Deborah Hayman Ehpid 2011 Dissertation

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Healthy 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.

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Acknowledgments

I would like to thank all of those who participated in the interviews and my

friends and family for their support and patience and their useful insights while

completing this dissertation.

I would also like to thank my tutor Ian Warwick for his support and listening to

me work through many half ideas until they turned into coherent sentences!

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Table of Contents
Acknowledgments.............................................................................................................2
Table of Contents..............................................................................................................3
Abstract..............................................................................................................................5
Chapter One: Background and Research Questions..........................................................6
Introduction...................................................................................................................6
Background ...................................................................................................................7
Chapter 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
Built Heritage..........................................................................................................40
Chapter Three: Methodology..........................................................................................47
Preparation...................................................................................................................48
The Study Design........................................................................................................49
Sampling......................................................................................................................50
Data Collection Methods.............................................................................................52
Analysis.......................................................................................................................54
Ethical Considerations.................................................................................................55
Limitations ..................................................................................................................56
Chapter Four: Findings....................................................................................................57
Group One...................................................................................................................57
Past Experience........................................................................................................59
Present Experience..................................................................................................63
Perceived Impact.....................................................................................................66
Group Two...................................................................................................................69
Past Experience........................................................................................................70
Group Three.................................................................................................................77
Past Experience........................................................................................................78

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Similarities between the Groups..................................................................................83
Definitions of Health, Wellbeing and Health Promotion........................................85
Chapter Five: Discussion and Implications.....................................................................87
Intangible Heritage..................................................................................................91
Tangible Heritage/Artefacts....................................................................................94
Built Heritage..........................................................................................................97
Implications.................................................................................................................99
Policy.......................................................................................................................99
Programming.........................................................................................................100
Further Research....................................................................................................102
Conclusion.................................................................................................................103
Appendices....................................................................................................................104
Appendix One ...........................................................................................................104
Consent Letter............................................................................................................104
Appendix Two .........................................................................................................106
Types of Activities.....................................................................................................106
Appendix Three .......................................................................................................108
Definitions ................................................................................................................108
References.....................................................................................................................110

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Abstract

There is an increasing awareness of the importance of cultural heritage in

health care but what of the value of heritage more generally in promoting health

and wellbeing? This dissertation focuses on how health and wellbeing might be

promoted through the use of heritage-focused programmes and activities.

Through individual and group semi-structured interviews, 18 respondents were

asked about their involvement in heritage-based activities, whether they

perceived these activities had an impact on their health and wellbeing and, if

so, in what ways. Analysis of interview findings highlighted that, for these

respondents at least, involvement in heritage-based activities generally had a

positive impact on their perceived health and wellbeing. This study contributes

to an emerging understanding of the associations between heritage and health.

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Healthy Heritage: The role of heritage in

promoting wellbeing

Chapter One: Background and Research Questions

Introduction

Every day we are surrounded by heritage, be it the buildings we pass on our

way to work, the train station we travel from, the parks, museums and galleries

we visit for leisure or the photographs and stories we pass down through the

generations. How do these places and artefacts make us feel? What effect do

they have on our health and wellbeing? This dissertation explores the

contribution heritage might make to our perceptions of health and whether a

heritage-based approach could contribute to the promotion of health and

wellbeing.

We live in a multicultural, globalised world in which societies, culture and our

financial 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 mean

equality. For some, the stages in history that have led to multiculturalism and

globalisation have meant a loss of agency as cultures have become diluted,

assimilated or marginalised. Policies and programmes that do not take into

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account the functionings and capabilities of an individual or community may

therefore cause more harm than good. No matter the view taken, there are

definite health and wellbeing consequences of the importance placed on what

different groups value. Questions have begun to be asked regarding social

capital and socioeconomic impacts on our health both in the UK and in the

international development context (Stephens, 2008; Wilkinson, 1997; Marmot,

2005). But how do our cultural surroundings influence the health and wellbeing

of an individual and the community in which they live? In particular, how could

the heritage that surrounds us be effectively used in promoting wellbeing?

Background

The idea for this dissertation began while I worked for the Heritage Lottery Fund

(HLF). Thousands of funding applications came through the office, all of which

claimed to be important to the heritage of the area for aesthetic reasons or for

the participation, inclusion and enjoyment of the local people. Some had

specific health-related outcomes, but often these were not made explicit. This

gave me cause to question if every such project contributed in some way to the

general wellbeing of the population, at least through its perceived emotional and

physical benefits. If such heritage-based projects had a wider value to the

participants in health terms, could this be used to inform the promotion of

health?

Heritage in its many forms is undeniably a part of our everyday lives.

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‘{T}he cultural industries employed close to 1.4 million persons, which

represented five percent of the total UK workforce at the time; revenues from

the cultural industries was in the excess of £60Bn; they contributed £7.5Bn to

export earnings (excluding intellectual property); and value added (net of

inputs) was £25Bn, which significantly was four percent of UK GDP, and in

excess of any (traditional) manufacturing industry’ (Pratt, 2004: 4).

It would seem reasonable to expect an industry of such magnitude to make a

significant impression on our health and wellbeing.

Over the centuries, the movement of people between borders and around the

globe has had profound consequences on the heritage of individuals and the

countries to which they have travelled and sometimes settled. As people and

therefore aspects of their cultures move around and settle in other countries,

the world becomes ever more multicultural. In fact, it has been argued that in

this ‘age of globalisation’ ‘peoples’ lives are no longer predominantly shaped by

what 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 health

and wellbeing, with the purpose of establishing whether and how heritage-

based activities could be used in promoting health. By exploring this area, I

hope 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, and

might provide a more holistic approach to promoting health. The research

questions below focus on definitions of health, wellbeing, health promotion and

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heritage and support an exploration of the possibilities of heritage-based

programmes and activities to promote health and wellbeing.

The dissertation is informed through the use of three overarching research

questions:

1. What is already known about the links between health, wellbeing

and heritage?

2. What perceptions do those taking part in heritage-based activities

hold regarding the links between their own health, wellbeing and heritage?

3. What are the implications of this for promoting health and

wellbeing through heritage?

In the following chapter, I will explore the various definitions of health, wellbeing

and heritage and contextualise the study. The Methodology used is explained in

Chapter Three, providing insights into how the semi-structured interviews were

carried out. Chapter Four lays out the findings of the interviews, explaining the

results both positive and negative of a heritage-based approach to promoting

health. These findings are discussed alongside literature from the fields of

education, health promotion and international development in order to explore

the impact heritage-based activities and programmes might have upon health

and wellbeing. The implications of a heritage-based approach to promoting

health and wellbeing based on the findings and discussions are explored in

Chapter Five.

The definitions used throughout this dissertation are: health promotion as an

activity that aims to strengthen individuals’ skills and capabilities in order to

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obtain better health and wellbeing. Wellbeing will be defined as a holistic term

looking at health as far more than the absence of disease. Heritage is anything

from the past that we value and want to keep for future generations, and, for the

purpose of this study, falls under five main categories: Intangible Heritage,

Tangible Heritage/Artefacts, Natural Heritage, Built Heritage and Cultural

Heritage.

