Online arts and culture for mental health in young people: a qualitative interview study

Abstract

Objectives

This study aimed to understand young people’s perception of the potential utility of arts and culture, focusing on online access, for supporting their mental health.

Design

A qualitative interview study.

Setting

Online.

Participants

Participants were selected by purposeful sampling from an online survey of arts and culture for mental health and well-being.

Method

Individual semi-structured interviews were conducted from 30 July 2020 to 9 September 2020. Rich interview data were analysed using reflexive thematic analysis.

Results

Thirteen participants aged 18–24 who were socio-demographically diverse and varied in their use of online arts and culture (OAC) and in their level of psychological distress were interviewed. Six themes, ‘Characteristics of other activities’, ‘Online engagement’, ‘Human connection’, ‘Mechanisms of impact’, ‘Mental health outcomes’ and ‘Engagement optimisation’, were identified along with subthemes. Participants identified that online engagement had some advantages over in-person engagement and benefits were greater with familiarity and regular use. Participants described that human connection was the feature of OAC most likely to benefit mental health and emphasised the importance of representation. Mechanisms included improving perspective, reflection, learning, escapism, creativity, exploration and discovery. Outcomes were described as the disruption of negative thought patterns, lifting of mood and increased feelings of calm and proactivity.

Conclusions

This study demonstrates that young people have a critical level of insight and understanding regarding their mental health and ways in which it might be improved. These findings can be used to optimise the mental health benefits of OAC in an engaging and acceptable way for young people. These methodologies could be applied to other types of community resources for mental health.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This is the first study of which we are aware to explore young people perceptions of the potential utility of arts and culture online for mental health, and was devised with public and patient involvement input.

• Research team members were multidisciplinary, diverse and reflexive in their approach.

• The findings of this study appear credible and dependable with cohesion and consistency in the themes identified.

• Despite participants being identified through an online survey which may have allowed a degree of volunteer bias, we were able to identify information-rich participants, with substantial socio-demographic diversity, a range of psychological distress scores and varied previous use of arts and culture.

Introduction

Mental illness is a large and increasingly recognised problem in young people, with the onset of three-quarters of all lifetime cases of mental disorder occurring before the age of 24.¹ Common mental disorders (CMDs), such as anxiety and depression, are not only distressing in young people but also impact on recurrent disorder² and suicidality in the long-term³ even when the young person’s symptoms do not reach the diagnostic threshold for mental disorder at the time.⁴ Only a minority of young people access professional help for CMDs.⁵ The main barriers to help seeking are lack of recognition of their own mental health problem, lack of awareness of help available and stigma.^5–11 Moreover, often the young people most in need of mental health support, such as ethnic minorities, are the least likely to seek help from health services.5–7 12 13

It is increasingly recognised that professional help, such as the provision of antidepressant medication and/or talking therapies, are neither accessible nor acceptable to many young people.^{10 11} Moreover, not all of the few young people who access professional help have a measurable improvement of symptoms. Evidence suggests that only around half of adolescents who received professional help for depression between 2011 and 2015 from specialist mental health services in England showed a reliable improvement by the time they left treatment.¹⁴ Subsequently, epidemiological studies have demonstrated that mental health dramatically worsened in young people during the COVID-19 pandemic¹⁵ and accessibility to mental healthcare decreased even further.¹⁶ Further, of those accessing community mental healthcare, there are higher rates of disengagement among young adults (aged 18–25 years old) when compared with adults for a range of reasons—for example, perceiving that services are not relevant to their needs, through language and cultural barriers.^{17 18} Thus, there is a compelling need for more evidence-based resources that are engaging, accessible and that meet the mental health needs of young people as we emerge from the COVID-19 pandemic. Therefore, consideration of other approaches appears timely.¹⁴

It is generally accepted that culture and the arts are good for mental health and well-being.^19–24 The proposed mechanisms are thought to include emotional activation, aesthetic engagement, social interaction, cognitive stimulation, sensory activation and imagination.^{19 23–25} However, there is a dearth of experimental research in this area. We commenced a preregistered evidence synthesis²⁶ of trials evaluating community resources including engagement with arts and culture on anxiety and depression. We screened 15 534 unique titles and abstracts and found no trials evaluating the effectiveness of online arts and culture (OAC) for depression and anxiety in young people.²⁷

