Introduction

Our chapter explores the relevance of an existing health equity and social determinants of health (SDOH) framework (see Schulz and Northridge 2004) for both researching and evaluating health and well-being outcomes for participatory music programmes. There is an increasing focus on how arts activities such as song writing, recording and music performance can contribute to health and well-being for marginalised groups while achieving broader health equity and social justice outcomes (see e.g. Harrison 2013; Pavlicevic and Ansdell 2004). Extending on the work of Wiggins et al. (2013) and others (see e.g. Harrison 2013; Parkinson and White 2013), we see music participation as an activity that can act as a positive SDOH in and of itself (see e.g. Batt-Rawden 2010) and as an activity that can affect the social conditions that shape health and well-being (see e.g. Harrison 2013; MacDonald et al. 2012; Parkinson and White 2013). Within this context, we draw on our experiences of research with refugee and asylum seeker participants in the Brisbane-based Scattered People (2015) music programme (see http://www.scatteredpeople.com) to enrich discussions on community music research and evaluation.

Music and the Social Determinants of Health and Well-Being

While it is currently difficult to find published music research outside of this book that overtly adopts an SDOH approach, practitioners and researchers in the broader field of arts and health do acknowledge the importance of social determinants of health and the role of the arts in addressing health inequalities (see e.g. White 2009; Parkinson and White 2013), as well as the impact of community-based arts programmes on public health (Sonke and Lee 2014). There have been promising developments in recognising the contribution that music participation can have on social determinants of health such as poverty. Harrison (2013), for example, conducted research in Vancouver, Canada, that explores how “musical offerings … address issues of poverty, including lack of health” (p. 58). She explored in particular how music participation could affect highly significant determinants of health and well-being by developing:

the skills, education levels, incomes, and occupational possibilities of participants living in material poverty, which in turn can enhance their socio-economic status, a social determinant of human health and mortality. (Harrison 2013, p. 58)

The 2013 Australian Government National Arts and Health Framework also acknowledges—albeit in a minimal way—that arts initiatives generally can have an “impact on the determinants of ill-health by changing individuals’ attitudes to health risks and supporting community resilience” (Standing Council on Health and the Meeting of Cultural Ministers 2013, p. 2). While the Framework identifies individual attitudes and risks and community resilience as “determinants of ill health”, Clift acknowledges broader determinants related to arts practice such as access to cultural capital (2012, p. 121). Putland et al. (2013) echo this idea and note the increased access to social capital via community arts and cultural programmes. Parkinson and White (2013) have also discussed that the strength and nature of local cultural engagement is a key determinant of health and well-being. This mirrors studies with Aboriginal and Torres Strait Islander peoples in Australia, which show the direct link between strong cultural practices and enhanced outcomes across a range of socio-economic and health and well-being outcomes (Dockery 2010).

Furthermore, Parkinson and White (2013) emphasise that the arts have an international role to play in supporting strong healthy cultures and promoting health equity and well-being. Drawing on key health promotion documents such as the World Health Organization’s (WHO) Declaration of Alma Ata (1978) and the 1981 Global Strategy for Health for All by the Year 2000, Parkinson and White (2013) advocate for culture and the arts as a key determinant of health and well-being. Similarly, Edge et al. (2014) note the importance of music and arts programmes, among other social and cultural activities, as a factor in mediating the health and well-being of refugee youth.

Using an SDOH approach, Davies et al. (2014) developed a framework to further understand the connection between arts engagement and population health to make the framework relevant to a wide range of health professionals, researchers and policymakers. This framework is constructed from a study of 33 Australian adults and incorporates a selection of health determinants and health outcomes. The authors list potential confounders and effect-modifiers that they believe will help to “avoid spurious conclusions about the health-arts relationship” (Davies et al. 2014, p. 8). In another instance of broad arts and health framework development, Fancourt and Joss (2015) formulated the concept of Aesop 1, which encompasses six stages through the lifecycle of an arts intervention, from development to implementation. While this is principally concerned with providing a useful synthesis of relevant but competing methodologies for arts and health researchers, it advocates for the consideration of social health outcomes as part of the evaluation phase.

