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Deborah Hayman Ehpid 2011 Dissertation

Deborah Hayman Ehpid 2011 Dissertation



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

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



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    Deborah Hayman Ehpid 2011 Dissertation Deborah Hayman Ehpid 2011 Dissertation Document Transcript

    • 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.
    • 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!
    • 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 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
    • 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 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
    • 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 ‘{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
    • 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
    • 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.
    • 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
    • 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
    • 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
    • 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.
    • 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
    • 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
    • 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
    • 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.
    • 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 • 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 ‘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.
    • 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.
    • 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
    • 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.
    • 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
    • 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.
    • 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).
    • 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.
    • 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
    • 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.
    • 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’
    • 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
    • 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
    • 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,
    • 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).
    • 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.
    • 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).
    • 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)
    • 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 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.
    • 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
    • 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.
    • 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
    • 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
    • 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
    • 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).
    • 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).
    • 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
    • 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
    • 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
    • 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.
    • 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.
    • 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
    • 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.
    • 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,
    • 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
    • 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
    • 58those taking part changed from week to week. The participants’ backgrounds,ages, nationalities, genders and levels of mental distress varied greatly as didtheir experiences with the medical profession. For example, one participant wasa young, white woman with mild depression and anxiety while anotherparticipant was a middle-aged man of African decent with schizophrenia.Each walk is based upon a theme chosen by participants; past themes haveincluded celebrating women in the area, the medical history of the area, literacyand walks for Black History Month and Lesbian, Gay, Bisexual and Transexual(LGBT) History Month. These walks have explored parks, architecture,graveyards, markets, and the homes of famous people, hospitals and museumsas well as art/modern art galleries. They are thoroughly researched beforehandand the organising group also become the tour leaders, giving everyone anopportunity to learn new skills and increase their confidence.Quotes from participants included in some of the organisations communicationsmaterial included: ‘ {The project} really helps people like me to stay well, whichsaves the NHS money’ , ‘I feel safe here and I feel the benefits of cominghere….I begun as a participant and now run a workshop. I would never havehad the confidence to do that!’ and ‘Since I have been at {the project} I feelmore confident to be able to work in the community’.The Chief Executive of the organisation stated in an interview in Mental HealthToday (2009) that
    • 59 ‘there needs to be a more holistic approach to mental health and a widerdefinition of what healing can encompass. When I was told I had depressionthere was an automatic assumption that I needed medication rather than beinggiven a choice in my treatment. I think the medical approach can be extremelyisolated in its thinking.’During my time with the participants of this project, I spoke with users, staff andvolunteers and carried out semi-structured interviews with five participants.These participants included three women and two men; four were of an ethnicorigin other than British. Three participants did not disclose the nature of theirmental health distress. The results of these interviews are as follows:Past ExperienceMarginalisation, Isolation and MisunderstandingFor all five of the participants in Group One, the main themes occurring abouttheir past experiences were those of marginalisation, isolation andmisunderstanding, even though they had all been participating in this project fordifferent lengths of time. One had been there since it started while another hadbeen taking part for just over two months at the time of the interviews. ‘…the whole idea for the organisation came about through a group ofpeople who had felt marginalised and isolated through poverty and healthissues and could not find a suitable remedy. They were all involved in the artsand heritage in some form and wished to use their skills and the local area in acreative way in order to increase wellbeing in an accessible way that did not
    • 60require participants to have money nor full health.’ (Female, Staff member,Group One) ‘Mental health problems are very isolating. If someone is sick people feelsorry for them but when it is mental illness people feel frightened anddistrustful.’ (Female user and volunteer, Group One)‘When I first moved here I felt very alone, I didn’t know the area and I had anew job but felt as if people would guess I have problems if I spoke up toooften. I found myself becoming very introverted and shy. I completely lostconfidence in myself and my own abilities…’ (Young, female user andvolunteer, Group One)Discomfort with medical-based treatmentsFour out of the five had had direct experience of medical-based treatment andthese four all agreed that they did not respond well to the more medicalapproach due to the lack of a holistic view. For three participants, it was thestigma involved in going to the hospital that made them feel uncomfortable withthe treatments. Two did not like therapy sessions particularly one-to-onesessions, as these felt clinical and impersonal. ‘Diagnosis and medicine feel like they are being done to you. I didn’t feelany control over what was happening to me.’ (Female user and volunteer,Group One)
    • 61 ‘I prefer not to go to get treatment, I don’t like the side effects of thedrugs and I hate the feeling that people are looking at you because you arewalking into the wing of the hospital that deals with mental health problems.’(Young, female user and volunteer, Group One) ‘I think health is more clinical/scientific whereas wellbeing is somethingpeople need to be more proactive in securing for themselves. Hospitaltreatment can’t do this.’ (Male user and trustee, Group One)One participant in particular had struggled with the medical system for manyyears and felt isolated and badly treated by medical staff, in the past, who hadnot taken into account his heritage and cultural beliefs. This lack ofunderstanding and his frustration at not being able to articulate himself couldthen turn into episodes of violence. Dreams and spirits hold an important placein his culture and so medical treatments that shut down his dreams caused himfurther distress. Although a more extreme case, all five participants agreed thatthey had experienced distress through a lack of cultural awareness or hadwitnessed it. ‘I felt frustration and distrust and didn’t mean to be violent but they didn’tlisten to what I was trying to tell them…They saw my dreams as part of theproblem while I saw them as part of me, I didn’t want them to go away but theysaid it was for the best. This made me sad and angry and feel out of touch withmy ancestors.’ (Male user, Group One)
    • 62 ‘I am one of the few staff here who does not suffer from mental healthdistress, but the culture here is very understanding to ill-health in general. Butduring my time here I have seen new members who were very reluctant to joinbased on their experiences in hospitals and other organisations…’ (Female,Staff member, Group One)DisconnectionAll participants had felt disconnected due to their mental health issues; oneparticipant in particular had moved around a lot as a child and felt a lack of ‘anyreal connection to a particular cultural background’. ‘During therapy, it had been pointed out to me that moving around a lotas a child may have been part of the reason for some of my current healthproblems, it was stated in such medical terms that I didn’t really connect it toreality. I can’t say that a lack of roots is really something I have ever thoughtabout; I always thought it was more to do with never making friends. But when Ithink about it, I don’t really associate myself with a particular place or feelconnected to a particular culture.’ (Young, female user and volunteer, GroupOne)StigmaAll four participants who suffered from mental health distress felt they hadsuffered from stigma, although for two of the participants this was to a fargreater degree. These participants felt that because they both displayed moresevere and at times, physical, symptoms of their mental health distress; as well
    • 63as the fact they were both of African decent, they suffered from discriminationas well as stigma. ‘Back home and in the Ugandan community here, mental health is stillnot always recognised as an illness. People used to laugh at me and call memad. In the UK, when I first arrived people said I was a strain on the NHS andthe NHS didn’t listen to my cultural perspective. I felt stuck betweendiscrimination and stigma. No one seemed to understand…’ (Male user, GroupOne)Present ExperienceAcceptance and breaking down barriersParticipants on the walk who did not take part in the interviews but were askedhow they felt about the activity stated that ‘as people walk and talk, barriers arebroken down and physical, mental and social wellbeing are all enhanced’.Another said that ‘the talks about the local area are very interesting, I learnedsomething about the area and the walk is relaxing and enjoyable.’These sentiments were echoed by all five of those interviewed. The heritage-based activities seemed to provide a social occasion in an acceptingenvironment where people felt comfortable and able to talk about their healthissues. The walks seem to provide a way of exercising that felt accessible to allof the participants whilst providing an emotional and creative outlet.