During the first UK lockdown we attempted to gain a deeper understanding of the use of OAC and its potential benefits to mental health and well-being, socio-demographic characteristics and self-reported data on usage, perceived mental health benefits and health status. In total, 1056 people completed the survey. A high proportion of participants reported finding OAC helpful for mental health. Those aged under 25 years were less likely to be regular users of OAC or to have increased their use during lockdown. Therefore, it appears that engagement with culture and the arts may be poorest for those who might benefit the most,²⁸ particularly young people. As per the survey, arts and culture is defined as content provided by cultural institutions, such as museums, theatres, art galleries, libraries, archives and natural heritage organisations.²⁸ OAC is defined as arts and cultural content that is digitally accessible via the internet.

While there is increasing interest in community assets in improving health, there is currently a lack of evidence for OAC for CMDs in young people.^{27 29} There is also a lack of engagement of young people in determining the most fruitful approaches to support their mental health,²⁹ most being investigated from the perspective of mental health professionals.²⁹

Aims and objectives

Given the current research gap regarding the use of arts and culture as an approach to addressing CMDs in young people,²⁹ particularly online engagement which might be more widely accessible, we set out to conduct a study to investigate the potential utility of OAC for CMDs in people aged 16–24. We aimed to interview socio-demographically diverse participants aged 16–24 years in order to generate theory on the potential use and optimisation of arts and culture, particularly online access for CMDs in young people.

Methods

A qualitative interview study was chosen in order to gain a rich description of the views of young people about arts and culture for mental health, whether this was a promising approach for supporting their mental health and to give them the opportunity to raise issues of significance to them. A phenomenological approach was adopted to view the data from a constructivist epistemological orientation adopting a bidirectional understanding of the language/experience relationship.

All participants were given £10 for every hour of participation. We used the Consolidated criteria for Reporting Qualitative research checklist for the comprehensive and explicit reporting of qualitative studies³⁰ and used the techniques described by Mays and Pope³¹ to ensure study quality and rigour. Data security followed institutional guidance.

Public and patient involvement

There was public and patient involvement (PPI) in this study which commenced prior to the outset. PPI informed this study design, topic guide and interpretation of the results as well as the preferred term for the target population as ‘young people’. PPI were involved via exploratory discussions and stakeholder meetings. With PPI we explored the utility of arts and culture in mental health service users who were not necessarily already familiar with OAC. During this consultation, people with lived experience of mental health problems said that lack of engagement with culture and the arts was not due to lack of interest but more related to lack of knowledge about how to access it. They thought that people from the target population should be an active part of any strategy to understand the potential use of such resources for mental health benefit.

Context

Participants aged 16–24 were purposefully sampled from an online survey of arts and culture for mental health and well-being.²⁸ Recruitment of participants for the online survey took place between 17 June 2020 and 22 July 2020. Recruitment was carried out via Facebook adverts, student unions, a press release, a pop-up advert that appeared on the Ashmolean Museum website and public relations avenues (eg, Twitter, newsletter) and PPI groups (based in Oxford and Blackpool). Participants followed the link to eConsent procedures in order to enter the survey. In all 78 people who completed the initial survey were between 16 and 24 years of age. The online survey of arts and culture for mental health and well-being is described in more detail elsewhere.²⁸ The survey demonstrated that there were age-related differences in the reported mental health benefits of OAC and that young people were less likely to be regular users of OAC. A broad socio-demographic range of young participants were reached in the original online survey and were then sampled using purposeful sampling techniques³² to gain information rich cases for this qualitative interview study.

Sampling strategy

The initial online survey²⁸ included items to elicit socio-demographic characteristics and psychological distress using the Kessler Psychological Distress Scale (K10)³³ to give an indication of probable mental disorder.³⁴ Purposeful sampling was used to gain an information rich sample that varied socio-demographically (age, sex, income, education, occupation, ethnicity), in previous use of OAC and level of psychological distress, as measured by the K10.³³

Procedure

Participants selected via purposeful sampling were emailed to alert them to the opportunity of participating in this study and a link was provided to further information and an online consent form for further contact. Once online consent was provided, an email was sent to organise an interview at a convenient time and mode (by Zoom or telephone) for the participant. All but one of the interviews were conducted via Zoom and hosted by the research team. The other interview was conducted via telephone at the request of the participant. Oral consent procedures were used at the outset of each interview and interviews were recorded. Interviews were scheduled for up to 1 hour and took between 45 min and 1 hour to complete. Interviews were transcribed verbatim manually by two of the researchers.

