both rural and urban economicallydepressed areas’ (Pretty, 2005: 6).Forget and Lebel (2001) explain their ecosystem approach in similar terms.They proffer that the development of nations is essential to human wellbeing butinappropriate development can have dire consequences on the environmentthrough over consumption of resources and degradation of ecosystems. Inorder to maintain human health and wellbeing, it is essential that theenvironment and our natural heritage be maintained. This approach takes theemphasis away from the individual as it seeks to ‘strengthen environmentalsupports within the broader community that are conducive to personal andcollective wellbeing’ (Stokols, 1996: 282). The UNCED Rio Declaration onEnvironment and Development (1992) put many of these sentiments into theinternational arena. Three particularly pertinent Principles found in thisDeclaration are: Principle 1- ‘Human beings are at the centre of concerns for sustainabledevelopment. They are entitled to a healthy and productive life in harmony withnature’;
  40. 40. 40 Principle 4 – ‘In order to achieve sustainable development,environmental protection shall constitute an integral part of the developmentprocess and cannot be considered in isolation from it’; and Principle 22 – ‘Indigenous people and their communities and other localcommunities have a vital role in environmental management and developmentbecause of their knowledge and traditional practices. States should recogniseand duly support their identity, culture and interests and enable their effectiveparticipation in the achievement of sustainable development’.There are many ways in which natural heritage activities can be used topromote health and wellbeing in a more individualistic way, such asencouraging people to use green spaces for exercise. However, naturalheritage activities can also be used effectively in policy and planning to ensurethe sustainability of natural heritage as well as improving the population’swellbeing (Barton et al., 2009; Bjork et al., 2008). This can only be achieved,however, by taking the emphasis away from individual behaviour change andensuring high levels of community participation.Built HeritageResearch has shown that the many health inequalities are produced by the waythe area we live in is built and designed and how much natural heritage can beeasily accessed. The unequal distribution of quality health care, schools, leisurefacilities and places of work as well as the condition of housing, communities,towns and cities are all described by WHO (2008) as being contributing factorsto health inequalities.
  41. 41. 41A Task Group set up to look into health inequalities in England (2009) found fivemain themes of health inequalities: Open and green spaces; Housingconditions, fuel poverty and inequality; Safety and security on the streets, anti-social behaviour; Density, noise, traffic (urban stress); and Public health(including violent incidents). It is clear from this that the way in which a town orcity is designed, the number of people using the same space and the quality ofservices available have an impact on people’s wellbeing.Built heritage can be historic buildings and towns that inspire and createbeautiful places to visit. It can also be about heritage-led regeneration of anarea that improves the area for all and impacts upon the wellbeing of itsresidents. A report on the Role of Historic Buildings in Urban Regenerationpresented to the House of Commons Select Committee (2004) stated that ‘Historic Buildings provide a foundation for the regeneration of many ofour towns and cities. Regenerating these buildings can reinforce a sense ofcommunity, make an important contribution to the local economy and act as acatalyst for improvements to the wider area. They should not be retained asartefacts, relics of a bygone age. New uses should be allowed in the buildingsand sensitive adaptions facilitated, when the reuse of an historic building is nolonger relevant or viable’ (p3).It has been noted that heritage-led regeneration can help to generate higherlevels of participation in communities. During landscape and townscapeheritage initiatives, HLF (2004) research found that because these projects
  42. 42. 42were long-term and concerned the built and natural environment of an area,they attracted a higher level of participation from ‘newcomers and longer termresidents’. In fact it found that ‘86% of respondents noted participation frompeople who “do not normally join in”’ (p4). The reasons for this may be thatpeople hold strong views about what they want their area to look like and how itmakes them feel.In areas where crime levels are higher, heritage projects that look to make useof derelict or empty buildings can help reduce vandalism and other anti-socialbehaviours that make residents feel unsafe. The knock on effect of this isimproved community pride and identity. Furthermore, participating in suchprojects promotes inclusion as well as new skills, which can have a beneficialimpact on our wellbeing through increased confidence and capabilities, whileactive participation such as volunteering can be beneficial for our physicalhealth (AHF, 2008).However, change can be stressful for many, especially for those who have livedin an area for a long time. This may be why there is often such opposition toregeneration projects. In these instances, heritage-led regeneration projectsmay be able to lessen the stress of the situation by encouraging participation,continuity and improving local identity (AHF, 2008). Further research into thisarea would be beneficial to health promotion, regeneration projects and townplanners.