    • 64 ‘I like knowing I have somewhere to go where I am not judged on mymental health, where I can relax and be creative. But this project is notexclusive, anyone can come along and take part in activities and many peoplecome to see the exhibitions we put on. All of the activities have a messageabout perceptions of mental health but it is subtle, people come along andenjoy themselves and begin to understand without being told what they have tothink.’ (Female user and volunteer, Group One)One participant believed that the heritage-based approach was more acceptingto his cultural beliefs and enabled him to articulate his feelings and the meaninghe attached to his dreams through creative means. ‘Since joining {the project} I feel more able to control myself, to cope withday-to-day life, knowing that my ancestors are still speaking to me through mydreams and being able to interpret the lessons they are trying to tell me fills mewith peace and belonging.’ (Male user, Group One)Taking controlAll of the interview participants felt that the heritage-based activities organisedthrough the project allowed them to gain a sense of control over their lives.Although the levels of control varied, all believed that the activities and theunderstanding atmosphere allowed them to make choices and decisions theywould have worried about making previously. For some, taking control meantnot relying solely on medication, which they felt often took away their ability tomake choices.
    • 65 ‘I originally just came along to find out what the project was all about butit is hard not to get more involved! Before I came I was very nervous, I hadnever been in control of my own ‘treatment’ before and I would never have putmyself forward to speak or take charge of anything. But the supportiveatmosphere here and the fact that everyone gets involved in some way meant Iwas able to slowly take on more responsibilities and as I did well, I began tofeel more and more in control of my anxieties...’ (Young, female user andvolunteer, Group One) ‘Researching the history of mental health and the social history of thearea has been important to my self-development. It has been empowering totake control over my own problems in a way that diagnosis, medication andtherapy did not allow me to’. (Female user and volunteer, Group One)Two of the participants were both users of the service and volunteers, helping toorganise events such as the heritage-walks. Both felt as if the project providedthem with a safe environment in which to try new things and because theproject is run for and by the people it is there to help, participants were able totake on as much responsibility as they felt comfortable with.One participant said that she ‘finds the heritage walks stimulating and a goodsource of exercise, it is easier to walk and talk than to sit in a therapy room witha complete stranger and share your problems. It feels unnatural and forced’.(Female user and volunteer, Group One)
    • 66 ‘{The project} is aimed at people like me and everyone here has somedegree of mental health distress. I have always wanted to work in museumsand have studied an MA in Curating, so this project feels very personal to me.’(Young, female user and volunteer, Group One)Perceived ImpactBelonging and acceptanceThe main perceived impact described by all five participants was a feeling ofbelonging. ‘…this project felt like the right fit for me, it involved three very importantaspects of my life heritage, art and mental health. Here there is no need forpretence to fit in with other people’s ideals of ‘normal’. (Female user andvolunteer, Group One) ‘understanding the historical context of {the local area} has helped me tofeel a connection to a place I have never felt before. I am originally fromScandinavia but have lived all over Europe and America before settling here.Being quite young I hadn’t thought about belonging to a place but now I do feelas if this is my home, I know it better than anywhere else now.’ (Young, femaleuser and volunteer, Group One) ‘I enjoy cultural events (theatre, museums, projects etc.) as I feel I amable to connect with events that are happening with community. It allows me to
    • 67expand my knowledge and gets me off the sofa!’ (Female user and volunteer,Group One)Advocacy and stigmaThe participants all believed stigma in the wider community to be the biggestproblem facing them. They perceived both the heritage-based outcomes suchas the walks and the exhibitions as well as the advocacy work carried out byprojects such as this one, as important steps towards increasing understandingabout mental health issues. ‘Researching how women with ‘hysteria’ were treated in the past hasalso helped me realise how far understanding of mental heath issues has come’which had the effect of lessening her feelings of ‘self-pity and bad luck andmade me want to do more to show that mental health distress does mean youare not able to lead a ‘normal’ life and we are not scary.’ (Young, female userand volunteer, Group One)Confidence and enjoymentThe staff member interviewed believed the success of the project ‘is down to the fact that heritage in its many forms attracts a wide rangeof people, who may not even realise they are taking part in a heritage-basedactivity, but are given the opportunity to come together and do somethingenjoyable’. (Female, Staff member, Group One)
    • 68Another reason she believes so strongly in this type of project is that it givesparticipants a sense of achievement and responsibility whilst being able toreflect upon their personal experiences of wellbeing in a safe environment.These were aspects picked up by all five participants as being essential to goodwellbeing. ‘Having like-minded people around and being given responsibilities andvaried experiences has helped my confidence and assertiveness.’ (Young,female user and volunteer, Group One) ‘Wellbeing is being happy in one self, having the opportunities andchoices to express yourself and interact in order to increase you confidence,self-esteem and physical health.’ (Male user and trustee, Group One) ‘I love traditional music because it makes me happy and feel relaxed,and I have people that help me learn it I can then pass on that knowledge atthis project.’ (Male user, Group One)However, one participant said they did not think another heritage-based projectthat had no link to mental health would produce the same results. ‘I feel safe here because I know I am not being judged. I could do similaractivities elsewhere but what if they found out I suffered from depression andanxiety? I don’t think I would ever feel comfortable, but here we all understandso we joke about it, we don’t always talk about our problems but we don’t haveto because we all have similar experiences.’ (Young, female user and volunteer,Group One)
    • 69One participant suggested that it is harder to be objective about your problems‘if sat alone at home’ and that other people can bring a sense of balance to yourthoughts. As the basis for the interaction was the activity rather than hispersonal issues, this allowed him to gain perspective, to ‘step out of myproblems and work through them objectively’. (Male user and trustee, GroupOne)However, for one participant the achievement of full health and wellbeing wasthought to be unattainable. ‘For the rich it is probably more within reach but for the working classesand the poor wellbeing is unattainable. You can have all the museum orartefacts in the world but if you go home to a damp roof and no food then howcan a person ever achieve lasting wellbeing?’ (Male user and trustee, GroupOne)Group TwoGroup Two works with Hospital patients, Hospital staff, local communities,artists, architects, consultants and other professionals and volunteers to helpfacilitate engagement in the arts and heritage by introducing ‘exciting newartwork and cultural experiences to the physical environment of healthcaresettings and the wider local community’.They believe that access to quality heritage, which includes the arts and culture,can improve the wellbeing of the local people. They also work to raise
