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Current State of Public Health Spending

Health as defined by the World Health Organization in 1946 is a state of complete


physical, mental, and social well-being rather than merely the absence of disease or infirmity
(WHO, 1948). By this definition, equal weight must be put in all these areas for a public health
system to provide optimal care. What is the truth, however, is that some of these elements are
more costly plus a lack of funding could lessen the pressure on certain parts of care. Other
elements of health, such as emotional and mental health, have less funding and focus, although
many times they are determinants of our physical health. For example, the brunt of funding for
public health is for heart disease, diabetes, and obesity, not mental health, which has a high cost
for quality care (Mental Health: What Foundations Are Funding 2012), even though depression
has been found to be detrimental to diabetic patients. Depressed diabetes patients saw worse
health outcomes as opposed to other patients (Zhang, Norris, & Gregg, 2005). Public health
needs to explore new types of programming to tackle the gaps associated with the high costs of
care.
Arts as an Engagement Tool
Given the ubiquity of creative expression, as well as the relative ease of engagement, the
extent to which psychological and physiological effects are sustainably health enhancing is an
important area for public health investigation (Stuckey & Nobel, 2010). The act of creating art
comes from an emotional reflection of everyday triumphs and challenges, therefore art is best
utilized when managing emotional health. Health psychologists have looked at how the arts
might be used to heal emotional injuries, increase understanding of oneself and others, and alter
behaviors and thinking patterns (Camic, 2008). In usual structures for art education, school for
instance, the creation of art is treated as something that can be easily need with little instruction
and totally individualized, rather than relative to community experiences (Chapman, 1982). This
makes modern art curriculums in the educational system uninspiring to art instructors (Erickson
2002) so more evidence needs to accrued across population on how to create impactful,
sustainable art programs that could be used in public health.
Defining the Populations
Three disparate populations will be reviewed to see how an arts based intervention was
used to address health outcomes. The reasoning behind using three different populations is to
help highlight how art can be a flexible medium for multiple populations. For this review, we
will be using a school environment, indigenous populations, and participants who have
experienced trauma. The school environment reflects how a structured environment could
facilitate childhood growth. Indigenous populations display how art is a flexible medium that can
be molded to fit the community's assets. Trauma survivors have created a community through
tragedy, so unlike the school and indigenous environments their connection comes from shared
experience(s).
Limitations
As a result of the newness of creative expression/art being used in formalized public
health interventions, there is a lack of formal articles about impact. Randomized trials are very
limited in the subject. Many of the studies were not done by people in the field of public health,
rather by psychologists and nurses, for example. They will all be placed under the umbrella term,
public health practitioners since they are all carrying out an intervention in hopes of generalizing

the results to the wider population. This reviews intent is to look at what has already been done
in the field followed by recommendations for going forward as a result.
Methods
Using search terms creative expressions, art, stakeholders, and trauma through Jstor and
PubMed. Only included articles from US, UK, and Canada are because of availability. This
literature review will highlight the structured classroom, native populations, and trauma victims.
Review of Multiple Populations
School Based
There is already a large amount of research that has been done about how arts education
can be utilized. This is the result of art already being a requirement of school curriculum. But as
it has been said before much of what is being taught is disconnected from the participants
experiences. These already existing art programs are based on teaching students new ways of
creating art and thinking outside the box so to speak. Rarely do these programs actually address
emotional health and how to deal with anxiety. For families for whom access to these services
is difficult and/or embarrassing, schools can be a more financially and geographically accessible
service site as well as a non-stigmatizing gateway to such support (Pumariega, Rogers, &
Rothe, 2005). With many art programs shuttering as a result of them being seen as costly and
non-essential programming, public health practitioners have gone into schools to show the
effects of school based interventions that are focused in the arts.
Liana Lowenstein compiled a large document encompassing a variety of intervention
related activities used by multiple public health practitioners as part of an arts based intervention
(2008). Many of these interventions seem like a usual class activity, but behind it that includes
facilitation time, discussion of the activity, and the activity actually fueling more positive
interaction than what may occur in therapy. For example, M.E. Leroys intervention involved
covertly creating a positive therapeutic environment so that they can isolate particular events that
may pre-occupy the clients in order to address any feelings of guilt and responsibility. The
children use materials to create a time machine, allowing them to escape through the physical
creation of art and the imaginary possibility of escaping to another time. It allows children to
address ideas of going back and addressing trauma. (Leroy 2008).
Trauma
Sometimes community is created through the school system, while sometimes they are
created through shared experience(s). Trauma survivors are usually greeted with feelings of
isolation, anxiety, etc.; as a result Southeast Missouri University Department of Nursing was
trying to find a way to show how nurses could be used in a creative way to have positive impact
on the well-being of trauma survivors. They decided to create a seven week course for women
who have experienced trauma to have a group space to create art and have the forum to discuss
their trauma, and/or have respite to focus their minds on something other than trauma. The
nurses discovered a dramatic rise in self-worth, esteem, and lower anxiety/depression. It was
concluded that creative group therapeutic practices were a cost effective, management tool for
trauma survivors outside of traditional therapy environments (Garner 2015).
This study shows that the physical creation of art for yourself and others is a way to take
control of your surroundings. Flow is the psychological concept that by absorbing oneself in an
activity allows for the participant to escape (Csikszentmihalyi 1990). They used the

