This review included a total of 256 resources. Fifty one of these (20 per cent) were peer reviewed studies, 72 (28 per cent) were grey literature, and 133 (52 per cent) were resources found in the public domain. Peer reviewed contextual data included literature on the impact of the pandemic on various vulnerable populations, for example increases in anxiety symptomology as government lockdowns progressed, coping mechanisms utilised by elderly or isolated individuals, or barriers to participation in outdoor activities for people with chronic health conditions. Intervention studies and review of interventions outlined the efficacy of community activity interventions during the COVID period. Grey literature also provided contextual information such as government and think tank reports on economic or policy impact, and additionally provided information from charities and community organisations on community activities. Public domain resources included a range of community activities providing an overview of the breadth of projects, schemes and community engagement occurring during the pandemic. Hereon public domain resources identified by this review are marked with ‘R’ and correspond to Supplementary Table 1. Peer reviewed and grey literature resources are referenced with the same number in both in the supplementary table and within the reference list.
Table 2: Number of resources within each type of literature
|
|
Population Area A -Psychological
(% total)
|
Population Area B -Physiological (% total)
|
Population Area C - Social
(% total)
|
Other Populations (% total)
|
Open to All
(% total)
|
Total
(% of total)
|
Peer reviewed (contextual literature)
|
23
|
11
|
1
|
1
|
4
|
40 (16%)
|
Peer reviewed (intervention study)
|
4
|
4
|
0
|
0
|
0
|
8 (0.03%)
|
Peer reviewed (reviews)
|
3
|
0
|
0
|
0
|
0
|
3 (0.01%)
|
Grey literature
|
26
|
19
|
23
|
0
|
4
|
72 (28%)
|
Public domain
|
22
|
9
|
71
|
6
|
25
|
133 (52%)
|
Total
|
78
(30.4%)
|
43
(16.8%)
|
95
(37.1%)
|
7
(0.03%)
|
33 (12.9%)
|
256
|
3.1 Contextual Literature Review
Sixteen per cent of resources identified were classified as ‘contextual’, i.e. peer reviewed data that provided an overview of the psychological, physical and, or, social impact of the COVID-19 pandemic. Within Population Area A (Psychological Vulnerabilities) contextual peer reviewed data reported population trends and regression data on coping mechanisms, poor mental health, or increased symptomology in established psychiatric disorders. This body of data revealed growing concerns around the psychological impact of the pandemic in the UK, a country in which increasing case rates of mental health conditions have been noted over the past several years (28). There additionally appeared to be an abundance of data reporting the increased need for mental health services during the pandemic (28–39). Pierce et al. (28) for example reported that lockdown-related trigger mechanisms such as entrapment and loneliness were associated with higher rates of depression, self-harm, suicide and overall poorer mental health during the pandemic. These rates may have been due to lockdown lifestyle adaptations such as increased screen time and decreased exercise impacting sleep, increased stress, and decreased wellbeing and physical health (40–43). In comparison to previous years’ trends, the Office for National Statistics General Health Questionnaire data showed an 8.1 per cent decrease in mental wellbeing between March-June 2020 (44). Office for National Statistics longitudinal data showed a significant decrease in mental wellbeing and affect alongside an increase in distress patterns particularly amongst those in lower socioeconomic brackets, young people, and mothers of preschool children, for whom the pandemic was associated with heavier socioeconomic impact (16). Several non-governmental organisations additionally reported psychological effects of lockdowns, as well as coping strategies. The Wellcome Trust for example captured how arts and creativity, community relationships, philosophy, nature, green spaces, gaming, volunteering, activism and learning were utilised as coping mechanisms for increased anxiety (45,46). The Royal Horticultural Society, National Trust, Royal Society for the Protection of Birds, 56 Degree Insight and Thrive reported increases in membership interest, alongside increased interest in nature and outdoor activities during the pandemic (47–51). The Crafts Council noted in its annual report the meditative benefits and increase in craft making during the pandemic (52). Meanwhile those with established psychiatric disorders, learning disabilities, neurodevelopmental conditions such as Autism Spectrum Disorder, or ongoing treatment for conditions such as eating disorders, experienced a severe reduction in access to points of statutory contact (53–55). Services designed to implement salutogenic approaches in the community were reported to be overstretched during the pandemic, having been fragile and at capacity beforehand (56,57). Such service gaps may be addressed through a participatory approach (58) or digital interventions (59,60).