    • 70awareness locally and nationally of the valuable role of heritage in healthcareand to health and wellbeing. Their main projects include showing art andartefacts from the local museum in hospitals, providing training for hospital staffin heritage-based activities, and organising participatory heritage-basedactivities such as archaeological digs and heritage walks. Green space has alsobeen created in the hospital grounds, through the ‘Creative Courtyard Scheme’funded by the Department of Health. Artefacts and pieces of art placed aroundthe hospital, in order to give patients visual stimulation, as well as mosaicsmade with the patients.The interview participants included three women and two men, including onemember of hospital staff, one project staff member, one patient, one parent of ayoung patient and one member of the public who took part in the activitiesorganised by the project. The health complaints of the participants variedgreatly. Only one participant was of an ethnic origin other than white British.A member of staff, who was not interviewed formally, stated that the activitieswere about learning, ‘offering opportunities for everyone to develop theirunderstanding of the local area and themselves in a way appropriate to theirneeds, interests and background’. She believed strongly that this understandinghelped develop a better sense of wellbeing: that there was a sense ofempowerment through being able to identify oneself culturally and historically.Past ExperienceThe five participants all had different backgrounds and perspectives. Four out ofthe five had the hospital in common, two as staff members, one as a patient and
    • 71one as a parent of a young patient. The fifth participant had not stayed in thehospital but had heard about the project through the community outreach team.Past experiences for Group Two are harder to categorise because the projectbrought museum artefacts and art to the hospital. Patients therefore did nothave to join the project to benefit from it and many had not been in the hospitalpreviously so had never seen it without the project.However, a few key concepts did appear throughout the interviews.Marginalisation, Isolation and MisunderstandingJust one of the participants of the project had not been a patient at the hospitaland joined the project after hearing about it form the community engagementteam. Similarly to participants in Group One, he joined because he felt isolatedand lonely. However, the patients at the hospital also stated that the hospitalcould be a lonely place, especially between visiting hours. ‘I first went on an archaeological dig first and then continued to attendother activities since. I was new to the area and had only been in the UK for ayear. I had been finding it difficult to make friends, find work and fit in. I felt soisolated and lonely.’ (Male, activity participant, Group Two)
    • 72For one elderly participant, who had had more than one trip to hospital and felt‘dread at going in, I am always terrified I will not come out again.’ He feltisolated and lonely on the ward and the ‘lack of stimulation for my mind mademe feel lethargic and depressed.’ (Male, patient, Group Two)DisconnectedOnly two of those interviewed had taken part in heritage-based activities in thepast. Three participants believed that the poverty of the area prohibitedactivities and meant that there would be very little of heritage value. ‘I have never been to the local museum and have never really thoughtabout heritage or heritage activities as enjoyable. I suppose I have alwaysbelieved that because this area, is so deprived, that it would have very little tooffer heritage-wise. I hadn’t really realised that heritage could mean so mucheither.’ (Female, parent of patient, Group Two)The physical environment of the hospital and around the town were describedas being ‘…all concrete around here and graffiti on the walls, I feel as if it is a bitof a mission to find greenery but I always feel so much better having spent theday in a park or out of the town.’ (Female, hospital staff, Group Two)BarriersMany of the participants mentioned barriers that prevented them from activelytaking part in heritage-based activities before the project.
    • 73 ‘I like how many museums and stuff are free here but other places canbe expensive to visit and people around here don’t have much money. Also, it’sdifficult to travel everywhere I would like to.’ (Male, activity participant, GroupTwo) ‘Money, time, location, company.’ (Female, parent of patient, Group Two)Present ExperienceInclusiveThe project was designed to be as inclusive as possible. All of the participantsagreed that it was inclusive, especially in the hospital where artefacts such asmuseum exhibits and photographs were accessible to all. ‘I heard through some patients and visitors that they felt some colour onthe walls would enhance the environment. As someone who is also involvedwith the local museum, which can be difficult to get to without transport, I hadthe idea to show collections from the museum in the hospital, widening accessto the collection. The project is driven by target groups such as children,vulnerable adults and the elderly as well as areas of deprivation, which makes ita very inclusive project.’ (Female, project staff, Group Two)
    • 74 ‘I feel included in the daily life of the hospital but once I leave I am notsure how accessible heritage-activities will be for me as my mobility is not whatit once was!’ (Male, patient, Group Two)Stimulation and enjoymentOne participant, the mother of a young patient has become a regular visitor tothe museum and takes part in many of the activities with her daughter andfriends, two other participants agreed that they would continue to take part inheritage-based activities because of the enjoyment and stimulation they gainedfrom them. Others found that the activities gave them an opportunity to be out ofcity and spend time outdoors. This seemed to not only have a positive effect ontheir physical health but also on their perceived wellbeing. ‘The artefacts and photographs were stimulating and enjoyable to lookat, they became topics of discussion between patients… They have inspired meto attend further activities run by this project and visit the local museum.’(Female, parent of patient, Group Two) ‘It has been so enjoyable and the people on the dig are sofriendly. I feel a part of something. It is nice to find an activity that challengesme mentally and physically.’ (Male, activity participant, Group Two) ‘I love being outdoors, I feel free, like I can breathe a proper breath,relaxed, enjoy looking at beautiful landscapes, fills me with awe.’ (Female,project staff, Group Two)
    • 75 ‘I feel happiest when I’m outdoors and away from the city.’ (Female,hospital staff, Group Two)FriendshipsFriendships were mentioned by all of the participants. For one participant, thephotographs on the walls, some of which were images of the area in the past,triggered memories that he shared with his ward fellows. This helped him feelmore connected and form friendships while remembering past friendships. ‘It had been a long time since I had seen the town looking like it did inthe photographs. Someone asked me if I remembered the places in them and Ifound that I had many happy memories to share. I remembered many goodtimes and friends now gone, while I made new friends who shared theirmemories with me. It felt less lonely on the ward between visiting hours.’ (Male,patient, Group Two)Perceived ImpactAiding RecoveryThe perspectives of Group Two differed slightly from Group One, in that theactivities for them were far less about acceptance and more about feelingbetter. Taking part in activities for enjoyment and stimulating the senses at anappropriate level gave many of the participants a sense of being able to copewith their current illness and they felt that aided recovery.