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Chapter Two: Literature Review

‘Everyone has the right to a standard of living adequate for the health

and wellbeing of himself and of his family, including food, clothing, housing and

medical care and necessary social services, and the right to security in the

event of unemployment, sickness, disability, widowhood, old age or other lack

of livelihood in circumstances beyond his control’ (Article 25, UN Declaration of

Human Rights, 1948; webpage)

As stated above, health and wellbeing are basic human rights of every

individual, regardless of race, religion or gender. But what is ‘health’, and what

makes ‘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 absence

of disease, adopting the scientific medical model. The belief that the body is like

a machine and so each part can be treated separately has influenced medical

thought for centuries (Naidoo & Wills, 2000). However, in recent times this view

has been widely criticised as being too narrow, ignoring the social and

environmental factors that contribute to health. As the Commission on Social

Determinants of Health stated, ‘Avoidable inequalities in health arise because

of the circumstances in which people grow, live, work, and age, and the

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systems put in place to deal with illness. The conditions in which we live and die

are in turn, shaped by political, social and economic factors’ (2008: 3). This

being so, is it sensible to think of health as the absence of disease or illness, or

should we look at health more holistically?

Although there is still much discussion about exactly what ‘health’ means, many

of those working in health promotion would now agree that health encompasses

more than the absence of disease. Aggleton and Homans (1987) and Ewles

and Simnet (1999) prefer an approach that accounts for the Environmental 1,

Societal2, Physical3, Mental4, Social5, Sexual6, Spiritual7 and Emotional8

dimensions of health (Naidoo & Wills, 2000). Sen (1999) agrees with these

views and expands further that health and wellbeing is more than just about the

physical; rather, good health and wellbeing are essential to achieving ones’ full

capabilities. Therefore, in addition to basic needs such as nutrition, shelter and

adequate sanitation facilities, human beings need optimal psychological

conditions as well, such as confidence, happiness and the political freedom to

make choices. The arguments put forward by Sen fall under the more objective

measures of health and wellbeing which argues that people may adapt to the

circumstances in which they find themselves and so self-evaluation in terms of

satisfaction and happiness will become distorted. Measuring functionings and

capabilities has the advantage of helping focus policy makers’ attention to

people’s primary needs. This has been the inspiration for lists of indictors such

1
physical environment in which we live
2
how society is structured, infrastructure
3
absence of illness
4
feeling able to cope, positive sense of purpose
5
having support, friends, family
6
ability to express one’s sexuality
7
ability to put religion, beliefs, principles into practice
8
ability to express feelings

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as 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 is

that of the WHO (19489): ‘Health is a state of complete physical, mental and

social wellbeing and not merely the absence of disease or infirmity’. Health and

wellbeing appear to be interlinked but what is wellbeing and what makes it

different 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 and

incapacity. It requires that basic needs are met, that individuals have a sense of

purpose, that they feel able to achieve important personal goals and participate

in society. It is enhanced by conditions that include supportive personal

relationships, strong and inclusive communities, good health, financial and

personal security, rewarding employment, and a healthy and attractive

environment. Wellbeing cannot be fully measured by a single indicator.

Numerous factors influence individual wellbeing. It is only possible to identify

and measure some of them’ (2011: webpage).

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Preamble to the Constitution of the World Health Organization as adopted by the International Health
Conference, New York, 19 June - 22 July 1946; signed on 22 July 1946 by the representatives of 61
States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7
April 1948. The definition has not been amended since 1948

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UNICEF in their 2007 report ‘Child Poverty in Perspective’ listed six dimensions

of child wellbeing: Material Wellbeing, Health and Safety, Educational

Wellbeing, Family and Peer Relationships, Behaviours and Risks, and

Subjective Wellbeing. This more subjective approach to health would take into

account how people evaluate their own lives.

Perhaps this is where the distinction lies between health and wellbeing. How

people measure their own feelings of pleasure and displeasure, happiness and

sadness, satisfaction and dissatisfaction may indicate how society is structured

and how this affects the individual in a way that has an impact on wellbeing.

While, perhaps harder to measure, these indicators have been found to

correlate with actual behavior and key physiological variables (NIACE, 2009)

and can be found in many countries definitions of health. For example, Canada

defines mental health as

‘the capacity of the individual, the group and the environment to interact

with one another in ways to promote subjective wellbeing, the optimal

development and use of mental abilities (cognitive, affective and relational), the

achievement of individual and collective goals consistent with justice and the

attainment and preservation of conditions of fundamental equality’ (Canadian

Department of National Health and Welfare, 1988, found in Sainsbury, 2000:

82),

This definition is a further example of the importance of how we evaluate our

own wellbeing.

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Wellbeing 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 well

as how people view their own lives. Wellbeing could be seen as a social and

cultural construct (Eraut & Whiting, 2008: 4) as well as having ‘positive and

sustainable characteristics which enable individuals and organisations to thrive

and flourish’ (Institute of Wellbeing, 2006-2008: webpage).

We have now established that the term ‘health’ encompasses far more than the

absence of disease, including emotional, spiritual, social and environmental

factors but is still measured objectively. Meanwhile, ‘wellbeing’ encompasses all

of these ideas of health as well as people’s own perceptions of their health and

their values, agency and behaviour. Wellbeing could be described as a

subjective 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. In

the UK, the 19th century saw a huge rise in top-down health promotion through

legislation and other government activities in response to health crises such as

cholera outbreaks and poor sanitation (Naidoo & Wills, 2000). Approaches have

ranged widely from exploring individual behaviour change to community action

and capacity building to policy change and inter-sectoral working (Nutbeam &

Harris, 2004). Programmes have targeted individual behaviour through

information and mass media campaigns aimed at changing the behaviour of

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individuals and groups. More recently, participatory techniques have begun to

gather greater momentum, particularly in the field of international development

(Manandhar et al., 2008). However, before the 1978 Alma Ata Declaration on

Primary Health, very little about international cooperation on health promotion

had been formalised. The Alma Ata Declaration pointed the international

community towards partnership working and for governments to work at all

levels to promote health. At the international level, the World Health

Organisation (WHO) has taken a leading role in health promotion. In 1984, the

WHO regional Offices for Europe described health promotion as the ‘process of

enabling people to increase control over, and to improve, their health. {Moving}

beyond a focus on individual behaviour towards a wide range of social and

environmental interventions’.

This concept was also captured by the Ottawa Charter for Health Promotion,

1986, which saw a real move towards recognising the complex interplay of

factors that contribute to health by providing a more holistic description of health

promotion:

‘Health promotion is the process of enabling people to increase control

over, and to improve, their health. To reach a state of complete physical, mental

and social wellbeing, an individual or group must be able to identify and to

realise aspirations, to satisfy needs, and to change or cope with the

environment. Health is, therefore, seen as a resource for everyday life, not the

objective of living. Health is a positive concept emphasising social and personal

resources, as well as physical capacities. Therefore, health promotion is not

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just the responsibility of the health sector, but goes beyond healthy life-styles to

wellbeing’ (p1).

The Jakarta Declaration on Leading Health Promotion into the 21st Century

(1997) was signed. This Declaration reiterated what had been set out in the

Ottawa Charter (1986).