Qualitative interviews

The interview topic guide and sample questions were developed by members of the study team (RS, HA and ER) based on a literature review, the online survey and the PPI consultation described above. Areas of inquiry and sample questions for use in the qualitative interviews are outlined in table 1.

Table 1.

Areas of inquiry and sample questions

Area of enquiry	Sample questions
Activities and experiences that benefit mental health in general	What sorts of things have helped your mental health and well-being in your everyday life?
	Is there anything that has helped particularly during the pandemic?
	Was there anything that helped particularly before the pandemic?
	Can you describe how they affect your mental health?
Ways in which online arts and culture impact mental health	Do you think online arts and culture are, or could be useful for mental health and well-being?
	What sorts of experiences related to online arts and culture do you think are or could be helpful?
	What sorts of impact might they have on mental health?
Ways in which online arts and culture could be improved for mental health	In what ways could online arts and culture be improved?
	What sorts of things might they target—mood/anxiety related?
	Any other elements—structure, connection, stimulation, other?
Engagement with online arts and culture for mental health	Do you or would you consider visiting online arts and culture if you thought it could help your mental health and well-being?
	What would attract you to accessing online arts and culture that might help with mental health and well-being?
	When do you think would be best to use it, for example, at all times, or when you have noticed a problem?
	Is it something would like as a series or programme, if so, about how many sessions, how would you like to be engaged?

The research team comprised of multidisciplinary researchers including a consultant psychiatrist and experienced qualitative researcher in adolescent mental health (RS) who worked collaboratively on the project. In addition, another experienced qualitative researcher was an integral member of the study team (MG) as well as a broad range of diverse researchers from multiple disciplines. Participants were not previously known to the research team.

All interviews were conducted by RS and one other interviewer (HA, ER and LBo), with up to four silent observers (LBe, LBo, BO, ER and HA) to take field notes and to ensure documentation of non-verbal cues and accurate transcribing of interviews. Interviews were audio-recorded using an audio-recorder, transcribed (verbatim by two of the researchers) and analysed as soon as feasible following the interviews. Identifiable data were removed from transcripts and data were handled in keeping with institutional (Oxford University) protocols and guidance

Data analysis

Qualitative interviews and analyses were conducted concurrently. The data collected in the interviews were analysed as soon as possible after the interviews to minimise information loss. Four members of the research team undertook the analysis (ER, LBe, RS and LBo) following the six phases of reflexive thematic analysis as described by Braun and Clarke.^{35 36} Multiple coders were chosen for a collaborative and reflexive analysis designed to develop a richer and more nuanced reading of the data with the sense-checking of ideas and an exploration of assumptions and interpretations of the data.³⁷

The analysis was approached from a constructivist epistemological orientation adopting a bidirectional understanding of the language/experience relationship. The data was interpreted prioritising the participants’ own descriptions of their experiences and opinions. Recurrence of terms as well as the meaningfulness of described phenomena was pivotal to informing the thematic analysis. For example, the term ‘distraction’ was used repeatedly throughout the data set, however its meaning varied from a shift in focus, to feeling entertained, to disrupting negative thought patterns, therefore themes were revised to more clearly reflect the phenomenon described rather than the language used per se. In this way meaningfulness was highly influential in the development and interpretation of codes and themes. We analysed the data set inductively and deductively. While a framework based on thoughts, feelings and behaviours was a starting point for sense making of the data, the analysis itself became more deductive in its approach as we progressed. Latent coding was adopted with the research team playing an active role in interpreting codes and developing and then challenging themes and identifying relevance to the research objectives.^{36 37}

Coding was developed with the aid of NVivo V.12.³⁸ Units of text were assigned nodes and themes were developed and then refined and explored in more depth in subsequent interviews in an iterative process. Themes and subthemes were generated, reviewed and revised with regular discussion. During these discussions, the researchers reflected on assumptions and prior knowledge and explored the data to develop new themes. Descriptions of themes were returned to participants individually for comment. The participants preferred mode of communication for the presentation of themes was via email. Participants were in agreement with the themes and it was not necessary to revise themes in response to participant feedback.