    • 76 ‘I enjoyed finding out about the area while visiting my daughter and Ihave no doubt that the photographs on the walls and the artefacts around thehospital aided my daughters’ recovery. My daughter was stimulated mentallyand visually and was able to move around the hospital when there were talksabout the artefacts. ’ (Female, parent of patient, Group Two)It is her opinion that it would be hard to prove that museums and such heritageas that included in this project can have an impact on physical health. However,participation and stimulation may have added to an overall sense of wellbeingthat impacted upon her daughters’ physical condition. This was a view sharedby other participants. The elderly patient believed that the shared interestprovided a focal point for conversation, reducing his loneliness and ‘taking mymind off the fact I am in hospital. My visitors are always commenting on howcheerful I am this time around!’ (Male, patient, Group Two)Staff members had also noticed a difference in the patients in general as well asthe staff. ‘I have noticed a huge improvement in how I feel about coming to worksince the project began. The green space that was added to the grounds hasgiven staff as well as patients a place to go to get fresh air and a nicer viewfrom the window, which looked out onto more concrete before. Thephotographs and artefacts change regularly and provide a stimulatingenvironment in which to work and a less hospital like atmosphere for thepatients.’ (Female, hospital staff, Group Two)
    • 77Belonging and connectionsFor all of the participants regardless of backgrounds and past experiences,there did seem to be a sense of belonging inspired by the project. For the staffmembers the project made going to work more enjoyable. ‘I feel proud to say where I work now and to be part of such a specialproject. I really think it is a boost to the whole area.’ (Female, hospital staff,Group Two)For one participant, learning about the area through the project, has helped himfeel like part of the community. ‘I feel less isolated and better understood, I tell people about myheritage, stories similar to ones here while we dig up facts from the past. I feellike now I am accepted and belong. As well as the social aspect, I learnt newskills and my English {has improved}. I have recently found paid employmentwhich I think is down to feeling more confident having been a part of thisproject.’ (Male, activity participant, Group Two)Group ThreeGroup Three is a group based at a local community centre that started a projectto archive their large store of photographs, taken since its opening in 1889.Although started as an archiving project, it attracted a wide variety of peoplefrom all generations and turned into a regular group of people getting togetherto talk about their memories based on the photographs. These meetings
    • 78produced oral histories and exhibitions. Young people have been involvedthrough learning how to set up exhibitions, photography and recording the oralhistories as well as helping to organise events. The main aim of the project is toorganise the photographs into a lasting archive that ‘can be enjoyed and addedto for generations to come’.There was no explicit health outcome for this project and participants were froma variety of backgrounds and ages, some with health issues and some without.Past ExperienceBarriersAs the project had no health link and was based solely on the archiving ofhistorical photographs of an area. The concepts that were reported by GroupThree during the interviews regarded barriers.Some participants felt that their age was a barrier to joining clubs as they weretoo old, while others thought that heritage-based activities would be boring.Many of the participants however, stated that they found that they were oftenbored or disinterested but found it difficult to feel motivated. ‘The heritage-based activities close to where I live have never reallyinterested me. I am interested in different cultures however and their heritage
    • 79so when I go travelling to different countries I am more inclined to take part inheritage-based activities.’ (Female, under 25, Group Three) ‘Finding out about events you want to attend can be difficult, unless it issomething your circle of friends attend or you have regular access to.’ (Female,under 30, Group Three) ‘Ignorance and thinking you will be laughed at and the fear of beingbored puts people off attending projects like this one. Although I felt bored allthe time before I started coming here, I know there is stuff to do but it is difficultto find the motivation to go out instead of watching TV sometimes. ’ (Male,under 25, Group Three) ‘Heritage-based activities are often seen as ‘old people’s’ activities whichprobably put young people off. They are often expensive like visiting old housesand gardens.’ (Female, under 65, Group Three)IsolationFor the older members of the group, similar to Group One and Two, they hadexperienced isolation and loneliness in the past. Mobility and lack of transportcould make getting to activities or social events difficult and often familymembers were too busy or lived too far away to visit on a regular basis. ‘Since my husband passed, I am alone in the house, my children all livequite far away and get very lonely sometimes. It can be frightening to go out on
    • 80my own, so I tended to stay indoors on my own.’ (Female, over 65, GroupThree)Present ExperienceBelonging and ConnectionsOne of the youngest members of the group stated that ‘as a white British male,I didn’t know what sort of heritage activities I would take part in! I didn’t feel thatI really had much of a heritage.’ (Male, under 30, Group Three)The project gave him a better understanding of his own heritage through thememories of others (intangible heritage) and artefacts (tangible heritage) fromthe local area. The building itself was part of his heritage, as his grandparentshad attended activities there as children. Learning about his heritage alongsidenew skills gave him a better sense of self and of belonging to a place withhistory.Others in the group felt a sense of belonging through being involved in anactivity. ‘It’s always nice to be a part of something. I enjoy getting out of thehouse and spending time with people who enjoy similar activities. I wassurprised by the diversity of the group when I joined but I think this adds to fun.’(Female, under 65, Group Three)
    • 81 ‘I enjoy going to museums. I normally go to fashion exhibitions or onesthat focus on amazing women because I find them inspiring and interesting.They broaden your horizons and make you feel a part of something. As awoman, they also show me how lucky I am to be as free as I am today andprovide good role models for younger people.’ (Female, under 30, Group Three) ‘I enjoy visiting historic buildings and walking round older parts of townsto see the architecture. I enjoy this as part of a learning experience (e.g.museum) but even without explanation I find it inspiring to experience thetangible achievements of different generations, and to see how these buildingscan be adapted in really practical ways to be used for modern purposes’ (Male,under 65, Group Three)Perceived ImpactBelonging and connectionsSimilarly to Group One and Group Two, the themes of belonging andconnectivity to the area and their own heritage was a common them.One participant stated that ‘health is mandatory. There are fixed steps a person can take to ensurethat they are healthy whereas wellbeing is choice. A choice of the activities theycan do that make them happy.’ (Male, over 65, Group Three)
    • 82She took part in the photography archive as part of this choice because shebelieves that ‘heritage is important as it allows someone to have pride in their originsand where they come from. Heritage is very important to me as it helps toshape the person that I am and have a sense of belonging.’ (Female, under 30,Group Three)Another participant stated that taking part in the activity made him feel ‘great –interested, interesting, connected.’ (Male, under 30, Group Three) Many of theparticipants mentioned this idea of being connected and agreed that they feltmore isolated when they had not spent time around friends and family. Theyviewed activities such as this one as a way of meeting new people andexperiencing new things all of which contributed to their overall sense ofhappiness and confidence. For the older members of the group, thephotographs became tangible prompts for oral histories. The project was localand provided transport for the older members of the group, increasing theirability to attend the sessions. ‘I heard about the project through Church and was instantly interested. Ihave grown up in this area and the thought of looking back over all thosephotographs and preserving them sounded great. They picked me up so I didn’thave to worry about getting there and once there I found a lovely group ofpeople of all ages enjoying each other’s company. I feel my spirits lift justthinking about going to the next session’ (Female, over 65, Group Three)