It was not until 2005 that the Bangkok Charter for Health Promotion in a

Globalised World identified actions and commitments for the international

community to make towards health promotion. It hoped to ‘[build] upon the

values, principles and action strategies’ (p1) of these foundations. However,

many feel that the Bangkok Charter was rather a change in discourse from

Ottawa. Mittlemark (2007) notes that Bangkok focuses on globalisation, macro-

level factors and policy, while Ottawa focuses more on community and the

socio-ecological approach. As Mohindra (2007) states ‘[t]he need for macro-

level, broad-based interventions is greatest among developing countries, where

the 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 all

levels, civil society, the private sector, international organisations and the public

health community are all critical to health promotion. These Charters taken

together show how complex health promotion is and prove the need for

appropriate interventions at all levels of society, from the individual to the

community, to the national Government to the international level. At the national

level, each country has its own health promotion entities and resources. Health

promotion has changed and evolved with the political ideologies and distribution

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of power of the time. In the UK, this has meant the creation of the Welfare

State, in particular the National Health Service (NHS), which has often been

seen as the best place for health promotion to take place. However, over time

preventative measures and health education have given way to the emphasis

being on policies to reduce social inequalities in order to allow people to make

healthier choices (DoH, 2008). This has meant health promotion is no longer

settled in one sphere but across government departments and the voluntary

sector. Current legislation such as the Localism Bill (2010) and the Health and

Social Care Bill (2011) alongside the Personalisation agenda will further change

how and where health promotion takes place.

What these international and national policies and bodies have in common is

the notion that health promotion as a shared responsibility: that action must be

taken 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 done

to an individual or a group of people. As Sen (1999) suggests strengthening

skills and capabilities so that individuals have the opportunities and ability to

take action is what health promotion should aim for. It is often thought that

health promotion must be based on a judgement of when an intervention is

needed to promote a particular area of health such as awareness of HIV/AIDS

or malaria (Naidoo & Wills, 2000). However, health promotion is not simply an

answer 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 we

socialise and the activities we take part in.

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Therefore, health promotion in its many forms and at all levels is for the purpose

of aiding individuals, communities and societies in increasing their abilities to

attain better health and wellbeing in order to live a fuller life. But how could a

heritage-based approach help promote good health and wellbeing? And what is

heritage?

What is heritage?

Just as health promotion, health and wellbeing are debated issues, so too is

heritage. Heritage can mean many things to many people and influences

everything we do and everywhere we go. It is a term that encompasses a huge

range of things from the past that we value and want to keep for future

generations, both tangible and intangible, yet is a concept that can feel very

remote from our everyday lives.

The Heritage Lottery Fund website (2009) lists the following as examples of

heritage:

• 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 history
11
including people who have migrated to the UK

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• 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 and

places, whether negative or positive, and therefore contribute to our overall

health and wellbeing. Although there is no absolute definition of heritage, for the

purposes of this dissertation, I will concentrate on what I consider to be the five

main 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 Cultural

Heritage.

These definitions are informed by professional thought as well as lay concepts

of 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, buildings

such as Tombs among others.’ (Male, user, Group One)

And

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‘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 Heritage

Intangible heritage is non-material heritage. Oral histories of people’s

experiences, spoken word, languages and dialects fall under this category. It

may also include folk stories and legends that have been passed down through

the generations but not written down, as well as skills such as dances or

hunting that we learn from elders. Faith and beliefs may also fall under this

category.

Tangible Heritage/Artefacts

Tangible Heritage/Artefacts concerns material heritage, such as museum

exhibitions, photographs, paintings, books, archives, and archaeological sites. It

can also include family heirlooms that have been passed down through the

generations.

Natural Heritage

Natural heritage includes areas of natural space such as parks, reservoirs,

designed and natural landscapes as well as wildlife, flora and fauna. Gardens

and allotments may also be included under this category.

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Built Heritage

Built heritage includes historic places, buildings and space as well as places

and objects linked to our industrial, maritime and transport history. This

category may also include urban or town regeneration projects.

Cultural Heritage

Cultural heritage includes cultural traditions such as art, stories, festivals, crafts,

music, dance and costumes as well as beliefs, religion and languages and

dialect. It may also include cultural practices such as rituals, theatre, sports, art

and other entertainment.

All of these categories will contribute to the histories of peoples and

communities and of place. Heritage does not necessarily have a monetary

value; the value is intrinsic and may change from person to person. A family

heirloom for instance may have no monetary value and no value to anybody

other than the family to whom it belongs but can still have a heritage value.

I will explore throughout this dissertation whether there is a perceived

association between health, wellbeing and heritage and the possibilities for a

heritage-based approach to promoting health and wellbeing. The next section

looks at what is already known about the links between heritage, wellbeing and

health promotion.

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Connections: what do we already know about the links between

heritage, wellbeing and promoting health?

Is heritage just genetics?

The link between wellbeing and heritage most often cited in the literature

focuses on the medical heritage of certain groups such as hereditary illnesses

or for example the prevalence of Lupus in women of African descent. Although

there is little scientific evidence to support it, genetic predispositions towards

morbidity and mortality are traditionally seen as being the reason for racial or

ethnic differences in health outcomes (Finch et al., 2001).

We may all have some genetic predispositions, but our wellbeing is more than

simply the absence of illness or disease. Predispositions can become actual

illness or not depending on the circumstances a person is put under. For

example, Finch et al., (2001) state that higher levels of stress, anxiety,

depression, paranoia and even psychosis have been linked to ethnic

discrimination. A person may be predisposed to depression but in one

circumstance will not suffer from depression, yet in circumstances under which

he/she is ethnically discriminated against, depression will develop.

Epidemology is used to help us measure aspects of health such as

environmental and socio-economic indicators, which may indicate the likelihood

of predispositions turning into illness. Palacios and Portillo (2009) found that to

understand health, not only should culture, lifestyle and genetics be taken into

account but also ‘how intersections of poverty, geography, discrimination and

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racism interplay individually and collectively on health’ (p15). Similarly, the

WHO have also found that social determinants of health such as where a

person is born, grows, lives, works and ages are mostly responsible for health

inequalities. A persons’ circumstances can in fact be shaped by the distribution

of money, power and resources at global, national and local levels (WHO,

2008).

This clearly shows that the link between heritage and wellbeing is about far

more than genetic heritage. But, in what other ways does heritage affect our

wellbeing?

Globalisation and Multiculturalism

The world is currently organised into approximately 200 sovereign states, each

one ‘embodying a separate normative tradition shaped by the vagaries of its

history 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 and

traditions and many ways to view even our shared history. In the America’s for

example, the Native American population has contained between 300 and 600

separate tribes, each with their own as well as shared cultures, beliefs, and

experiences and take on history (Native American Education Centre, 2005).

Canada claims to have over 200 different ethnic groups (Centre for Addiction

and Mental Health Policy, 2007); and Africa contains hundreds of different

ethnic groups with their own dialects and cultures.

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Since the 1960s, the term ‘multiculturalism’ has been used to describe the

acceptance and promotion of multiple cultures within a society (McLean &

McMillan, 2003). It is the view that all cultures are equal. However, for many

groups and communities around the world, multiculturalism and globalisation

have meant a loss of freedoms and of functionings. Colonialism, the slave

trade, westernisation and other political movements have forced many cultures

and religions to change or disappear. While increased trade, travel and

migration in modern times have continued to spread cultures around the world,

increased globalisation has also exacerbated of historical inequities and a

widening 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 sees

functionings as the activities or states of being that we value and therefore

contribute to our wellbeing. If policies focus on single functionings then

inequality is more likely. However, by focusing on capabilities or a combination

of functionings, a person is more likely to have the agency to pursue what they

value (Human Development and Capability Association, 2005; Sugden, 1995).