Schulz and Northridge (2004) SDOH Conceptual Framework

We have previously used Schulz and Northridge’s (2004) comprehensive SDOH framework as a basis for research with the Scattered People asylum seeker and refugee music programme. The framework is reproduced in its original form below (see Fig. 1). Schulz and Northridge (2004, p. 456) describe their work as a “conceptual framework for understanding the implications of social inequalities for environmental health [that] emphasizes the interplay of social processes with features of the physical environment”. Hence the model adopts an explicit health equity focus. The model “outlines the multiple and dynamic pathways through which underlying social, political, and economic conditions influence aspects of the environment, thereby affecting individual and population health and well-being” (ibid.).

Fig. 1
figure 1

Adapted from Schulz and Northridge’s (2004) social and environmental determinants of health framework

Full size image

We selected Schulz and Northridge’s (2004) framework primarily due to the detailed way that it maps social and environmental determinants of health at different levels of the social-ecology (see Levins and Lopez 1999) of health and well-being. Our use of the framework also extended on previous collaborative place-based health promotion research conducted by the project leader (see Sunderland et al. 2012; Kendall et al. 2012). We favoured the Schulz and Northridge framework for this research in particular, due to its overt and detailed recognition of human rights, ideologies and racism as significant factors that shape health and well-being outcomes. We argue that the recognition of such factors is particularly relevant when working with intensely marginalised, politicised and stigmatised groups such as refugees and asylum seekers in Australia and other resettlement countries.

We did not substantially amend or adapt Schulz and Northridge’s (2004) framework in our original research project. We make some recommendations in this regard, however, in this chapter and suggest adaptations for music, health and well-being research.

Key Learnings: Applying an Existing SDOH Framework to Complex Community Music Making

Reported Health and Well-Being Outcomes That Did Not Fit Neatly on the Existing SDOH Continuum

While many themes arising from participant interviews fit neatly onto the SDOH framework, we also identified a number of factors that were reported as contributing directly and indirectly to participants’ health and well-being that sit outside this model. Specifically, these outcomes related to aspects of (1) cultural expression, (2) music making and (3) consolidation of personal and social identity (see Sunderland et al. 2012 for a full discussion). These factors are interrelated, with each impacting on the others in relation to well-being outcomes for participants. Thus, consideration of these three aspects that are broadly related to artistic and cultural influences, can contribute to broadening current understandings of SDOH and well-being.

Cultural Expression

In the Scattered People sessions, participants were encouraged to share aspects of their own culture, while also participating in musical activities from other cultures. Several of the participants emphasised the role of both first and second or even third languages, including English, in making music within the group. Being able to sing in one’s first language afforded individuals the opportunity to express not only aspects of their culture but also an articulation of their thoughts and feelings. So too did this experience allow participants to hear and sing in their own language—a practice which may be difficult to maintain in a resettlement setting. One participant described an example of this:

[J] also enjoyed hearing songs in Persian, maybe more than in English. … [J] said he would not sing Persian songs otherwise and he would not sing them at home. He also said that he doesn’t hear Persian songs anywhere else in Brisbane. (J & T’s story)

Musical expression in first or familiar languages appeared to be an important contributor to the well-being of this culturally diverse group. As one participant, Joy, noted, “when people can sing in their ‘mother language’ it creates happiness”. Joy goes on to describe the importance of acknowledging individual languages in the coming together of many different cultures at the Scattered People sessions (Joy’s story). In this way, participants in the programme were able to connect with and maintain a sense of individuality within the culturally based plurality among participants.

Music Making

On the other hand, the idea of participating in musical activities in the absence of proficient English language skills was at first daunting for some participants. As explained by S:

I always think you should speak very well English to connect to people, but I saw many people, they try to speak slowly to me … I was so excited. … It was really good. They push for me, hey, [S], sing! (S)

An initial perceived language barrier was soon overcome for S when it became apparent that there were many people speaking different languages and from diverse culture groups present, yet all participants had gathered for the one common purpose—to share music. Another participant, Z, echoed S’s sentiment and said:

Always music can explain … there are lots of languages in the world. The music and song or poetry could be one of those [languages] which could transfer people’s feelings and emotion to other people. So we kind of speak to [the] world [through] the music. (Z)

Z is alluding to how music has the ability to communicate emotions regardless of the language of any lyrics, as well as the ability for Scattered People participants to perceive this emotion.