  43. 43. 43Cultural HeritageThe different views of a culturally diverse area and the way health messagesare communicated will influence how messages get through. Health messagesmust be adjusted to suit the intended audience by incorporating their culturalheritage, language and ethnicity (Canadian Centre for Addiction and MentalHealth Policy, 2007). Sims (2007) agrees saying that mental health tends tocross boundaries between social care and bio-medicine. Consequently, ‘theremay be issues of culture and upbringing, social expectations and reception andclinical susceptibility involved in detection, diagnosis and care’ (p18)It is largely due to Western thinking that a distinction is made between the artsand culture and science (Vadi, 2007). A recent study carried out in Norway onwellbeing and cultural activities found that simply observing cultural activitieswas good for men’s physical health and wellbeing, while women received morebenefit from actively participating in cultural activities. In fact, the researchshowed that for men, taking part in any cultural activity was associated withhigher level of perceived wellbeing. Meanwhile, women reported betterperceived wellbeing when they participated in Church, meetings, singing, music,theatre, outdoor activity, dance and exercise or sports (Cuypers et al., 2011).The cultural heritage of an individual, community or nation can thereforeinfluence choices and behaviours. Negative impacts of cultural heritage such aslasting trauma from regime change and colonisation and other such events canhave a dramatic impact on future generations. Culturally sensitive health careand interventions must consider this. In fact, Huff and Kline (1999) believe thatcultural consideration may determine whether a health promotion initiative willwork. A ‘one-size-fits-all’ attitude towards many policies, including health
  44. 44. 44promotion, in the past has meant messages have failed to reach the mostmarginalised (Centre for Addiction and Mental Health Policy, 2007). In manycases in the UK and around the world, the majority of health educationmaterials and programmes have reflected only the cultural values of a majoritygroup. This is perhaps based upon Modernisation Theory which propounds theview that ‘the economic, political and social formations associated with WesternEurope and North America were at a more evolved level of development’(Unterhalter, 2008: 771) than the rest of the world. This has excluded not onlyimmigrants to the country but also indigenous peoples, minority ethnic groups,non-ruling religions, rural populations and women.In the international arena, the results of colonisation on indigenous peopleinclude ‘loss of culture, loss of land, loss of voice, loss of population, loss ofdignity and loss of health and wellbeing’ (Drurie, 2004: 1138). Article 24 of TheDraft Declaration on the Rights of Indigenous Peoples (1993) states thatindigenous peoples have the right to the provision of ‘traditional medicines andhealth practices as well as the protection of vital medicinal plants, animals andminerals’ (webpage). The Declaration rightly points to people having ‘heritagerights’ which include ‘the maintenance and the development of culture andresources’ (webpage). UNESCO (2009) state that there is increasing evidencethat the psychological effects of post-colonial life and acculturation have a largerole to play in the far lower life expectancy rates of indigenous peoples, andtherefore shows a direct link between cultural heritage and wellbeing.Palacious and Portillo (2009) put forward Historical Trauma Theory (HTT) as away of explaining how future generations can still feel the repercussion of past
  45. 45. 45events. This trauma and the resulting health problems can then be compoundedby the stress of everyday life, particularly for indigenous or minority groups. Thisstress and marginalisation then increases the likelihood of these populationsadopting unhealthy behaviours such as smoking and drinking. As discussedunder intangible and tangible heritage, museums and other heritage-basedprojects are now looking into how important cultural artefacts can be re-socialised and returned to the cultures they come from.In the past, Modernisation Theory linked indigenous beliefs and traditions asgoing against the movement towards Western-style development. Thereforeculture was used as a ‘mark of the otherness of peoples still prevented byprimordial bonds from joining the rational pursuit of progress’ (White, 2006: 6).Later, ideas of culture and tradition were not seen as ‘other’ but as things thatneeded changing towards an affiliation to the nation, for example one religionand one language (Unterhalter, 2008).While ideas of nations and cultures have changed significantly withglobalisation, heritage has often been seen as more nationalistic. This could beseen as a barrier to multicultural heritage-based projects; however, celebratingthe heritage of a nation or the local area no longer means the unity ofModernisation Theory. Rather, as has been discussed earlier, heritage is thingsfrom the past we wish to keep for future generations and therefore is neverstatic.It is important to understand the past to understand the present and future andso there is a place for preserving even the relics of past nationalism such as
  46. 46. 46Memento Park in Budapest. This does not mean, however, that heritage-basedactivities and projects must be nationalistic; they can be inclusive, using lessonsfrom the past to inform the future. The Basic Needs Approach blurred the linedbetween modernisation and tradition by proposing that satisfying the basicneeds of development naturally led to looking after the culture of an area. It infact ‘empowers individuals in any society and confers upon them aresponsibility to respect and build upon their collective cultural, linguistic andspiritual heritage, to promote the education of others, to further the cause ofsocial justice, to achieve environmental protection, to be tolerant towards social,political and religious systems which differ from their own, ensuring thatcommonly accepted humanistic value and human rights are upheld, and towork for international peace and solidarity in an independent world’ (WDEFA,1990 in Untehalter, 2008: 776).