    • 83 ‘Wellbeing is contentment and acceptance of life and a sense of capacityto cope with life. This project has got me out the house, I have learnt new skills,met new people and learnt about the place I live in. The atmosphere is relaxedand friendly and I know that my work will be there for years to come and I feelmuch more organised having learnt how to archive!. All of this definitely adds tomy sense of contentment and acceptance and ability to cope with life.’ (Female,under 65, Group Three)The participants also pointed out that heritage is an ever-changing thing, ‘astoday becomes tomorrow, so our decisions become part of our heritage’ andthis idea of living heritage added to their sense of acceptance and belonging. ‘I agree with...being part of something like this is exciting. I feel like Ireally know the area now but it has also inspired me to think about otheractivities.’ (Female, under 30, Group Three)Similarities between the GroupsThe majority of participants believed that the heritage-based activities they tookpart in had a particular and identifiable impact on their wellbeing. Sixteen out ofthe 18 participants believed the activities improved their confidence and feelingsof being able to cope with day-to-day life.Interestingly for all three groups, most participants took part in the activities forreasons other than their heritage value and many had not realised the activitieswere heritage related and had not thought about heritage before. When askedwhy, the most common reply was that the word ‘heritage’ itself was a barrier as
    • 84it often felt very remote or brought up images of ‘anoraks polishing old steamengines and making mediaeval skeps that no-one uses any more’. (Male,Group Three)The majority of participants stated that they occasionally visited museums orheritage sites to learn about different cultures or ways of life, particularly whenon holiday. Seven out of the eighteen participants thought that cost was abarrier to visiting heritage sites, ten found distance and travel arrangements tobe a barrier and only three had believed that heritage was accessible prior tothe taking part in the projects. ‘I am a committed Christian and my parents and grandparents were.Much of my social life on a day-to- day basis revolves around faith issues andchurch life. This has a heritage angle, which certainly contributes to my senseof wellbeing.’ (Male, Group Three)As we can see from the interview findings ‘heritage’ can be a difficult word toconnect with yet everyone takes part in some form of heritage activity,organised or not. There was also a strong sense that white, British people felt abigger disconnection to their own heritage than people did of a different ethnicorigin. Although the later felt that, their heritage needed to be taken more intoaccount by health professionals.The idea of promoting health also caused some problems for the participants.The majority saw it as only the passing on of information and many weresceptical about its usefulness. One participant described it as
    • 85 ‘setting an example of a way of living regarded by some as being betterthan other ways’. (Male, Group One)Another stated that health promotion was ‘Societies attempts to persuade the population of the need for particularlifestyle changes to improve their mental or physical state for the better’.(Female, Group Two)Many seemed to agree that it only consisted of ‘Advertising certain goods/ideas with the aim of improving the physicalhealth of an individual (and with maybe the aim of making money)’ (Members ofGroup Three)Definitions of Health, Wellbeing and Health PromotionEach participant was asked for their views on the definitions of health,wellbeing, heritage and health promotion at the beginning and end of eachinterview. This was because I had anticipated a difficulty with the terms, whichmay not reflect how the participants felt about the activities. As statedpreviously, the majority of participants did not relate the activities to heritage, atleast to begin with. However, by the end of the interviews there was a positiveshift in how people viewed the terms and how they related to the activities.
    • 86 ‘I love history and thinking about all the exciting times long ago. I like toput things into context – if I see a castle then I want to know when it was built,why, who lived there etc to give it meaning. I enjoy knowing more about theworld and not being a person who takes things for granted. I like feeling proudof being British as we have such a rich background! I like to know about othercultures and see a bigger picture. But I have never thought about it as beingheritage and certainly not as promoting health. It is certainly an interestingthought’ (Female, Group Three) ‘I attend heritage events that I can relate to and want to partake in. Itallows me to connect to my own heritage and gives me a sense of belonging.’(Male, Group Two)Participants interviewed for this dissertation saw health promotion as: ‘… important, giving people access to information they may not have. Ifeel that health promotion has been used in the wrong way on occasions,especially on the perceived image of what a ‘healthy body’ is. The focus shouldnot be on what health looks like but how to stay healthy in body and mind.’(Female, Group Three)And ‘Health Promotion is the provision of information and/or education toindividuals, families, and communities that-encourage family unity, communitycommitment, and traditional spirituality that make positive contributions to their
    • 87health status. Health Promotion is also the promotion of healthy ideas andconcepts to motivate individuals to adopt healthy behaviours.’ (Female, GroupTwo)The interviews seem to point towards a range of positive health and wellbeingoutcomes for the participants of the heritage-based projects. It is true that someof these benefits may be produced through a range of less heritage-specificactivities including sports and other clubs. However, there is an argument,perhaps, that the heritage-based approach might promote health in innovativeways that produce better wellbeing outcomes not just better physical healthoutcomes. So what are the possible implications of this on promoting wellbeingthrough heritage? And how can the perceived barriers be broken down?Chapter Five: Discussion and ImplicationsChapter Two established that health promotion is an activity that aims tostrengthen individuals’ skills and capabilities in order to obtain better health andwellbeing. Wellbeing has been defined as a holistic term encompassing morethan the absence of disease. Heritage has been shown to be anything from thepast that we value and want to keep for future generations. The majority ofinterview participants agreed or strongly agreed, with these definitions.
    • 88The main themes appearing throughout the interview process were those ofmarginalisation, isolation, misunderstanding, disconnection, stigma andperceived barriers prior to taking part in a heritage-based activity. Themes suchas belonging, acceptance, advocacy, enjoyment, confidence, stimulation,friendships, aiding recovery and taking control, were recurring themes fromparticipants’ perceptions of their wellbeing in relation to heritage.But what does all of this mean for a heritage-based approach to promotinghealth? And how do the five categories of heritage: Intangible Heritage,Tangible Heritage/Artefacts, Natural Heritage, Built Heritage and CulturalHeritage, relate to the research findings?John Rawls (1999) wrote that ‘..even if the material means that support our mode of life can always beimagined to be greater, and a different pattern of aims might often have beenchosen, still the actual fulfilment of the plan itself may have, as compositions,paintings, poems often do, a certain completedness which though marred bycircumstances and human failing is evident from the whole’ (p482).There may be many different activities in which we can participate to improveour health and wellbeing, but it is the achievement of completing the activity thatbrings about a greater sense of happiness. If we strongly believe in thegoodness of the activity and can gain a sense of achievement from it then wecan also gain a higher level of wellbeing through the perceived benefits. This is