psychological idea of flow to suffice the explanation of creative expression as a therapeutic


medium. Furthermore, finding a solution when traditional support services that are labor and
psychologically intensive have been exhausted, art was seen as an easier to execute alternative.
There was also the positive outcome that came outside of the sessions in that art kits could be
taken home, so the boundaries of the facility did not limit artistic expression.
Native Populations
In the intersections of art and intervention, Native populations are a good example of
taking the abstract concept of art and applying it to the communitys history. Many interventions
that have to do with Native populations are sensitive to the imperialism they have faced, and how
art could be used not just as a tool of empowerment but also a way of expressing cultural history.
These interventions fully involve the community, beyond just stakeholders, to the development
and implementation of the program. This allows the interventions to remain culturally relevant
and sustainable even after the interventionists may leave the program (Gray, Boehm, Farnsworth,
& Wolf 2010).
With the trauma and school environment, they are more communities brought together
by circumstance, meaning school ends, and trauma is not a desirable way to create community.
In communities connected by ethnicity and history, however, there is more of a need to connect
to that history for a successful intervention. When extending this to a creative expression based
intervention, what must be taken into consideration is that all ethnic groups have a history of
artistic expression far before the intervention. Traditions have been passed down through the
generations that include methods of communicating belongingness, creating group cohesion, and
maintaining community identity. (Gray, Boehm, Farnsworth, & Wolf 2010). The interventions
found had success because they did not propose to create a different perspective of art for Native
populations, rather they opened up an intellectual space for the possibility of recreating art from
their ethnic group. For example, using storytelling as the activity in the intervention worked as a
result of the interventionist working collaboratively with the participants and art facilitators to
create a socially collaborative event. This opened a dialogue to reflect upon how past creative
expression could be used for modern day struggles and development (Richardson 2010).
Discussion
Interventions presented in this literature review displayed that using creative expression
as a tool to increase self-awareness, self-expression, constructive behavior, and communication
skills utilitarian capabilities. Furthermore developing these skills are fundamental to successful
behavioral change (Gussak and Ploumis-Devick 2004). Public health practitioners were the ones
assessing, implementing, and evaluating the program consenting psychological text, past arts
based programming with high efficacy, and easy to execute art activities. What many of the
interventions documented were missing were actual artists.
While these interventions showed positive results, they lacked artists who could have
contributed their skills and/or expertise to many parts of the intervention. There are important
aspects to an intervention that can only be enacted by a public health practitioner (such as
creating a theoretical model that includes health theories), but including artists could improve the
efficacy of the intervention. Credible evidence has been generated over the last decade to
demonstrate the synergies and positive outcomes that arise from research processes bringing
together diverse skills and expertise from amongst artists and scientists (Edmonds and Leggett
2010). Generally artists of have been seen as high cost, low return parts of the labour force.
However, having an artist present who does not need any training in the tools for the intervention

will give the public health practitioners time to train and facilitate less arts based components of
the intervention (Casserta & Cuccia 2001).
The only interventions that involved artists were for Native populations. While the public
health practitioners moved on to other interventions, artists were the ones able to stay after the
interventions conclusion. They were sustainable not only because they built upon the history of
their culture, but also because the facilitators created a community connection to the participants
(Bequette 2009). They built upon the already existing cultural capital, something that was not
feasible on the school environment and for trauma victims for obvious reasons. This does not
mean that the interventionists cannot pull from the wealth of cultural competence that already
exists in the education and counseling fields (Cheng 2006). Public health needs creative
expression based programming for innovative programming is needed to further the field.
Innovation is needed to more effectively address issues within communities that are outside the
norm.
Recommendations
Recruiting artists to work in interventions is just like recruiting any other community
stakeholder, and the work is already being done. There is already work being done in public
health in conjunction with artists that are more about restructuring the ecology and built
environment of the area. Nine Mile run used artists to reinvent Pittsburgh recession stricken
factories into collaborative art pieces. Art is not just a medium for display, it is interactive and
individually based even in a group setting with specific instruction. Since many arts education
specialists have difficulty sufficing the high cost of some art programs, having a public health
basis as a justification for programming could be an asset to them as well (Carney 2010).
Two years after a highly successful arts program in an indigenous community, they found
even more success my looking into the community artists as educators. Students trusted the
artists more since they came from the community and there was not that issue of holding back
that could come from someone outside the community comes in. Usually this sort of tap into the
community for resources is intrinsic to modern intervention development and implementation,
yet this is the only study found wherein they saw the utility of community based artists as
intrinsic forces for the intervention. In their conversations with the youth participants,
facilitators also found that youth commented on how the workshop taught them new skills, and
provided new possibilities and opportunities for them to explore the arts in the future. Finally,
artist facilitators talked about the relationships formed between themselves and the youth
participants as being one of the most positive components of the workshop. (Fanian, Young, &
Mantla 2015).
It makes a lot more sense to plan a curriculum focusing on understanding the role of
artists, artistic practices, and the arts in reflecting and shaping history and culture and to then
incorporate objectives related to formal properties, analytic techniques, or media processes into
these larger themes. What is at stake is making use of the structure (intervention) to exemplify
the very heart of the art educational experience for the student, for the school, and for the
community (Gude 2007).
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