Most importantly for wellbeing, the capability approach emphasises freedom to

pursue what we value. This emphasis on participation and functionings means

that many capabilities must be culturally specific. They will depend upon the

knowledge, history and values that shape a society (Alkire, 2005; Robeyns,

2005).

According to Rawls (1993), people’s desire for social belonging is an essential

human characteristic and a prerequisite for human personalities to flourish. It is

26

therefore important in a multicultural society to allow individuals to find

communities12 where they feel comfortable and can feel a sense of belonging.

Multiculturalism should mean living in a society made up of many different

cultures that are linked by a common cultural thread. For instance, the Nigerian

diaspora community in London will have an identity based upon their Nigerian

heritage but will have a common link of British culture with many other groups in

Britain. However, there is a careful balance between a multicultural society and

one 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 term

actually encouraged separatism (Baldwin & Rozenberg, 2004). For many, the

common view of multiculturalism is rather negative seeing communities as living

side by side without interacting or groups of people with similar identities

excluding others, eventually leading to tensions or conflict (Levy, 2000).

The UN Declaration of Human Rights (1948) states that ‘Everyone has the right

to freely participate in the cultural life of the community, to enjoy the arts and to

share in scientific advancement and its benefits (Article 27) as well as having

the right to health as described in Article 25. Not only should everyone have the

right to enjoy all these aspects of life but they could also be used to promote

inclusion and therefore a better sense of wellbeing. A heritage-based approach

may be able to do just this; celebrating the heritage of an area or community

and all of the different groups who live there can therefore be seen as a way of

encouraging an inclusive and participatory multicultural society.

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A community does not have to be a geographical area. I use the term to mean any group of people
sharing a similar characteristic over which they feel a tie to each other. This could be a diaspora, a sports
team, a geographical area, an internet based group that talks about a certain subject, a single mothers
group etc.

27

The heritage of an individual, group or society is also important when

understanding why they think about health and wellbeing in the way they do.

Lay Concepts of Health and Cultural Heritage

Lay concepts of wellbeing are based upon the history and knowledge of the

society in which we live, work and grow. These rich tapestries of human

experience and heritage create different lay concepts of health and wellbeing,

all of which are equally valid when promoting health. A heritage-based

approach should enable these cultural beliefs to be intricately bound with the

prevention methods. Even when a cultural belief leads to misunderstanding

about a health issue, surely there is still value in understanding where it came

from in order to adjust it in a culturally sensitive way.

The WHO definition of health and wellbeing (1948) may be the most used today

but it still provides health promotion with some difficulties over conceptual

clarity, particularly concerning wellbeing. As we are each influenced by our

cultural, professional or societal context, we tend to view health and wellbeing

issues from the narrow confines of our own sphere, hence different countries

and different groups within countries will view health and wellbeing in different

ways. This causes problems when creating appropriate public health

programmes. For example, ‘ in the Western world the Enlightenment in the 19 th

Century brought with it a change in how we viewed the world; traditional

religious belief gave way to more scientific thought, rational, free thought and

formal organisation replaced ideas of clan, race and kingdom’ (Chabbot, 2003:

6).

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However, for others this meant colonisation and a very different history.

Understanding these heritages helps us to understand the wellbeing issues

people face today.

It is reported that the indigenous Maori population of New Zealand see health

as four dimensions of life; the spiritual, the intellectual, the physical and the

emotional, all of which are in unity with the environment which are then reflected

in the Maori culture through song, custom, subsistence, approaches to healing,

birthing and rituals associated with death (Durie, 2004). Similarly the Australian

Aboriginals define health as ‘not just the physical wellbeing of an individual

but...the social, emotional and cultural wellbeing of the whole community in

which each individual is able to achieve their full potential as a human being

thereby bringing about the total wellbeing of their community’ (National

Aboriginal Community Controlled Health Organisation, 1997 found in Sainsbury,

2000: 82).

Indigenous views on health and wellbeing and their intrinsic relationship with the

natural and cultural heritage are now beginning to be accepted internationally.

These definitions are important as they show a long history of holistic

approaches to health and wellbeing as well as strong connections between all

five of the heritage categories. They place the responsibility of one’s health

upon 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 effective

health promotion does not always lie in the obvious areas such as the health

sector alone.

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What is common sense in one culture may not be in another and lay concepts

of health will be acquired through various experiences within society solutions

therefore must also be found in various aspects of that society, as well as being

based upon medical and scientific knowledge. The ways in which heritage can

be presented and used can provide a strong platform on which to base this mix

of the scientific and lay concepts of health and wellbeing. This can be seen

through the five types of heritage:

Intangible Heritage
Intangible heritage can also help explain the reasons why we believe in certain

values and hold certain perceptions and knowledge. Some long-held

perceptions can be extremely damaging such as the belief held by many in

South Africa that having unprotected intercourse with a virgin girl would cure or

prevent HIV/AIDS. This has caused a high number of young girls to be forced

into sexual relations with men who often carried the virus (Cameron; 2005). This

sort of misinformation, which can be passed down through the generations as

fact, is a negative consequence of intangible heritage.

There are some who may use intangible and other heritage as a way to inspire

fear and misconceptions, especially damaging notions of ‘the other’. However,

by looking deeper into such myths we can often find reasons behind them and

ways to help people reinterpret ‘knowledge’. More often than not, traditional

knowledge can help inform and aid understanding. In fact, there is a danger in

disregarding and avoiding notions of otherness (Said, 1995). It is perhaps better

30

to try to understand them and critically asses these notions in order to

overcome them.

Over 80% of the world’s population depend upon traditional medical knowledge

for their primary care (Ross; 2007). However, traditional knowledge has in many

cases been lost, especially in Britain, where according to Dr Susan Antrobus of

Tees Valley Biodiversity Partnership,

‘we have lost a vast amount of our folk knowledge and plant identification

skills....The resurgence of interest has gone back to pre-First World War printed

material. The only thing that I find older rural people remembering is using

rosehips in the war, eating nettles and hawthorn leaves, eating clover flowers

as sweets, whereas in the past we used a great deal of herbal remedies, which

is documented, although not well, as these would have been mainly

administered by wise woman and midwifes who were often illiterate’ (From

preparatory discussions with Dr Susan Antrobus, September 2010)

Dr Antrobus believes this is what often happens when the responsibility for

something is handed entirely over to professionals. Before the NHS people

managed minor ailments themselves using knowledge passed down through

the generations. Applying these herbal practices meant people took decisions

on 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 and

subsequently lost confidence in treating ourselves and our families for minor

ailments.

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Although ‘old wives tales’ have been responsible for ineffective remedies, the

reasons why these came about are interesting in themselves. It may be that an

individual’s endorsement of certain heritage values could influence health fears,

which in turn may affect the performance of preventative behaviours or

encourage people to try ineffective remedies. Theories such as Diffusion of

Innovations (Nutbeam & Harris, 2004) that rely on messages being picked up

by some and then diffused to others do not just apply to good ideas. Health

promotion should aim to use such theories to dispel myths about traditional

remedies, for instance, and pass on the very real benefits of traditional

medicine.