    • 89something the majority of participants mentioned in interviews and is one of themany reasons a heritage-based approach might provide an innovative way topromote health and wellbeing. Simply visiting a museum and seeing a beautifulsculpture or learning something new about a figure from history can bring with ita sense of achievement, of education, which in itself can be empowering.Sen’s (1999) Capabilities Approach would seem to agree with these sentimentsas it proffers the notion that it is a person’s ability to perform certain acts orreach a certain state of being that should be measured as well as what theyactually do. Therefore, any activity that encourages human development,particularly health and education, by providing opportunities to expandcapabilities is of value (Unterhalter, 2008). This approach also stresses theimportance of participation and diversity. Heritage-based activities can helpexpand peoples’ capabilities through education, participation and providinginsights into the cultures of others and our own in order to increaseunderstanding and consequently equality and justice.The things that people place value upon will change depending upon thesociety in which they live and grow. For example, one participant from Ugandaplaced importance on his dreams and ancestors while other participants placedlittle or no importance on these but did value academic knowledge. Thecapability approach aims to expand the freedoms of people to be able to makechoices and enjoy valuable beings and doings (functionings) (Alkire, 2005). Incountries like the UK, where most basic needs are met through the State morevalue may be put upon cultural and leisure activities and participation. Aheritage-based approach to promoting health could therefore be used to
    • 90promote more than just basic needs and individual functionings and movetowards a more extensive capabilities approach. Participants in this study statedthey felt happier, more confident, included and less stigmatised. They alsoacknowledged the new skills and knowledge they acquired throughout theprojects. All of these attributes contributed to an increased agency or ability topursue the goals that they valued as individuals and as groups.In international development, the capabilities approach is often focused onfreedoms through education, shelter and other basic needs (Alkire, 2005;Robeyns, 2005). And while these functionings all have fundamental value, theyare not the only things that people value. As described by participants who hadnot been born in Britain, cultural heritage both from their homeland and the UKwere valuable to their wellbeing.Projects in Uganda such as ‘Freedom in Creation’ use art to help child soldiers,their website claims that ‘conflict art-making is especially important as it istherapeutic and affirms individuals in their relative autonomy and ability to beginto articulate pain, relationships, and reality. Artistic expression is often a sign ofone’s resolve as it reflects the will to persevere in the face of despair’ (Freedomin Creation, 2010). This is just one example of where stories of a traumaticheritage such as war can be articulated and understood, through a positive formof heritage.Reader (2006) and Stewart (1985) believe that basic needs such as education,health, housing, food, security and other aspects of wellbeing cannot beconsidered individually but must be taken as a whole. ‘The multi dimensionality
    • 91of need and the implication that needs could be met by a range of persons orinstitutions, indicated that the aims of education would not be realised only inschools’ (Stewart, 1985 in Unterhalter, 2008: 775). Just as the aims of healthpromotion cannot be achieved by the health sector alone; by taking healthpromotion out of its usual spheres there is great potential for improving itspractices. As stated by UNESCO ‘Quality education is a dynamic concept thatchanges and evolves with time and changes in the social, economic andenvironmental context of place. Because quality education must be locallyrelevant and culturally appropriate, quality education will take many formsaround the world’. This is equally true of activities promoting health. I will nowlook at the five categories of heritage and explore ways in which they mightcontribute to health promotion.Intangible HeritageIntangible heritage is perhaps the hardest type of heritage to grasp becauseoften it cannot be physically seen nor touched. UNESCO (2007) describesIntangible Heritage as being ‘living expressions and the traditions that countlessgroups and communities worldwide have inherited from their ancestors andtransmit to their descendants, in most cases orally’. It is often considered themost fragile type of heritage because it relies on peoples’ memories and thepassing of information down through the generations. Yet it is also extremelyimportant to peoples’ lives and how we relate to others.Participants from all three Groups had a strong connection to intangibleheritage. Group One used intangible heritage to pass on experiences of mentalhealth distress and of the local area, often in relation to other types of heritage.
    • 92Group Two used the connection between tangible heritage/artefacts andintangible heritage to help aid patient recovery. For Group Three the intangibleheritage aspect was not the aim of the group but came about naturally throughthe activity providing oral histories to go with the photographs. Many of theparticipants found the use of intangible history to be confidence building andcreated a stronger sense of understanding between participants.The Convention for the Safeguarding of Intangible Cultural Heritage kit (2009)states that intangible heritage is an ‘important factor in maintaining culturaldiversity in the face of growing globalisation. An understanding of the intangiblecultural heritage of different communities helps with intercultural dialogue, andencourages mutual respect for other ways of life’ (p4)As described by participants in Group Three, this encouragement of mutualrespect can be intergenerational as well as intercultural. The passing on of suchinformation can help family and peer relationships as well as behaviours andrisks, and subjective wellbeing in children, three of UNICEF’s six dimensions ofchild wellbeing. It also corresponds with the environmental, societal, mental,social and spiritual spheres of health as described by Naidoo & Wills (2000).In everyday terms, intangible heritage may be considered to be the gossip weswap with our friends, recipes passed on to us by our parents or the memorieswe share with our children. Heritage-based projects that enable the passing ofintangible heritage such as oral histories, folk dances, and stories amongstothers can help create forums for discussion and understanding such as thatfound in Group One.
    • 93For the participants in Group One, the project allowed tangible, natural, builtand cultural heritage to contribute to enabling intangible heritage to havemeaning in current contexts and personal circumstances. It providedparticipants with the opportunity to speak about their health issues in a safe andunderstanding environment. The issues raised by participants were also usefulfor the advocacy team who worked alongside the project to raise awareness ofmental health issues in the area. This meant that all advocacy work wasinformed by the participants of the project, ensuring a holistic and appropriateapproach to their work.Similarly, Richmond MIND has carried out an oral history project called‘Reflection: Conserving Richmond Borough Mind 50 Years of Service - 50Years of Mental Health Heritage’. The projects main aim was ‘To identify, explore and celebrate the heritage associated with mentalhealth and well being, through oral history interviews, mainstream exhibitions,and public documentary viewings and lectures. These will be done as a way toeducate, conserve and raise awareness in order to reduce the stigmaassociated with mental health.’ (From preparatory conversation with HelenRobinson, 2010).These heritage-based projects show how advocacy aims can be met throughusing oral history and other forms of intangible heritage. Heritage-basedprojects provide a way to explore our surroundings and our place within them
    • 94and find innovative ways to put wellbeing messages across to a variedaudience.Tangible Heritage/ArtefactsThere are many advantages to using intangible heritage in health promotioninitiatives, such as oral history, as part of health related or other exhibitions.This is because intangible heritage is important to many aspects of ourwellbeing, it is often how we learn skills or find out about our family history,however, it can also be fragile. Some intangible heritage is lost naturally, astimes change and some has been forced from everyday use throughcolonisation and ‘civilisation’ of other cultures. However, it is often linked withtangible heritage/artefacts that may encourage reminiscences and oral historydue to a ‘symbiotic relationship between the tangible and the intangible. Theintangible heritage should be regarded as the larger framework within whichtangible heritage takes on shape and significance’ (Bouchenaki, 2003: 2).For Groups Two and Three, photographs did exactly this. Tangible heritagebecame a powerful reminder for oral histories; for many participating in theseprojects, the tangible heritage provided a prompt from which they could shareknowledge and stories. The shared experiences of mental distress for GroupOne became the inspiration for exploring tangible heritage while producing theirown art works using skills passed down through the generations such as batikmaking. Group Three used tangible heritage as a way of exploring andexhibiting the heritage of the local area. In both projects, the group activitieshelped to lessen feelings of isolation and anxiety.