For these participants, music allowed a connection that did not require a common spoken language. S explained, “music is an international language for every people, for all of us” (S & Z interview). While cultural differences were acknowledged and indeed celebrated within the group, participants also recognised the shared function of music making for all those present. In the context of the sessions, music was used for an expression of self, an expression of trauma and grief. As stated earlier in this chapter, music making became an avenue to build social bonds. Indeed, this activity was emphasised by participants as being integral to their well-being and was recognised as a quick and effective method for connecting with others. For example, J described that meeting people through Scattered People was very important to him, stating that he thought it would not be as easy to connect with people through other activities (J’s story). S also expressed how the welcoming nature of the group and the inclusiveness of the musical activities made her feel “excited”, while Z described the group as “part of our family” (S & Z interview). In these ways, music comprised a universal function to this diverse group and contributed to positive well-being outcomes for participants.

Consolidation of Personal and Social Identity

Participants frequently described music as having an effect on their mental well-being. Specifically, they noted feelings of happiness or relief, but in speaking about their relationship with music, they also referred to concepts of identity and agency. Closely related to the ideas of expression and communication discussed above, “self and social identity” as a concept appears to contribute greatly to health and well-being outcomes, yet it too is absent from the SDOH continuum. Nevertheless, individuals felt excited, happy and proud to sing songs in their own language, indicating elements of strong self-identity. Similarly, music gave participants a certain freedom of expression that they may not have had before. For example, S described how women were not allowed to sing in her home country, but that being able to sing in her new country gave her a sense of agency, and a feeling that she may be able to change the world around her through music (S & Z interview).

It also appears that participants retained part of their ethnic identity, especially through language, but also created a new, shared social identity with other people in similar circumstances. For example, Joy described his ideal scenario on putting together a musical concert with other participants, “if we have five songs for example, three should be for the refugees [i.e. in refugee languages] and two for the audience [i.e., in English]” (Joy’s story). This split between “songs for refugees” and “songs for the audience” can be understood as a representation of integrated identity within this particular group. Thus, in the context of the Scattered People sessions, participants were creating a shared identity through the unified function of music for the group, as an avenue of expression, communication and reception of thoughts, feelings and stories. Music making activities can therefore positively contribute to a sense of well-being for participants through the promotion of music as part of personal and social identity.

The Need to Adapt Existing SDOH Models for Community Music Making Research and Evaluation

The above discussion highlights that the themes emerging from participant interviews surrounding cultural expression, music making and consolidation of personal and social identity do not integrate into the SDOH framework in its current form. However, as the discussion also suggests, they all played a key role in the achievement of health and well-being outcomes as identified by participants. This finding indicates a gap in the recognition of the position of artistic and cultural influences in terms of both health and well-being interventions. This gap is especially glaring within the context of culturally and linguistically diverse target groups, in which, as shown, cultural identity is one of the few aspects that individuals carry with them into new societies. More attention should thus be paid to these aspects as important determinants of well-being that can be highlighted through interdisciplinary research.

While absent from the model used within this study, recent Indigenous specific SDOH frameworks have included cultural expression and/or cultural identity as health determinants. For example, the 2009 National Collaborating Centre for Aboriginal Health [NCCAH] report, Health Inequalities and Social Determinants of Aboriginal Peoples Health includes Cultural Continuity—generally defined as having a strong understanding of history, language and culture—as an intermediate determinant of Indigenous health. Similarly, the 2013 Assembly of First Nations [AFN], A Transitional Discussion Document on the Social Determinants of Health (hereafter the Discussion Document) includes Language, Heritage and Strong Cultural Identity as a determinant of Indigenous health. The Discussion Document clarifies that for Indigenous people: “[a] positive and balanced state of well-being cannot be achieved unless individuals, families, and communities are supported to openly express their cultural identity” (p. 16). The two referenced SDOH frameworks affirm the notion that cultural identity is an important health determinant among Indigenous people. Given that cultural expression and identity contributed to the health and well-being of culturally and linguistically diverse participants within this study, there is a strong argument towards also including cultural expression and identity as a determinant within SDOH models for culturally and linguistically diverse groups, newcomers and refugees and asylum seekers.