  47. 47. 47Chapter Three: MethodologyThe purpose of this study is to explore the link between heritage and wellbeingand in doing so investigate how this link could provide an approach foreffectively promoting health. It is not intended to prove or disprove theusefulness of heritage in health promotion, but may be used as a basis forfurther investigation into this area of study.This piece of research explores a heritage-based approach to promoting healththat is often set in a non-medicalised environment, and asks questions aboutsome avenues that may not have been examined before. The researchquestions and the overall aim of this study are likely to bring up more questionsthan can be answered in this piece of research. However, it is important to thesubject area that such questions are brought to the fore. The methodology usedwill help to distinguish between the questions that can be explored in thisdissertation and those that must be asked in future pieces of work. Therefore,the approach taken is one that looks at a variety of perspectives on whatindividuals and groups value (functions) and whether or not they enjoy thecapabilities to put these values into action (agency).
  48. 48. 48It is for these reasons that I have undertaken this research within a CriticalRealist approach that offers a third option between Positivism (objective) andInterpretativism (subjective). It ‘endorses or is compatible with a relatively widerange of research methods, but implies that the particular choices shoulddepend on the nature of the object of study and what one wants to learn aboutit’ (Sayer, 2000: 19)The Critical Realist approach states that the real world is complex but is ‘alsostratified into different layers’ (Robson, 2002: 32). Social reality incorporatesindividual, group and institutional and societal levels, as well as economic andpolitical circumstances. According to Sayer (2000) it is by acknowledging thisinterdependency of actions on shared meanings that we can understandphenomena. As this dissertation looks at how heritage is perceived to influenceour wellbeing, it was important to use an approach that takes into account all ofthese spheres.The subject matter of this dissertation is one that has had little previously writtenabout it: therefore the research needed to be carried out in a setting thatallowed participants to explore issues of health and wellbeing in the context ofheritage-based activities enabling their perceptions to be put into their ownwords.PreparationWhen preparing for this dissertation I searched the awards section of the HLFwebsite looking for any projects/activities relating to health and wellbeing,before arranging preliminary discussions. I spoke to members of HLF staff in
  49. 49. 49order to gain a better understanding of what HLF see as heritage and howhealth and wellbeing fit into projects.I conducted an online literature search through the SirisiDynix database at theInstitute of Education, Swetwise and on GoogleScholar, using key words suchas ‘health’, ‘wellbeing’, ‘heritage’, ‘health promotion’, ‘international development’and ‘culture’. The results were far lower for combinations including the word‘heritage’. However, the searches came up with 111 articles of some relevance.48 of these were excluded for being based upon genetic heritage or beingdiscussions of heritage in a historical context but not related to health andwellbeing. Further searches came up with over 50 relevant articles. Theinclusion criteria were far wider than the exclusion criteria due to the nature ofthe study. This included mentions of health and wellbeing in relation to historicalcontext, culture or heritage. I also looked out for programmes in internationaldevelopment or in the UK that used the arts or culture and theories based oninclusion, the environment or other aspects that could also be positiveoutcomes of using a heritage-based approach.The Study DesignDuring the initial literature search, I found a number of fixed design studies ongenetic heritage that used quantitative methods to measure the likelihood ofcertain health issues being passed down through generations or ethnic groups;and a few flexible design studies about particular cultures’ health beliefs and theimpact of these on their health behaviour. I therefore decided that a flexibledesign would be the best suited to the smaller number of participants and thetype of data I wished to gather. A small-scale qualitative study design provides