Although there may be some negative perceptions of the31professionalization

of health, ‘health promotion has thrived at community level even when national

policy environment has been less supportive’ (Mittlemark, 2007: 101). The

heritage-based approach to promoting health could contribute to a positive

relationship between professional and lay concepts. For example, in South

Africa in 2004, the traditional Health Practitioners Bill was passed to recognise

the important role of traditional healers in South African culture and medicine.

The Bill set out ethical norms and standards which hoped to regulate traditional

healers and their practices while allowing them to continue to treat people with

traditional methods (Ross; 2007). This Bill shows the importance of keeping

traditional medical practices alive as well as benefits they present particularly to

indigenous populations.

Heritage-based projects and activities could be a participatory and informative

way of passing on these traditional practices as well as influencing peoples’

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wellbeing through social interaction and learning. The interview findings point to

a level of empowerment found in being able to have control over treatment

without necessarily visiting the doctor. This may also be where intangible

heritage can combine with natural heritage to create projects in line with the

ecosystem approach put forward by Forget and Lebel (2001). They state that

‘the ecosystem approach draws on science and technology to explain the

causes and effects that harm ecosystems and public health, and especially the

linkages between them’ (p4)

As stated by UNESCO, the cultural importance of intangible heritage is not the

only factor to take into account. Our health and wellbeing are affected by the

social, economic and political climate; therefore, the impact of heritage on our

health and wellbeing can be seen in the socioeconomic value of the wealth of

knowledge and skills passed down through the generations. Furthermore,

intangible heritage is also living heritage. Celebrations such as the Mexican Day

of the Dead that are important culturally are also essential to the tourist industry

and therefore the economic wealth of a community. This link between heritage

and economic development may help to break down nationalist barriers while

preserving 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 to

encourage community cohesion and a sense of identity, both of which are

important to our wellbeing, group and individual identity and aid our confidence

and ability to express ourselves. However, intangible heritage will also influence

our perceptions of others. Discrimination and racism often come from a lack of

understanding about the cultural practices of another group or individual. The

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barriers such discrimination creates impact upon all aspects of life for those

being discriminated against, which in turn has a negative impact on their

wellbeing.

Projects that aim to celebrate the intangible history of a community or area may

help instil a sense of cultural pride while enabling others who may not share the

same culture to participate and learn. This might spread understanding and

inclusion, which are essential to wellbeing, and might also break down barriers

put up through false perceptions. Of course, misconceptions and misinformation

can be spread as well, but a heritage-based approach would aim to explain the

reasons behind such information and re-inform with ‘correct’ knowledge.

Tangible Heritage/ Artefacts
The way we perceive and interpret heritage may be just as important to our

wellbeing as the way we are perceived. Museum exhibitions are probably the

best known source of tangible heritage/artefacts, but how these artefacts are

displayed and interpreted can create certain perceptions, some of which may be

damaging to a group’s wellbeing. This has become more evident in recent years

as indigenous peoples’ voices begin to be listened to and contribute to how

heritage is defined and displayed. Links have been established between this

new voice in heritage and increased indigenous wellbeing as they ‘seek to

restore cultural values and identity and renew spiritual dimensions of their

cultures’ (Simpson, 2009: 122). Museums now understand that heritage is not

just about the preservation of objects from the past but also about how these

objects can be re-socialised. In some cases this has meant returning objects to

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their 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 and

educate. However, artefacts have often been displayed in inaccessible ways

and museums are now beginning to realise the need for inclusivity through

changing the way they display artefacts, how they advertise and how special

exhibitions are run. For example, Birmingham Museum and Art Gallery ran a

project called Hair: Community Stories from Birmingham. This exhibition was

free and included information and artefacts alongside hair related workshops

and talks, which explored the links between hair and cultural identity in the city

over the past 50 years. Tangible heritage was brought alive through the stories

of people living in Birmingham. Intangible heritage both living and from the past

was also used throughout the workshops and talks and in the exhibition itself.

The innovative methods used helped create an interactive, informative and

inclusive exhibition that brought in new visitors to the museum and provided

visitors with news skills and confidence.

They also developed an exhibition in the Community Gallery that addressed

mental health issues and have since developed further work including an Asian

Women’s textile group to tackle mental health distress in the Asian community

and an Ability Plus training programme for people with disabilities. The

Museum’s Audience Development Strategy 2010-13 described a need to

contribute to wellbeing by ‘developing inspiring audience development

programmes that support a range of social, intellectual, emotional and spiritual

needs. {And} Developing programmes that encourage healthy living.’ Of course,

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not all change will be so successful. Successful change requires money and

knowledgeable staff as well as displays that create a ‘continuity between

creation and heritage… {and} enable various publics, notably local communities

and disadvantaged groups, to rediscover their roots and approach other

cultures’ (UNESCO, 2011).

As more people live longer there are many challenges to be faced by society

including ‘social isolation, increasing physical frailty, declining mental health

and a decline in peoples’ ability to access services and programmes’ (IDeA,

2010: 2). Furthermore, participation in cultural or heritage activities could be an

effective way for older people to maintain their independence (HELM, 2006).

Tangible heritage such as museum displays, art, sculptures, photographs and

other artefacts can be excellent ways of engaging older people. Organised

transport for museum visits and heritage-based groups could encourage

increased levels of physical activity, mental stimulation and social inclusion.

Being able to move around and visit new places can have a positive impact on

wellbeing but tangible heritage projects do not always have to rely on taking

people to the artefacts.

‘Hospitals and other care settings that pay close attention to the overall

physical environment for patients can achieve real improvements in the health

of patients. Access and participation in the arts are an essential part of our

everyday wellbeing and quality of life’ (Speech by Secretary of State for Health,

2008).

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Heritage-based projects and activities may be a good way to use peer

education and provide positive role models (Turner & Shepherd, 1999). Peer

educators in a heritage-based setting can help reinforce behaviours particularly

in young people, who may be more willing to get involved in heritage-based

projects if they see other young people taking leading roles in the activity.

Furthermore, the skills gained by being a peer educator could increase

employment opportunities (UNICEF, 2004).

There is also potential for concepts to be reinforced and for participants to feel

empowered through heritage-based projects. One such project was ‘There Be

Monsters’ which was inspired by the Map and Atlas collection within The

National Archives. Sarah Griffiths, a project leader explained that the project

used expert conservators, map specialists and artists, alongside participants

from an outreach programme to ‘use devices and imaginary creatures inscribed

on some of the oldest maps to inspire adults with experience of mental ill

health. They would create a sculpture that was to be placed within the grounds

of The National Archives’ (From preparatory discussions with Sarah Griffiths;

2010).

The participants were from Workshop and Company, which is an organisation

that forms part of the Central and North West London Mental Health Trust. The

organisation found throughout the project that participant self-esteem and

confidence grew while the profile and reputation of the organisation was greatly

improved. The National Archives staff also found that the project helped them

overcome their own preconceptions and prejudices about mental health.

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Natural Heritage
In 2011, the Government White Paper ‘The Natural Choice: securing the value

of nature’ stated that ‘over 500 scientists from around the world have now

developed a tool by which we can assess more accurately the value of the

natural world around us. The National Ecosystem Assessment has given us the

evidence to inform our decisions’ (p2)

The National Ecosystem Assessment put the value of living close to a green

space at £300 per person per year in savings to the NHS. This is the first time a

monetary value has been put on the significance of green space to our health

and wellbeing. Although, previous studies have shown that contact with natural

heritage including plants and animals has ‘significant positive psychological and

physiological 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 of

hands-on contact with nature on children’s health and wellbeing recommended

nature-based activities in schools and lessons on sustainability. The basis for

this was that by identifying ways to improve wellbeing from a young age,

children ‘…would be more likely to reach their full potential both academic and

personal...’ (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 could

be instrumental in the ‘development of a positive self-image, confidence in ones

abilities and experience of dealing with uncertainty {which} can be important in

helping young people face the wider world and develop enhanced social skills’

(Ward et al., 2006 in RSPB, 2010: 4).