Categorised within Population Area B (Physiological Vulnerabilities), a considerable amount of contextual literature was found regarding the importance of regular physical exercise in combatting COVID-19, as well as the effect of comorbidity on case rates. Physical activity was reported to be useful in combating diseases associated with increased inflammation, including metabolic and infectious diseases acute respiratory infections, whilst sedentary lifestyles impact negatively on general health status and mental health outcomes (61–64). COVID-19 is a multi-organ disease in which physical activity and inflammation status is a mediator of symptom severity and cross-organ communication. Adverse viral effects are regulated by skeletal muscle contraction, immune system responses and effects on adipose tissue (63). Higher body mass index (BMI) is associated with higher disease impact, alongside lower mental health, lower physical activity levels and higher overeating during the pandemic (65), whilst reduction in inflammation status allowed effective counteracting of COVID-19 infection (63). Thus public health messages around staying active were crucial during the pandemic.
3.2 Community Activities within Population Area A: Psychological Vulnerability
A total of 78 identified resources, comprising peer reviewed and grey literature, and public domain resources, addressed psychological vulnerability (Table 2). Resources within Population Area A were comprised of interventions and activities for individuals with mental health needs as well as activities and interventions targeting all groups with general mental health or wellbeing as an intended outcome. The main groups identified or targeted were individuals experiencing addiction, anxiety, cognitive impairment, depression, eating disorders, adults with learning difficulties, or Autism Spectrum Disorder.
In response to the issues highlighted by the pandemic, numerous community organisations adapted services to reach out to people with psychological vulnerabilities. At the beginning of the pandemic, community organisations and charities adapted their websites to contain online resources to navigate users towards shopping, test and trace, and health services (R68, R69, R72, R73, R75). Others offered information on what to do in the event of a mental health crisis during lockdown (R3) or, in the case of adults with learning disabilities, user friendly and accessible factsheets outlining the meaning of COVID-19 ‘lockdown’, the need to wash hands and socially distance (R64, R65). The majority (66%) of community organisations moved their offers online. Several used platforms such as Zoom to deliver arts and craft or painting tutorials (R10, R48, R160), photography and mindfulness courses (R146), interpretative dance (R10) or choir practice (66) with the intent of alleviating psychological distress arising from addiction (R24, R48, R73), head injury (R18), palliative care (R18), caregiver burden (R48, R67, R72), postnatal depression (R52) or general wellbeing (R56, R57, R59, R72) and mental health (R1, R10, R18, R29, R48, R49) as intended outcomes. Some community organisations sent ‘creative care packages’ through the post such as papercraft activity packs containing pencils, paint, coloured paper, glue, stickers and activity work books (R121, R132, R160, R159) as well as music and singing at home activity packs (R132). Three community organisations, Beaney House of Art and Knowledge, Look Again South West, and Suffolk Art Link, hosted online art tutorials, sent out art packs and presented their users with the opportunity to exhibit artwork in online galleries (R4, R18, R57). One private sector organisation uploaded pictures and videos of serene railway journeys from around the world in order to promote mindfulness and calm (R127).
Of the 31 community activities identified targeting people with mental health difficulties, three evaluated their activities using validated outcome measurements (R18, R29, R70). Tees, Esk and Wear Valley NHS Trust reported a music and wellbeing programme for NHS staff using validated wellbeing questionnaires alongside regression analysis to measure impact (R29), whilst others such as Look Again and Performance Medicine partnered with universities to measure impact (R18, R70). The other 28 community activities either reported outcomes, participant feedback, challenges and successes, survey results, or output including numbers of participants, phone and video calls as measures of impact, but did not employ validated outcome measures. Six reported more generic outcomes with two stating that their outcomes “promote wellbeing” and “support mental health” (R48, R49) and others suggesting that their offer aimed to promote “practical ways to stay connected” (R69), “combat loneliness” (R72), support the ‘Six Ways to Wellbeing’ framework (R4) or “reduce anxiety and increase resilience” (R34). Four used feedback quotes from participants (e.g. “I found the process of drawing and painting both cathartic and healing at the most difficult time of my life”; R30, R52, R56, R59); four reported challenges and successes (e.g. “unable to engage with digital content”, “offline activity is more labour intensive”; R17, R29, R48, R49); and one community group used their own survey to measure impact (R1). Others reported their outputs as a measure of impact (e.g. “we created a new website”; R48) whilst others counted participant numbers and retention (R18, R52, R56) or increased use of phone calls and zoom meetings (R57).