  50. 50. 50the opportunity to use qualitative methods that ask questions and explore theviews of participants and is adaptable to each participant, project or situation.This flexible design is also suited to the Critical Realist approach within which Iam undertaking this study.SamplingDuring the small-scale qualitative study, purposive sampling matched best withthe study aims. Throughout the preparation stage, I undertook web-basedsearches for heritage-based projects that have a health or wellbeing focus andprojects that matched my heritage criteria including the five types of heritageused throughout this dissertation. I found it useful to look for the HLF logo onthese websites as a sign that they had been funded by HLF and thereforematched my criteria.I contacted 50 projects out of which ten responded, three to say they did notfeel they would be relevant, three sent hard copy information and four madethemselves available for a phone conversation. These conversations helped tofinalise my research questions and methodology. They also confirmed thatqualitative methods would work best for this topic. All four of those who tookpart in a preliminary interview said that they had found it hard to collectquantitative data around the effects of heritage on health and wellbeing forresearch they had carried out within their projects.Out of the four projects with which I made initial contact, three activities/projectswere chosen for the interview process based upon their suitability against myheritage criteria and their locality. Group One used cultural heritage, tangible
  51. 51. 51heritage/artefacts, built heritage and natural heritage. All participants in thisproject have some level of mental health distress. Group Two used intangibleheritage, built heritage and tangible heritage/artefacts and cultural heritage. Thisproject was based in a hospital. Group Three used intangible heritage mainlyand on occasion all of the identified types of heritage. This group had nocommon health link such as mental health distress or being based in a hospital.Preparatory work was carried out with each project, which involved observingthe groups taking part in the activities and meetings and spending time withparticipants. This enabled me to gain a focused overview of the aims of theprojects and the participants as well as sensitising myself to group dynamicsbefore deciding on whom and how to interview.Consent letters were given out to all staff, volunteers and users at the projects.Participants were chosen from those who returned the consent form stating theywould like to take part. Staff at the projects helped to decide upon the finalsample, as some participants would have been unsuitable due to the severity oftheir health issues. I then interviewed 10 individuals across two of the chosengroups (Group One and Group Two), which both had a health focus. Individualinterviews were most appropriate with Group One and Two due to thesometimes confidential health issues of the participants. A group interview washeld with Group Three because there was no health-related focus to the groupand therefore dealt with less confidential subject matter. The group interviewallowed participants to explore the issues further with input from otherparticipants in the group.
  52. 52. 52Data Collection MethodsData collection consisted of three sets of semi-structured interviews. Fiveparticipants from Groups One and Two took part in hour-long, individual semi-structured interviews, and Group Three took part in a two hour-long semi-structured group interview facilitated by myself and including eight participants.Group One included three females and two males. One member of staff tookpart in the interviews alongside four users, two of whom were also volunteersfor some activities. One was also a Trustee of the organisation.Group Two included three females and two males. One participant was aproject staff member; one was a nurse at the hospital. Three participated in theproject but came from different backgrounds – one was a parent of a patient,one was an elderly patient and one was a member of the community who hadheard of the project through the community outreach programme.Group Three consisted of five females and three males. Three participants werebelow the age of 25 and two were over the age of 65. Five were of an ethnicminority other than white British.The interviews began with an introduction and an explanation of what theinterviews were for and how they would proceed. Participants were informedthat they were being recorded and that they did not have to answer anyquestions they felt uncomfortable with.