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In fact, Drurie (2004) suggests that the alienation of people from their

environment can be closely linked to the host of health problems that plague

many indigenous populations. This is not just a phenomena experienced by

indigenous peoples. It has been found that a lack of natural heritage in urban

communities can contribute to higher rates of violence and crime, less social

interaction 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 for

explaining and promoting health and wellbeing and that the ‘failure to embed

healthy settings within ecosystems is also a missed opportunity to enable more

integrated approaches to promoting the commonalities between health

promotion and sustainable development’ (Dorris, 1999 in Parkes & Horwitz,

2009: 95).

They use water as an example of an ecosystem, which is highly meaningful to

all human beings, has fundamental features that can be understood by all and

has huge importance to security, climate change and many other aspects of

political, economic and social life. The fact that it can also be geographically

placed allows for participation among communities including indigenous people

and place-based cultures. Ecosystems provide ‘tangible contexts within which

to fulfil overlapping objectives across fields with a preventative and pro-active

orientation’ (Parkes & Horwitz, 2009: 100)

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Of course, there are also many gaps in research that must be explored in order

to improve the accessibility of natural heritage for all. For instance, the impact of

bad experiences while outdoors or participating in a heritage activity may

negatively impact wellbeing. At the local government level better planning,

design and management of natural spaces can help keep them accessible, safe

and attractive. The Countryside Recreation Network recommended that

‘planners and developers should take green space into account especially as

part of economic regeneration strategies in both rural and urban economically

depressed 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 but

inappropriate development can have dire consequences on the environment

through over consumption of resources and degradation of ecosystems. In

order to maintain human health and wellbeing, it is essential that the

environment and our natural heritage be maintained. This approach takes the

emphasis away from the individual as it seeks to ‘strengthen environmental

supports within the broader community that are conducive to personal and

collective wellbeing’ (Stokols, 1996: 282). The UNCED Rio Declaration on

Environment and Development (1992) put many of these sentiments into the

international arena. Three particularly pertinent Principles found in this

Declaration are:

Principle 1- ‘Human beings are at the centre of concerns for sustainable

development. They are entitled to a healthy and productive life in harmony with

nature’;

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Principle 4 – ‘In order to achieve sustainable development,

environmental protection shall constitute an integral part of the development

process and cannot be considered in isolation from it’; and

Principle 22 – ‘Indigenous people and their communities and other local

communities have a vital role in environmental management and development

because of their knowledge and traditional practices. States should recognise

and duly support their identity, culture and interests and enable their effective

participation in the achievement of sustainable development’.

There are many ways in which natural heritage activities can be used to

promote health and wellbeing in a more individualistic way, such as

encouraging people to use green spaces for exercise. However, natural

heritage activities can also be used effectively in policy and planning to ensure

the sustainability of natural heritage as well as improving the population’s

wellbeing (Barton et al., 2009; Bjork et al., 2008). This can only be achieved,

however, by taking the emphasis away from individual behaviour change and

ensuring high levels of community participation.

Built Heritage
Research has shown that the many health inequalities are produced by the way

the area we live in is built and designed and how much natural heritage can be

easily accessed. The unequal distribution of quality health care, schools, leisure

facilities and places of work as well as the condition of housing, communities,

towns and cities are all described by WHO (2008) as being contributing factors

to health inequalities.

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A Task Group set up to look into health inequalities in England (2009) found five

main themes of health inequalities: Open and green spaces; Housing

conditions, 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 or

city is designed, the number of people using the same space and the quality of

services available have an impact on people’s wellbeing.

Built heritage can be historic buildings and towns that inspire and create

beautiful places to visit. It can also be about heritage-led regeneration of an

area that improves the area for all and impacts upon the wellbeing of its

residents. A report on the Role of Historic Buildings in Urban Regeneration

presented to the House of Commons Select Committee (2004) stated that

‘Historic Buildings provide a foundation for the regeneration of many of

our towns and cities. Regenerating these buildings can reinforce a sense of

community, make an important contribution to the local economy and act as a

catalyst for improvements to the wider area. They should not be retained as

artefacts, relics of a bygone age. New uses should be allowed in the buildings

and sensitive adaptions facilitated, when the reuse of an historic building is no

longer relevant or viable’ (p3).

It has been noted that heritage-led regeneration can help to generate higher

levels of participation in communities. During landscape and townscape

heritage initiatives, HLF (2004) research found that because these projects

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were long-term and concerned the built and natural environment of an area,

they attracted a higher level of participation from ‘newcomers and longer term

residents’. In fact it found that ‘86% of respondents noted participation from

people who “do not normally join in”’ (p4). The reasons for this may be that

people hold strong views about what they want their area to look like and how it

makes them feel.

In areas where crime levels are higher, heritage projects that look to make use

of derelict or empty buildings can help reduce vandalism and other anti-social

behaviours that make residents feel unsafe. The knock on effect of this is

improved community pride and identity. Furthermore, participating in such

projects promotes inclusion as well as new skills, which can have a beneficial

impact on our wellbeing through increased confidence and capabilities, while

active participation such as volunteering can be beneficial for our physical

health (AHF, 2008).

However, change can be stressful for many, especially for those who have lived

in an area for a long time. This may be why there is often such opposition to

regeneration projects. In these instances, heritage-led regeneration projects

may be able to lessen the stress of the situation by encouraging participation,

continuity and improving local identity (AHF, 2008). Further research into this

area would be beneficial to health promotion, regeneration projects and town

planners.

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Cultural Heritage
The different views of a culturally diverse area and the way health messages

are communicated will influence how messages get through. Health messages

must be adjusted to suit the intended audience by incorporating their cultural

heritage, language and ethnicity (Canadian Centre for Addiction and Mental

Health Policy, 2007). Sims (2007) agrees saying that mental health tends to

cross boundaries between social care and bio-medicine. Consequently, ‘there

may be issues of culture and upbringing, social expectations and reception and

clinical susceptibility involved in detection, diagnosis and care’ (p18)

It is largely due to Western thinking that a distinction is made between the arts

and culture and science (Vadi, 2007). A recent study carried out in Norway on

wellbeing and cultural activities found that simply observing cultural activities

was good for men’s physical health and wellbeing, while women received more

benefit from actively participating in cultural activities. In fact, the research

showed that for men, taking part in any cultural activity was associated with

higher level of perceived wellbeing. Meanwhile, women reported better

perceived 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 therefore

influence choices and behaviours. Negative impacts of cultural heritage such as

lasting trauma from regime change and colonisation and other such events can

have a dramatic impact on future generations. Culturally sensitive health care

and interventions must consider this. In fact, Huff and Kline (1999) believe that

cultural consideration may determine whether a health promotion initiative will

work. A ‘one-size-fits-all’ attitude towards many policies, including health

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promotion, in the past has meant messages have failed to reach the most

marginalised (Centre for Addiction and Mental Health Policy, 2007). In many

cases in the UK and around the world, the majority of health education

materials and programmes have reflected only the cultural values of a majority

group. This is perhaps based upon Modernisation Theory which propounds the

view that ‘the economic, political and social formations associated with Western

Europe and North America were at a more evolved level of development’