    • 95Social exclusion has many levels or is ‘inherently multifactorial’ (Burchardt et al.,2002 in Schneider & Bramley, 2008). It can include poor health, housing,education and the structures of society and so is often related to theories ofsocial change. Health promotion theories often concentrate on behaviourchange, towards healthier lifestyles; however, as health is not the only factor insocial exclusion, health promotion needs to match the multifactoral elements ofsocial exclusion. Heritage-based projects, especially those that use tangibleheritage can encourage better wellbeing through enabling groups of people tocome together and learn knew skills in a supportive atmosphere. This not onlytackles the health issues due to loneliness or isolation but contributes towardsbuilding a new skills base which may encourage better employmentopportunities.However, research has shown that some types of tangible heritage such asmuseums and other heritage sites are more likely to be visited by those whoalready have a higher level of education or visit for nostalgic reasons (Kerstetteret al., 2001). A number of the participants in this dissertation said they joinedthe groups based on other elements rather than heritage and that they felt therewere barriers to visiting museums and other heritage sites. Health promotioninitiatives, whether using heritage or not must reach the most needy andmarginalised in order to be successful (WHO, 2008).Having an agreement with local museums, colleges, Universities and otherprojects and activities, in order to have artefacts, art, photography and otherstimulating objects around hospitals and other care facilities could have apositive impact on patients wellbeing and in turn their recovery. The physical
    • 96environment can make a real difference to how people perceive their wellbeing,research has found that simply having a view of nature from a hospital windowsped up recovery from surgery (Spedding, 2008).Not only can tangible heritage placed around hospitals help aid recovery byproviding mental stimulation and a prompt for conversation, as experienced byGroup Two, they could also be used to relay health promotion messages,convey lessons from the past and provide information about traditional healingmethods. The interest and social inclusion these objects may inspire could thenturn into higher levels of heritage-based activity once out of hospital.Natural HeritagePossibly the most studied area of heritage and its connection with health andwellbeing, natural heritage is the most widely recognised for its intrinsic value.Dating back to the Victorian era in Britain when parks were introduced as a wayof improving health and reducing social discontent natural spaces havecontinued to be seen as valuable (Health Scotland et al., 2008).This is also the area most easily identified by participants. All three groups usednatural heritage throughout the projects, and many participants placed greatvalue on natural heritage. Participants who did not have gardens appreciatedparks and other greenspace areas. For some just being able to see naturalspace was perceived as beneficial and for others the value lay in being able toutilise these spaces.
    • 97WHO (2011) have estimated that depression and related illnesses will becomethe second highest source of ill health on the Disability Adjusted Life Years(DALYs) list by 2020. Mental illness already costs the UK an estimated £76billion each year, and obesity costs up to £37 billion per year (SustainableDevelopment Commission, 2008). Group One try to tackle this issue and foundthat natural heritage had much to contribute to mental wellbeing. In order tobegin reducing these figures, Scottish National Heritage (SNH) have promisedto ensure that the contribution of natural heritage to wellbeing is recognised andenhanced ‘…through recreation, volunteering and outdoor learning, and {by}support{ing the} provision of local green space, path networks and attractivelandscapes’ (SNH, 2009: 1).The report cites a large evidence base for this policy including green exercise,contribution to effective recovery and the outdoors as a preventative medicine.Group Two experienced how successful simply having some green space inthe hospital ground was to the recovery of patients, while Group Onedemonstrated that heritage walks that incorporated natural heritage werebeneficial to the participants wellbeing as well as their physical health.Built HeritageOften closely linked with natural heritage, built heritage also has an impact onour wellbeing, through the environment in which we live and work. Built heritagecan be described as the manmade landscape to which each generation hasadded, be it historic buildings, such as Castle’s, tomb’s or Stonehenge to theway our towns are planned. It is therefore both everyday and ancient.
    • 98Participants from all three groups used built heritage. For Group One and Threethe changing landscape of the built heritage of the towns became a base fororal history and sharing knowledge. For Group One, built heritage in the form ofold asylums and hospitals and the history of these buildings had profoundeffects on the participants. These building became tangible reminders of thestruggles of people with mental health distress as well as being part of theactivities to increase wellbeing.However, while participants often used built heritage to inform their activities, italso seemed to be the area of heritage they found hardest to associate withtheir wellbeing. This area was mentioned the least of all the types of heritageduring interviews, although many described the enjoyment they found in visitingold buildings.Cultural HeritageCultural heritage is probably the most all-encompassing category in thisdissertation and in many cases is used to describe most types of heritage andthe arts. Purnell defines culture as ‘the totality of socially transmitted behavioural patterns, arts, beliefs,values, customs, lifeways, and all other products of human work and thoughtcharacteristics of a population of people that guide their worldview and decisionmaking. These patterns may be explicit or implicit, are primarily learned andtransmitted within the family, are shared by most members of the culture, andare emergent phenomena that change in response to global phenomena.
    • 99Culture is learned first in the family, then in school, then in the community andother social organisations such as the church’ (Purnell, 2003: 3).For many of the participants cultural heritage was important to their generalwellbeing and particularly so in relation to their health care and services. This isshown most clearly in Group One but all three groups mentioned their culturalheritage or feelings of lacking a cultural heritage as having a profound impacton their wellbeing. A claim that participants from all three groups agreed withwas that heritage-based activities that concentrate on cultural heritage can helpindividuals and groups feel empowered through cultural identification, whichmay help these messages become imbedded more naturally. An understandingof other cultures was also perceived as improving feelings of belonging andunderstanding between participants.ImplicationsPolicyAt a policy level, a heritage-based approach to promoting health could beeffectively used to ensure the cultural background of patients are taken intoaccount during healthcare interventions and that health promotion campaignsboth National and International are appropriate and embedded in cultural life.‘The arts are and should be firmly recognised as being integral to health,healthcare provision and healthcare environments’ (Department of Health,2007: 16). However, it is not only the arts that can contribute to healthpromotion and wellbeing. A heritage-based approach to promoting health could
    • 100be innovative and effective and can take place through a variety of activities andenvironments. Whether this is through projecting health messages, displayingthe history of medicine, allowing people to talk and understand each other or bybrightening up spaces such as hospital walls, there is much that a heritage-based approach could contribute. Few people would dispute that heritagecontributes to quality of life but establishing a robust causal link betweenheritage and wellbeing in terms of measurable impact is more difficult.ProgrammingA briefing note for the Local Area Agreements in London (HELM, 2006) made aclear case for the potential of cultural13 services for joined up working with otherpublic and voluntary agencies, due to the ‘people oriented nature of the culturalservices’ (p4). The briefing report cited many heritage-based activities as part ofthese cultural services including libraries, museums, parks, and art. TheHounslow Local Area Agreement states that ‘…culture brings people together and plays a significant role inimproving our quality of life. The vibrant mixture of diverse cultures in Hounslowis a major strength. Culture can be a powerful force, promoting understandingand a sense of identity. It can bring people together from different backgrounds,transcending barriers and celebrating difference. Culture plays a crucial role ininclusion, educational attainment, economic development, health and wellbeing’(HELM, 2006: 4)13 The Local Area Agreements uses the DCMS definition of culture, which encapsulates many of the areasof heritage being looked at in this dissertation: performing and visual arts, media, film, television, video andlanguage, museums, artefacts, archives and design, libraries, literature and publishing, the built heritage,architecture, landscape and archaeology, sports events, facilities and development, parks, open spaces,wildlife habitats, water environment, children’s play, playgrounds and play activities, tourism, festivals andattractions, as well as informal leisure pursuits.