The prominence of the three themes—cultural expression, music making and consolidation of personal and social identity—in the literature indicates their importance, and provides an impetus for more critical discussions from an SDOH perspective. For instance, the complexity in “measuring” happiness and well-being across cultures remains an important theme, as does the critical role of interdisciplinary research to address this issue (Mathews 2012). Moreover, the notion that music comprises traits that are understood within all cultures was initially proposed within early studies of ethnomusicology in the nineteenth century. Throughout the twentieth century, the debate as to whether music could really be considered universal to all cultures continued, spurred on by theories of human evolution, linguistic development and greater philosophy on music (e.g. Harwood 1976; Hood 1977; Merriam 1964). These trends highlight the social nature of human existence and the function of music therein.

Furthermore, research in the area of music sociology has shown clear connections between music activities, such as sharing, listening and music making and the formation and consolidation of personal and social identity such that music can become representational of the self (see for instance, Bennett 2000; Cohen 1991; DeNora 2000; Frith 1981, 1996; Hesmondhalgh 2008). While concepts of music-related identity and well-being in culturally and linguistically diverse groups are currently under researched, the limited evidence suggests that self and social identity in ethnic communities can be positively related to psychological well-being (e.g. Liebkind and Jasinskaja-Lahti 2000; Liebkind 1992; Nesdale et al. 1997; Phinney and Kohatsu 1997; Phinney et al. 2001). Other studies indicate that a shared social identity within minority groups can also have positive well-being effects (Haslam et al. 2009; Reicher and Haslam 2006). The findings outlined in this chapter also align with these ideas.

Thus, designing a new SDOH framework based on the Schulz and Northridge (2004) model, but encompassing other more relevant aspects to culturally diverse groups in the context of arts-based research may provide a more accurate picture of health and well-being outcomes in interdisciplinary contexts. This adapted framework could then be tested through another set of interviews with the same participants using a slightly different line of questioning that would focus on those themes identified here as external to current SDOH framework. The outcome would be that collaborative, interdisciplinary and participatory-based research, as described in this chapter, could then yield clearer indications of the importance of arts in achieving positive well-being outcomes for refugees and asylum seekers and other marginalised groups.

Our final advice to other researchers entering this area is to carefully consider the complexity of arts-health research and approach collaborations with something akin to intercultural work. We found that common interests were effective in linking researchers across disciplines and represented a valued opportunity to learn from and contribute to different perspectives. Factors that contributed to productive interdisciplinary processes for us included collegiality and a common objective, respect for and openness towards diverse standpoints, listening and responding to all input and convergence during the analysis phase. Aspects that were more difficult to reconcile included differences in discipline-specific “jargon” and writing styles, differing expectations about authorship and publications, experiences and expertise of researchers and (unsurprisingly) bridging the gap between quantitative-qualitative traditions. We see that these elements are akin to “culture shock” experienced in a new environment requiring adaptation and adjustments to ensure the benefits of interdisciplinary collaborative outweigh the difficulties and achieve the project aims.

Conclusion

Returning to Edge et al.’s (2014) point on the importance of music programmes as a factor in mediating health and well-being, our chapter shows the great potential for interdisciplinary research and evaluation to enrich knowledge across those fields. This chapter summarised our key learnings from applying a social determinants of health to a research evaluation of an existing community music activity. We found there to be both power and limitations in using an existing SDOH model. Future research should work on developing bespoke SDOH models that can attend to the specific work that is achieved in music and other art forms particularly with marginalised groups.