  53. 53. 53The interviews took place at the projects in private rooms and were paused forinterruptions. Having spent time at each project prior to the interviews,participants were more at ease with the interview process. However, a memberof staff was present at two of the interviews. One was at the request of theparticipant and the other was on the advice of the staff members due to thelevel of mental distress.All interviews included the same seven questions: 1. What is your understanding of the term health? 2. What is your understanding of the term wellbeing? 3. What is your understanding of the term health promotion? 4. What is your understanding of the term heritage? 5. How long have you been involved in the project? 6. What attracted you to this particular project? 7. What do you perceive to be the benefits of taking part in this project on your health and wellbeing? 8. Do you think another project would have the same effects? Please explain.Further questions depended upon the answers given and where I wished theparticipant to expand upon their answer. Indicators such as feelings, types ofactivities mentioned, medical information and key words relating to health,wellbeing and heritage guided further questioning.I then returned to the original four questions about the definitions of health,wellbeing, health promotion and heritage at the end of each interview. This was
  54. 54. 54because the terms used could seem technical to the participants and thereforeat the beginning of the interviews were not immediately recognisable in theactivities they took part in. By the end of the interviews participant views onthese terms had often changed as they began to match the terms to theirperceptions of the activities and projects.AnalysisA flexible, qualitative approach allowed semi-structured interviews thatencouraged participant discussion. This meant that very few codes or templatescould be set beforehand. However, an interview guide based on the eightquestions mentioned above helped to identify key words and phrases thatwould guide further questioning. This was important as the participants camefrom a range of backgrounds and therefore their ideas of heritage, health andwellbeing would need to be interpreted. For this reason, the analysis of thefindings has been carried out with an immersion approach which is the leaststructured and most interpretive approach, requiring the researchers’ insight,intuition and creativity (Robson, 2002).The preparatory work, which included observations, was informal and servedthe purpose of letting the participants get to know me before taking part in theinterviews. Notes from these observations were written out and analysed forrecurring themes, which were covered during the interviews. These were usedin the generation of grounded theory (Robson, 2002). Words such as ‘happy’,‘lonely’, ‘understanding’, ‘fitting-in’, ‘accepted’ and types of heritage-basedactivities that appeared the most were then used to direct questions in the semi-structured interviews.
  55. 55. 55The semi-structured interviews were transcribed and analysed for recurringthemes as well as missing information. The transcripts were interpreted usingthe definition of heritage, health and wellbeing used in this dissertation.Participants’ ideas on these definitions have also been interpreted to ensurethat the definitions used here are appropriate. All interviews were listened totwice before being transcribed. Transcripts were then analysed for key words orthemes occurring throughout the interviews as well as anticipated themes thathad not appeared.Ethical ConsiderationsDue to the nature of the research ethical issues needed to be taken intoaccount throughout the research process. I therefore made sure I was familiarwith both the British Educational Research Association (BERA) Revised EthicalGuidelines for Educational Research (2004) and the Statement of EthicalPractice for the British Sociological Association (2002).Before undertaking the interviews, I met with the organisations and participantsto explain who I am and what my dissertation research is about as well asensuring they understood that it was part of my MA course. A consent form(Appendix One) was prepared for each participant to sign. All participatingorganisations who wished to receive a copy of the finished report will be sentthe final copy.No organisation or project will be named as having taken part in the research.This is because the projects are small and localised and participants could,
  56. 56. 56therefore, be identified by their answers. Projects/organisations will bedescribed, but no location or other easily identifiable information will be given.Some of the participants have mental or other health issues and so carefulconsideration was given as to where, when and how I met these participants. Allof the interviews were undertaken at times that the participants would normallybe at the project/activity, and I always travelled to them. For those with moresevere mental health distress a member of staff was present throughout theprocess leading up to interviews and at the interview if the participant wished.LimitationsThis is an area with little research already completed and therefore informationhas been difficult to find. The majority of information had to be taken fromresearch into other aspects that relate to the study. However, some very recentreports did help to strengthen the literature base.The timeline for this dissertation meant that I was restricted to a more localisedarea and the interviews took place spread out over time. However, thepreparatory work undertaken served the purpose of sensitising me to the projectand the project participants to me. The background information gatheredthrough this exercise also allows the reader to understand the heritage-basedproject and is important in giving some perspective to the interviews.The subject matter and the number of people interviewed meant that nosubstantial quantitative data could be captured. However, for the purposes of
  57. 57. 57this dissertation the qualitative data gathered may be enough to point to a needfor further exploration and add to the current literature on the subject.Due to a word count limitations, some aspects of this study could not bedescribed in full in this dissertation.Chapter Four: FindingsGroup OneGroup One is based in a charitable organisation which is run by and caters forpeople with mental health distress. They believe that mental wellbeing isimproved through creativity. They run a variety of activities based in the arts andheritage, including visual arts, batik, digital arts, video, poetry, and performingarts, exhibitions, public art projects and websites that help break down thestigma of mental distress. Volunteering programmes and advocacy offer‘meaningful engagement and the opportunity to learn useful skills’.One of the regular events is a walk organised by volunteers who also use theorganisations facilities. The walk is themed and the route changes toincorporate areas, museums and objects that relate to the theme. The walk isopen to the public and so a large mix of people takes part. I observed thepreparation meetings for one such walk and then took part in the walk later inthe month. The organising group consisted of around eight people but some of

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