(Unterhalter, 2008: 771) than the rest of the world. This has excluded not only

immigrants 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 people

include ‘loss of culture, loss of land, loss of voice, loss of population, loss of

dignity and loss of health and wellbeing’ (Drurie, 2004: 1138). Article 24 of The

Draft Declaration on the Rights of Indigenous Peoples (1993) states that

indigenous peoples have the right to the provision of ‘traditional medicines and

health practices as well as the protection of vital medicinal plants, animals and

minerals’ (webpage). The Declaration rightly points to people having ‘heritage

rights’ which include ‘the maintenance and the development of culture and

resources’ (webpage). UNESCO (2009) state that there is increasing evidence

that the psychological effects of post-colonial life and acculturation have a large

role to play in the far lower life expectancy rates of indigenous peoples, and

therefore shows a direct link between cultural heritage and wellbeing.

Palacious and Portillo (2009) put forward Historical Trauma Theory (HTT) as a

way of explaining how future generations can still feel the repercussion of past

45

events. This trauma and the resulting health problems can then be compounded

by the stress of everyday life, particularly for indigenous or minority groups. This

stress and marginalisation then increases the likelihood of these populations

adopting unhealthy behaviours such as smoking and drinking. As discussed

under intangible and tangible heritage, museums and other heritage-based

projects 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 as

going against the movement towards Western-style development. Therefore

culture was used as a ‘mark of the otherness of peoples still prevented by

primordial 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 that

needed changing towards an affiliation to the nation, for example one religion

and one language (Unterhalter, 2008).

While ideas of nations and cultures have changed significantly with

globalisation, heritage has often been seen as more nationalistic. This could be

seen as a barrier to multicultural heritage-based projects; however, celebrating

the heritage of a nation or the local area no longer means the unity of

Modernisation Theory. Rather, as has been discussed earlier, heritage is things

from the past we wish to keep for future generations and therefore is never

static.

It is important to understand the past to understand the present and future and

so there is a place for preserving even the relics of past nationalism such as

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Memento Park in Budapest. This does not mean, however, that heritage-based

activities and projects must be nationalistic; they can be inclusive, using lessons

from the past to inform the future. The Basic Needs Approach blurred the lined

between modernisation and tradition by proposing that satisfying the basic

needs of development naturally led to looking after the culture of an area. It in

fact

‘empowers individuals in any society and confers upon them a

responsibility to respect and build upon their collective cultural, linguistic and

spiritual heritage, to promote the education of others, to further the cause of

social justice, to achieve environmental protection, to be tolerant towards social,

political and religious systems which differ from their own, ensuring that

commonly accepted humanistic value and human rights are upheld, and to

work for international peace and solidarity in an independent world’ (WDEFA,

1990 in Untehalter, 2008: 776).

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Chapter Three: Methodology

The purpose of this study is to explore the link between heritage and wellbeing

and in doing so investigate how this link could provide an approach for

effectively promoting health. It is not intended to prove or disprove the

usefulness of heritage in health promotion, but may be used as a basis for

further investigation into this area of study.

This piece of research explores a heritage-based approach to promoting health

that is often set in a non-medicalised environment, and asks questions about

some avenues that may not have been examined before. The research

questions and the overall aim of this study are likely to bring up more questions

than can be answered in this piece of research. However, it is important to the

subject area that such questions are brought to the fore. The methodology used

will help to distinguish between the questions that can be explored in this

dissertation 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 what

individuals and groups value (functions) and whether or not they enjoy the

capabilities to put these values into action (agency).

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It is for these reasons that I have undertaken this research within a Critical

Realist approach that offers a third option between Positivism (objective) and

Interpretativism (subjective). It ‘endorses or is compatible with a relatively wide

range of research methods, but implies that the particular choices should

depend on the nature of the object of study and what one wants to learn about

it’ (Sayer, 2000: 19)

The Critical Realist approach states that the real world is complex but is ‘also

stratified into different layers’ (Robson, 2002: 32). Social reality incorporates

individual, group and institutional and societal levels, as well as economic and

political circumstances. According to Sayer (2000) it is by acknowledging this

interdependency of actions on shared meanings that we can understand

phenomena. As this dissertation looks at how heritage is perceived to influence

our wellbeing, it was important to use an approach that takes into account all of

these spheres.

The subject matter of this dissertation is one that has had little previously written

about it: therefore the research needed to be carried out in a setting that

allowed participants to explore issues of health and wellbeing in the context of

heritage-based activities enabling their perceptions to be put into their own

words.

Preparation
When preparing for this dissertation I searched the awards section of the HLF

website looking for any projects/activities relating to health and wellbeing,

before arranging preliminary discussions. I spoke to members of HLF staff in

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order to gain a better understanding of what HLF see as heritage and how

health and wellbeing fit into projects.

I conducted an online literature search through the SirisiDynix database at the

Institute of Education, Swetwise and on GoogleScholar, using key words such

as ‘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 being

discussions of heritage in a historical context but not related to health and

wellbeing. Further searches came up with over 50 relevant articles. The

inclusion criteria were far wider than the exclusion criteria due to the nature of

the study. This included mentions of health and wellbeing in relation to historical

context, culture or heritage. I also looked out for programmes in international

development or in the UK that used the arts or culture and theories based on

inclusion, the environment or other aspects that could also be positive

outcomes of using a heritage-based approach.

The Study Design
During the initial literature search, I found a number of fixed design studies on

genetic heritage that used quantitative methods to measure the likelihood of

certain health issues being passed down through generations or ethnic groups;

and a few flexible design studies about particular cultures’ health beliefs and the

impact of these on their health behaviour. I therefore decided that a flexible

design would be the best suited to the smaller number of participants and the

type of data I wished to gather. A small-scale qualitative study design provides

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the opportunity to use qualitative methods that ask questions and explore the

views of participants and is adaptable to each participant, project or situation.

This flexible design is also suited to the Critical Realist approach within which I

am undertaking this study.

Sampling
During the small-scale qualitative study, purposive sampling matched best with

the study aims. Throughout the preparation stage, I undertook web-based

searches for heritage-based projects that have a health or wellbeing focus and

projects that matched my heritage criteria including the five types of heritage

used throughout this dissertation. I found it useful to look for the HLF logo on

these websites as a sign that they had been funded by HLF and therefore

matched my criteria.

I contacted 50 projects out of which ten responded, three to say they did not

feel they would be relevant, three sent hard copy information and four made

themselves available for a phone conversation. These conversations helped to

finalise my research questions and methodology. They also confirmed that

qualitative methods would work best for this topic. All four of those who took

part in a preliminary interview said that they had found it hard to collect

quantitative data around the effects of heritage on health and wellbeing for

research they had carried out within their projects.

Out of the four projects with which I made initial contact, three activities/projects

were chosen for the interview process based upon their suitability against my

heritage criteria and their locality. Group One used cultural heritage, tangible

51

heritage/artefacts, built heritage and natural heritage. All participants in this

project have some level of mental health distress. Group Two used intangible

heritage, built heritage and tangible heritage/artefacts and cultural heritage. This

project was based in a hospital. Group Three used intangible heritage mainly

and on occasion all of the identified types of heritage. This group had no

common health link such as mental health distress or being based in a hospital.