Peer reviewed data identified by the review consistently reported increased wellbeing in relation to community activities. Pierce et al (28) reported that individuals with higher levels of social support were more likely to participate in community volunteering whilst those with diagnosed mental health conditions were more likely to engage in social action volunteering, in contrast to volunteering trends during non-emergency periods (29). “Happiness” and “gratitude” were significantly associated with nature walks and hiking (67) whilst one meta-analysis (54) reported that self-guided interventions such as Cognitive Behavioural Therapy, mindfulness and acceptance therapy used alongside music and physical exercise, helped with stress and coping behaviour (54). Meanwhile cooking, decorating, diary writing and researching were related to positive emotions (67) whilst amount of gaming time, contrary to popular belief, was slightly but statistically significantly correlated (β = 0.31; R2=0.15) with wellbeing (68). Volunteering (56), showing kindness (69), gaming (70), foraging (71), being in nature (72,73), listening to music (74), exercising (75), sewing (76) and engaging in arts and crafts (77) were shown to positively impact wellbeing during the pandemic.
Further peer reviewed evidence suggested that interaction with nature increased during lockdown with 60-72 per cent of one large scale survey of 703 UK adults reporting an increased desire to spend time amongst nature, with 94 per cent of this sample recording that they had heard more birdsong, with benefits of noticing nature described as: “mindful”, “liberated”, “togetherness” or “self-worth” (51, p.9)
Table 3 outlines the major and minor themes organised by PICO for Population Area A.
Table 3: Major and Minor themes organised by PICO for Population Area A
|
|
Population
(% resources)
|
Intervention
(% resources)
|
Control
(% resources)
|
Outcome
(% resources)
|
Major theme
|
All Individuals with general mental health or wellbeing as an outcome
(56%)
|
Art/ Creativity
(27%)
|
No Controls
(100%)
|
Wellbeing
(28%)
|
Minor themes
|
Learning difficulties (11%), Eating disorders (5%), Anxiety (4%), Other (24%).
|
Nature (13%), Gaming (3%), Gardening (3%), Other (54%).
|
|
General mental health (25%), Other (47%).
|
3.3 Community Activities within Population Area B: Physical Vulnerability
Seventeen percent of all resources identified were categorised into Population area B: Physical Vulnerability. The largest number of these were aimed towards individuals with Dementia; these are reported separately below. The remaining resources were targeted towards participants with physical health conditions and focused on individuals who were shielding, with immunocompromising conditions, or living with chronic pain. Other resources were aimed at a wider audience but focused on different physical interventions such as singing for lung health, exercise, activity or dance.
The pandemic increased public park visits and highlighted the need for more green spaces to be integrated into the urban infrastructure (79). Operational changes and upheaval to exercise referral schemes impacted mental health particularly due to pandemic related restrictions and a lack of available exercise (61,80). According to a cross-cultural comparison study (81), lower levels of exercise were associated with poorer mental health outcomes in the UK, Ireland, New Zealand and Australia, with the younger age category of 18-29 year-olds showing the largest decrease in physical activity out of any of the measured demographics (61). Similarly, a longitudinal study with almost 6,000 participants (82) found a population-wide 63 per cent decrease in physical activity during the pandemic, with high income earners increasing activity levels, and younger age groups showing the highest reduction in physical activity (82). Sport England reported “unprecedented” drops in physical activity amongst its survey of 2000 UK adults (83) which coincides with increased levels of over-eating behaviours (65). Conversely, younger people were most likely to engage in more intense physical exercise with confounding factors being access to outdoor space, higher income and being female. Those with obesity, hypertension, lung disease and living alone appeared less likely to change their physical activity habits (80).
The literature reported several physical exercise, outdoor activity, dance and movement-related activities that were established during the pandemic that were aimed both at individuals who were shielding due to underlying health conditions, and the community as a whole. Online yoga classes for instance had positive effects on pain intensity, anxiety and depression (84), whilst interpretative dance practice generated feelings of collectiveness and cultural togetherness (85), although the challenges of teaching and limited proximity raised concerns around the equity of access. There were mixed reports on the impact of arts-based activities on physical health. For instance singing during the pandemic helped improve lung health, depression and confidence but not other psychological or health measures including physical function, energy, emotional wellbeing, pain, social function, general health or health change over the past year (86). In-person singing additionally was found to increase the aerosol risk of transmitting COVID-19 (87).
Within the community, grey literature and public domain resources described various arts-based interventions. Escape Arts (R12) and University of Cambridge Museums (R58) sent out creative art packs, physical resources and family activity ideas to parents who were shielding and parents of children with terminal illness. Several community organisations organised live music including classical concerts and choirs (R116, R172), online exhibitions for shielding individuals to display their work (R4, 13), art on windows (R19), at home museum collections and crafts (R23), food creativity and world culture (R27) and drama, entertainment and doorstep theatre (R28) for individuals who were shielding.