    • 101However, there are still questions to be asked regarding motivating people totake part in activities when they have not previously been actively involved orare reluctant to engage. ‘Social capital/social cohesion needs to be based ontrue participation, which requires empowerment through redistribution of powerto increase community influence over decision making and policy developmentconcerning their wellbeing and quality of life’ (Pridmore et al., 2007:131).Understanding the various types of heritage, and how they affect differentgroups of people, may help to adapt health promotion messages for theintended audience. Incorporating cultural references and role models throughheritage can ‘empower individuals in any society and confer 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 values and human rights are upheld, and towork for international peace and solidarity in an independent world’ (WDEFA,1990: Article 1, webpage).All of which is beneficial to peoples overall wellbeing.Of course ‘past experiences show that national public health action to buildsupportive environments and responsive services requires innovation, boldreform and a long-term investment…’ (Catford, 2007: 2). All of this requires
    • 102evidence and so it is important that further research is conducted and outcomesof participation in heritage-based activities and their impact on wellbeing aremeasured.Further ResearchBuilding a body of knowledge, research and evaluation is perhaps where themost work must be done with regards to a heritage-based approach topromoting health. The most advanced area in terms of measuring impact iscertainly natural heritage, which has benefited from numerous studies. It isperhaps also easier to see a link between being outside and taking exerciseoutdoors with health benefits, as physical health is less problematic to defineand measure. However, the other four categories of heritage can also createsocial energy, which contributes greatly to wellbeing. ‘These social benefits canbe generated by promoting heritage not as an isolated technical exercise, butas a process of engaging communities in decision-making and learning’ (HLF,2004: 38)Furthermore, there is a need to gather evidence about how a heritage-basedapproach to promoting health and wellbeing may impact different ages, gendersand other groups. There is ‘compelling evidence that children’s early life experiences can stronglyimpact their health and wellbeing later in life. {and}..health outcomes are likelyto be most optimal when good health is promoted throughout life…..ensur{ing}accessible and equitable services that are inclusive of ethnicity, culture,
    • 103religion, linguistics, sexuality, stage of development, age, gender, education,income and geographic diversity’ (Catford, 2007: 2).However, as discussed by participants in this dissertation, there are barriers topeople taking part in heritage-based activities. These may be age, accessibility,and mobility, appropriateness of the activity and a lack of effectiveadvertisement. The implications of not addressing these barriers would damageany attempt at promoting health and wellbeing using heritage. Therefore,innovative methods of making heritage accessible and embedding healthmessages are needed.ConclusionThe potential for a heritage-based approach to promoting health and wellbeingis vast. They can be stimulating, fun and varied and can be targeted atdisadvantaged groups as well as being open to all. Barriers such as cost,transport and awareness of such projects should also be looked into with thepossibility of partnerships and collaboration between industries as a potentialway of making it easier for all to access heritage-based activities.Although more research is needed into a heritage-based approach to promotinghealth and wellbeing, what is clear is that it could provide an innovative way ofpromoting wellbeing within a diverse number of groups. Heritage in its manyforms can be made accessible in appropriate ways to all, and even when theheritage is morally wrong, health messages can be relayed by understandingwhere certain knowledge came from and therefore how to correct that
    • 104knowledge in a culturally sensitive way. A heritage-based approach topromoting health and wellbeing could in fact be a powerful way to embed healthmessages and empower people with the tools to achieve higher levels ofwellbeing. It could also provide a more holistic use of money for non-governmental organisations and for government departments such as the UKDepartment for International Development (DFID).AppendicesAppendix OneConsent LetterADDRESS LINE 1 Deborah HaymanADDRESS LINE 2 114 Wellmeadow RoadADDRESS LINE 3 Flat CPOSTCODE SE6 1HWDATEDear Sir/ Madam
    • 105My name is Deborah Hayman and I am currently studying a Masters inEducation, Health Promotion and International Development at the Institute ofEducation.The final part of my course is a dissertation for which I am exploring thefollowing title:Healthy Heritage: The role of heritage and culture in promoting health andwellbeing.For this piece of research I am looking into the links between how we view ourown health and the world around us from the perspective of heritage-basedprojects and how this could have an effect on health promotion.In order to find out how people feel about the issues I am exploring I would liketo use …………….. as a short case study in which I will observe the group andattend activities. I would also like to take some informal interviews with staff,volunteers and participants of various types of organisations and projectsincluding …………………….., to better understand how people view health,well-being and aspects of heritage.I will be transcribing each interview and findings will be displayed and discussedin my final dissertation. However, no individuals’ name will be mentioned in thedissertation, although the organisations’ name may be.In accordance with the BERA and BSA ethical guidelines, all transcribedinterviews will be kept in a secure place and will not be shown to anyone else.Participants are free to leave the interview at any time. There is no anticipatedrisk to the participants but they do not have to answer any questions they do notwish to.The interview findings will be used only for the purposes of the research and willbe displayed in the dissertation, with all names taken out.Before any interviews are undertaken I will brief participants about the projectand give them time to brief me on their expectations. After each interview I willdebrief with the participant. Once completed one copy of the final dissertationwill be sent to each participating organisation.The final dissertation will be published in the University Library.If you would like to take part in this piece of research, by participating in aninterview, please fill out and return the form below.If you have any questions, please do get in touch atdeborahhayman@hotmail.com or on 07762793218.Kind regards
    • 106Deborah HaymanI………………………………………… agree to being interviewed by DeborahHayman for the purposes of her dissertation topic: Healthy Heritage: The role ofheritage and culture in promoting health and wellbeing.By signing this form:I consent to my comments being used within the dissertation.I understand the purpose of this research and understand that I can withdrawmy consent at any time.Please tick the appropriate box below:I give my explicit permission to have this interview recordedI do not wish my interview to be recorded but am happy for the interviewer totake notesSignature:Date:Appendix TwoTypes of ActivitiesParticipants were also asked which activities they took part in that they believedincreased their physical health and/or wellbeing. We can see form this that theinterview participants took part in a number of different activities.
    • 107Although every activity we take part in will have some level of heritage value,participants thought of sporting activities, dance and theatre as being in adifferent category.Type of Activity Number of participants who take part in activityTeam Sports 3Individual Sports 8Dance 8Acting 2Attending Theatre Performances 8Visiting museums and other places of 11interest (incl. historic places)Spending time outdoors 11Discussion Groups 5Seminars and Lectures 6Reading 11Local Activities and Projects 7Other: 20 Crafts 3 Church related activities 2 Gigging 1 Beekeeping 1 Shopping 1 Charitable Activities 4 Music – playing instruments 1 Music – attending 7performances
    • 108Appendix ThreeDefinitions18 participants’ took part in interviews, each participant was asked to score thethree definitions I use in this dissertation to ensure that they were accurate inlay terms. This was to help explore the participants’ views about promotinghealth and the possible associations with health and wellbeing.Definition Strongly Disagre Undecide Agree Strongly Disagree e d Agree‘Health promotion in 2 1 3 7 5its many forms and atall levels is for thepurpose of aidingindividuals,communities andsocieties in increasing
    • 109their abilities to attainbetter health andwellbeing in order tolive a fuller life.’‘Wellbeing is the 0 0 3 8 7ultimate expression ofholistic ideas of health.Encompassing themore holistic social,mental andenvironmentalelements over themore physical idea ofhealth’‘Heritage is things 0 0 6 4 8from the past that wevalue and want tokeep for futuregenerations, bothtangible andintangible.’
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