Preparatory work was carried out with each project, which involved observing

the groups taking part in the activities and meetings and spending time with

participants. This enabled me to gain a focused overview of the aims of the

projects and the participants as well as sensitising myself to group dynamics

before 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 they

would like to take part. Staff at the projects helped to decide upon the final

sample, as some participants would have been unsuitable due to the severity of

their health issues. I then interviewed 10 individuals across two of the chosen

groups (Group One and Group Two), which both had a health focus. Individual

interviews were most appropriate with Group One and Two due to the

sometimes confidential health issues of the participants. A group interview was

held with Group Three because there was no health-related focus to the group

and therefore dealt with less confidential subject matter. The group interview

allowed participants to explore the issues further with input from other

participants in the group.

52

Data Collection Methods
Data collection consisted of three sets of semi-structured interviews. Five

participants 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 took

part in the interviews alongside four users, two of whom were also volunteers

for some activities. One was also a Trustee of the organisation.

Group Two included three females and two males. One participant was a

project staff member; one was a nurse at the hospital. Three participated in the

project 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 had

heard of the project through the community outreach programme.

Group Three consisted of five females and three males. Three participants were

below the age of 25 and two were over the age of 65. Five were of an ethnic

minority other than white British.

The interviews began with an introduction and an explanation of what the

interviews were for and how they would proceed. Participants were informed

that they were being recorded and that they did not have to answer any

questions they felt uncomfortable with.

53

The interviews took place at the projects in private rooms and were paused for

interruptions. Having spent time at each project prior to the interviews,

participants were more at ease with the interview process. However, a member

of staff was present at two of the interviews. One was at the request of the

participant and the other was on the advice of the staff members due to the

level 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 the

participant to expand upon their answer. Indicators such as feelings, types of

activities mentioned, medical information and key words relating to health,

wellbeing and heritage guided further questioning.

I then returned to the original four questions about the definitions of health,

wellbeing, health promotion and heritage at the end of each interview. This was

54

because the terms used could seem technical to the participants and therefore

at the beginning of the interviews were not immediately recognisable in the

activities they took part in. By the end of the interviews participant views on

these terms had often changed as they began to match the terms to their

perceptions of the activities and projects.

Analysis
A flexible, qualitative approach allowed semi-structured interviews that

encouraged participant discussion. This meant that very few codes or templates

could be set beforehand. However, an interview guide based on the eight

questions mentioned above helped to identify key words and phrases that

would guide further questioning. This was important as the participants came

from a range of backgrounds and therefore their ideas of heritage, health and

wellbeing would need to be interpreted. For this reason, the analysis of the

findings has been carried out with an immersion approach which is the least

structured and most interpretive approach, requiring the researchers’ insight,

intuition and creativity (Robson, 2002).

The preparatory work, which included observations, was informal and served

the purpose of letting the participants get to know me before taking part in the

interviews. Notes from these observations were written out and analysed for

recurring themes, which were covered during the interviews. These were used

in the generation of grounded theory (Robson, 2002). Words such as ‘happy’,

‘lonely’, ‘understanding’, ‘fitting-in’, ‘accepted’ and types of heritage-based

activities that appeared the most were then used to direct questions in the semi-

structured interviews.

55

The semi-structured interviews were transcribed and analysed for recurring

themes as well as missing information. The transcripts were interpreted using

the definition of heritage, health and wellbeing used in this dissertation.

Participants’ ideas on these definitions have also been interpreted to ensure

that the definitions used here are appropriate. All interviews were listened to

twice before being transcribed. Transcripts were then analysed for key words or

themes occurring throughout the interviews as well as anticipated themes that

had not appeared.

Ethical Considerations
Due to the nature of the research ethical issues needed to be taken into

account throughout the research process. I therefore made sure I was familiar

with both the British Educational Research Association (BERA) Revised Ethical

Guidelines for Educational Research (2004) and the Statement of Ethical

Practice for the British Sociological Association (2002).

Before undertaking the interviews, I met with the organisations and participants

to explain who I am and what my dissertation research is about as well as

ensuring they understood that it was part of my MA course. A consent form

(Appendix One) was prepared for each participant to sign. All participating

organisations who wished to receive a copy of the finished report will be sent

the final copy.

No organisation or project will be named as having taken part in the research.

This is because the projects are small and localised and participants could,

56

therefore, be identified by their answers. Projects/organisations will be

described, but no location or other easily identifiable information will be given.

Some of the participants have mental or other health issues and so careful

consideration was given as to where, when and how I met these participants. All

of the interviews were undertaken at times that the participants would normally

be at the project/activity, and I always travelled to them. For those with more

severe mental health distress a member of staff was present throughout the

process leading up to interviews and at the interview if the participant wished.

Limitations
This is an area with little research already completed and therefore information

has been difficult to find. The majority of information had to be taken from

research into other aspects that relate to the study. However, some very recent

reports did help to strengthen the literature base.

The timeline for this dissertation meant that I was restricted to a more localised

area and the interviews took place spread out over time. However, the

preparatory work undertaken served the purpose of sensitising me to the project

and the project participants to me. The background information gathered

through this exercise also allows the reader to understand the heritage-based

project and is important in giving some perspective to the interviews.

The subject matter and the number of people interviewed meant that no

substantial quantitative data could be captured. However, for the purposes of

57

this dissertation the qualitative data gathered may be enough to point to a need

for further exploration and add to the current literature on the subject.

Due to a word count limitations, some aspects of this study could not be

described in full in this dissertation.

Chapter Four: Findings

Group One

Group One is based in a charitable organisation which is run by and caters for

people with mental health distress. They believe that mental wellbeing is

improved through creativity. They run a variety of activities based in the arts and

heritage, including visual arts, batik, digital arts, video, poetry, and performing

arts, exhibitions, public art projects and websites that help break down the

stigma 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 the

organisations facilities. The walk is themed and the route changes to

incorporate areas, museums and objects that relate to the theme. The walk is

open to the public and so a large mix of people takes part. I observed the

preparation meetings for one such walk and then took part in the walk later in

the month. The organising group consisted of around eight people but some of

58

those taking part changed from week to week. The participants’ backgrounds,

ages, nationalities, genders and levels of mental distress varied greatly as did

their experiences with the medical profession. For example, one participant was

a young, white woman with mild depression and anxiety while another

participant was a middle-aged man of African decent with schizophrenia.

Each walk is based upon a theme chosen by participants; past themes have

included celebrating women in the area, the medical history of the area, literacy

and 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 museums

as well as art/modern art galleries. They are thoroughly researched beforehand

and the organising group also become the tour leaders, giving everyone an

opportunity to learn new skills and increase their confidence.

Quotes from participants included in some of the organisations communications

material included: ‘ {The project} really helps people like me to stay well, which

saves the NHS money’ , ‘I feel safe here and I feel the benefits of coming

here….I begun as a participant and now run a workshop. I would never have

had the confidence to do that!’ and ‘Since I have been at {the project} I feel

more confident to be able to work in the community’.

The Chief Executive of the organisation stated in an interview in Mental Health

Today (2009) that

Deborah Hayman Ehpid 2011 Dissertation

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