3.3.1 Dementia
Fifteen of the 39 items identified by the review pertaining to individuals with physical health conditions were targeted at individuals with dementia and their caregivers, owing presumably to the impact of the pandemic on this population. A national survey reported that the public health restrictions reduced day to day access to statutory social support services, social activities in the community such as choirs, reading groups and befriending services, and were negatively associated with the mental health and wellbeing of older people, people with dementia and their caregivers (88).
Alzheimer’s UK published online resources for people with dementia and their caregivers, outlining available support within hospitals and care homes as well as general information on Coronavirus and its effect on individuals with dementia (R71). Similarly, the Alzheimer’s Society published positive mental health resources for individuals with dementia and their carers as well as advice on shopping, leaving home and safeguarding; music and reminiscence activities were published on their website with large fonts and an accessible user interface (R144). Reminiscence resources were also published by the BBC and the Museum of London in 2020 providing visual prompts for individuals with dementia to remember and reflect on the past by scrolling through archival film footage of the twentieth century (R21, R149).
There is evidence to suggest wellbeing can be enhanced through community-based arts activities, which can create feelings of social connections, happiness and rejuvenation (89). Community organisations targeted at individuals with dementia sent out visual art, arts and crafts creativity packs and regular telephone check ins (R21, R22, R38, R45, R47) whilst others such as Acto Dementia used in-community focus groups to test and recommend art, gardening, sports or boardgame touchscreen apps to aid with activity setting during self-isolation (R145). Museum and social prescribing resources were also made available either through online weekly meetups or signposting to remote access art events aimed for people with dementia (R147, R51). Three community organisations identified offered online weekly workshops: the Garden Museum offered ‘Clay for Dementia’, an eight week pottery class (R50); Aspex offered a weekly art workshop over zoom (R43); and Lost in Art (R47) has been delivering visual arts based activities during the pandemic. Table 4 outlines the major and minor themes organised by PICO for Population Area B.
Table 4: Major and Minor themes organised by PICO for Population Area B
|
|
Population
|
Intervention
|
Control
|
Outcome
|
(% resources)
|
(% resources)
|
(% resources)
|
(% resources)
|
Major Theme
|
Dementia (35%)
|
Creative/ Art (51%)
|
No control (91%)
|
Improve health and wellbeing (58%)
|
Minor Themes
|
Shielding (16%), Physical activity (12%), Other (37%)
|
Music (14%), exercise (14%), Other (21%)
|
Control RCT (n=4; 9%)
|
Reduce isolation and loneliness (32%), Other (10%).
|
3.4 Community Activities within Population Area C: Socioeconomic vulnerabilities
This review sought to assess the extent to which health inequity was addressed by community initiatives. The majority of the literature found was based on community initiatives or interventions around social isolation, loneliness and community togetherness but only 16.5% (17 out of 103) of articles were aimed specifically at individuals in deprivation categories. Higher rates of covid-related impact amongst individuals in the more deprived categories highlights social and regional health inequity and a social gradient in health outcomes (7) whilst policy and societal responses will largely determine future health, wellbeing and economic outcomes for individuals in these deprived and protected categories (9). Arts on prescription and leisure initiatives can address health inequity (90,91) but there is a long way to go particularly given that engagement in arts activities (as well as the availability of such resources) is limited and influenced by social and geographic factors (33).
The most obvious starting point for this hand search was found within the resources aimed at ameliorating financial worries for low paid workers, small business owners and third sector organisations. Financial and business advice for arts professionals were found (R86) alongside many microsites outlining aid to recovery, help with universal credit, “staying well, supported and creative” during the pandemic, as well as resources for networking, online collaboration, contingency planning or mental health advice for students and young renting professionals on low incomes (R77, R79, R80, R81-R83, R87, R88). The National Council for Voluntary Organisations offered business advice, identifying risk and resources on managing budgeting and staffing (R85) and the National Endowment for Science, Technology and the Arts published a repository of advice and funding avenues for small businesses (R84).
The majority of arts based community resources identified (58 out of 103) were targeted towards isolated and lonely individuals. Creative and arts-based interventions included initiatives such as communal art, community notice boards, chalk murals, online arts and crafts clubs, participatory arts projects (R89-R93, R96-R98, R100-R104, R110, R111, R151), online workshops, digital art creative community for carers, at home DIY art kits, block printing, art tutorials, stand-up comedy, reading groups, heritage from home and art from home resources (R3, R25, R39, R105, R110, R117, R118, R119, R120, R121, R125, R128, R164). Others provided singing workshops, neighbourhood singalongs, sing for better breathing workshops (R95, R112, R139, R140). A number of music related provisions were also offered for isolated individuals such as back garden gigs, online jamming sessions, dance live streams and a BBC orchestra for isolated people (R60, R99, R124, R130, R132). Nature activities for isolated individuals focussed on foraging, outdoor hiking ideas and wildlife webcams (R36, R42, R94, R135, R142, R143).
Seventeen resources were identified that were targeted towards individuals experiencing deprivation, themed into: abuse, asset poor, care leavers, families in chronic crisis, digital poverty. For those experiencing abuse, Creative Learning Guild sent out arts based creative care packages which were praised by social workers as promoting family togetherness and reducing stress (R9). Two organisations, the Wildlife Trust and Outdoors for All, set up webcams in natural environments to enable people in urban areas to access green spaces and nature digitally, however evaluation and feedback was not available for either activity (R36, R42). Collective Encounters published a report on the positive role of participatory theatre on social change, but that challenges remain in reaching vulnerable audiences such as those experiencing situational and digital poverty for whom online activities are difficult to engage in (92). During the pandemic a number of novel partnerships within the community arose between cultural organisations and local risk registers. ‘No-one in Holbeck and Beeston Goes Hungry’ for example was a community scheme in Leeds in which a food bank and theatre were established within a working men’s club (R179), whilst another organisation, the Old Courts Arts Centre in Wigan, used their event and management logistics, existing technology and furloughed workers to turn the arts centre into a food bank warehouse and distribution centre for the community (R182). Another local authority organisation, FEAST, utilised out of work artists to work within deprived communities in Cornwall (R181). Create is a national organisation that reached out to young carers and their families during the pandemic through photography, dance, drama and music workshops run by artists over four weeks of lockdown (R8) and Coram - Letters in Lockdown provided writing workshops for young carers and their families (R7). Both Create and Coram used novel (unnamed) evaluation questionnaires and feedback quotes to evaluate their services. Everyone Connected and the Arts Council offered support for communities experiencing digital poverty through access to accurate health information online, allowing interaction with medical support, using essential services and allowing individuals to stay locally connected (R61, R62, R157) and Arts council through developing digital skills, networking and digital training. Resources for prison staff and voluntary organisations working with people in the criminal justice system both within prison and in the community (R74).
Table 5 outlines the major and minor themes organised by PICO for Population Area C.
Table 5: Major and Minor themes organised by PICO for Population Area C
|
|
Population
|
Intervention
|
Control
|
Outcome
|
(% resources)
|
(% resources)
|
(% resources)
|
(% resources)
|
Major Theme
|
Isolated (53%)
|
Creative/ Art (73%)
|
No control
|
Improve community cohesion (56%)
|
Minor Themes
|
Deprivation (15%), Low income (10%), Older (6%), Other (16%)
|
Music (12%), Nature (4%) Other (11%)
|
-
|
Isolation (8%), Other (36%).
|
3.5 Quality Assessment of Literature
Due to the varied nature of the reviewed literature, several quality assessment frameworks were used to evaluate quality. Examples of activities, case studies that formed part of grey literature resources, and public domain resources were quality assessed using the Arts for Health and Wellbeing evaluation framework (23). Broadly speaking the assessment fell into two categories – essential information (for example, aims and objectives, commissioner and funding sources, timescales, exposure, type of intervention, quality assurance) and evaluation details (evaluation aims, type of evaluation, evaluation design). Considered together, this information can paint a picture of the impact and need for the intervention. Peer reviewed data was quality assessed using Cochrane and AMSTAR evaluation methods, whilst grey literature was measured using AACODS critical appraisal tool. In conducting quality assessments it may be possible to evaluate whether efficacy claims could be validated with a robust methodological framework. As Table 6 shows, whilst a number of peer reviewed and grey literature articles were identified, less than half of the identified literature met quality thresholds.
Table 6: Quality appraisal of resources
|
Appraisal tool
|
Resources (n)
|
Cochrane (total applicable)
|
50
|
Cochrane Bronze
|
45
|
Cochrane Silver
|
5
|
Cochrane Gold
|
0
|
AMSTAR (total applicable)
|
3
|
AMSTAR High
|
0
|
AMSTAR Moderate
|
1
|
AMSTAR Low
|
0
|
AMSTAR Critically Low
|
2
|
PHE (total applicable)
|
181
|
PHE > 10
|
54
|
AACODS (total applicable)
|
22
|
AACODS > 22/34
|
11
|