Results

Participants

Thirteen socio-demographically participants aged between 18 and 24 years were interviewed between 30 July 2020 and 9 September 2020; four of whom identified as male, seven as female and two as non-binary. Annual household income ranged from less than £16 000 to over £120 000. Only one participant lived alone, and the others lived with up to eight other people. They were geographically dispersed, 11 living in the UK (2 in the West Midlands, 2 in the East Midlands, 2 in South East England, 1 in South West England and 2 in greater London), and 2 overseas, 1 in a high-income country and 1 in a low/middle-income country. They had a broad range of levels of psychological distress, all but two scoring 20 or more on the K10 indicating the likely presence of a mental disorder.³³ They varied in their regularity of use of OAC, with four having used it only once or twice ever. No participants dropped out after informed consent was provided (please see table 2).

Table 2.

Participant demographics and mental health status

Pseudonym	Ethnicity	Gender	Age	Frequency of engagement with arts and culture online	K10
Abi	White	Female	18–24	Daily	20–24
Nina	Asian	Female	18–24	Once a week or more	>30
Alex	White	Non-binary	18–24	Once a week or more	>30
Kate	White	Female	18–24	Only once or twice ever	>30
Jake	White	Male	18–24	Only once or twice ever	20–24
Tom	White	Male	18–24	Once a month or more	<20
Luke	White	Male	18–24	Only once or twice ever	<20
Jo	White	Non-binary	18–24	Once a week or more	>30
Jaya	Asian	Female	18–24	Once a week or more	20–24
Layla	White	Female	18–24	Daily	20–24
Mia	White	Female	18–24	Once a month or more	>30
Cara	White	Female	18–24	Once a month or more	20–24
Eve	White	Female	18–24	Only once or twice ever	>30

Asian, Asian/British, Indian, Pakistani, Bangladeshi, other; K10, Kessler Psychological Distress Scale; White, white British, Irish, other.

Six themes, ‘Characteristics of other activities’, ‘Online engagement’, ‘Human connection’, ‘Mechanisms of impact’, ‘Mental health outcomes’ and ‘Engagement optimisation’, were identified from the interviews along with subthemes. Themes and subthemes are outlined in table 3 along with example quotes using pseudonyms to identify participants. Themes are described in more detail below.

Table 3.

Themes, subthemes and additional quotes

Theme	Subthemes	Example quote
Characteristics of other activities	Regular, connecting, absorbing	It’s a ‘we are all in the same boat’ thing that makes me feel better because it means I’m not the only one going through whatever is stressing me out. Luke, male, white
Online engagement	Flexible engagement, diverse content, in depth, alternative to social media	I liked that online people can take you through and explain things a little more as I felt more connected to it. I liked knowing why paintings were made. Mia, female, white
Human connection	Human stories, alternative viewpoints, representation/diversity	Both expressing your views and hearing other people’s views is helpful. It is also good to have diverse views… Most of the time, your social circle shares the same views as you but I think it’s also good to hear opposing views so you can question your own views. Jake, male, white
Mechanisms of impact	Relatability, reflection, perspective, exploration and discovery, learning, creativity, escapism	Sometimes hearing what others are feeling helps you to think about your own thoughts and feelings and helps you to empathise with others too. Kate, female, white
Mental health outcomes	Reduce negativity, lift mood, calming, proactivity	The content helps me to be calm. It’s about zoning out of your mind-set and calming down. Alex, non-binary, white
Engagement optimisation	Regular, familiar, optionality, not ‘targeted’ at mental health	Enhancing the content can be more fun and also more informative. You wouldn’t just stare at the picture but be more involved or more absorbed. Jo, non-binary, white

Characteristics of other activities

Participants described activities they did in their everyday life that they thought benefitted their mental health and well-being. Subthemes under Characteristics of other activities were ‘Regular’, ‘Connecting’ and ‘Absorbing’.

Activities included sewing and cookery to running outdoors and socialising that they felt benefitted their mental health. Although types of activity were wide ranging, what seemed more important and had greater commonality between participants was the characteristics of activities that were perceived as being helpful mental health. These were mainly activities that they did regularly and proactively, to keep themselves well and prevent mental health problems, rather than activities that they would do if they felt their mental health was deteriorating.

I think the positive effects are heavily tied up with the routine aspect of it. The loss that you feel for not doing it for whatever reason, mitigates against the benefit of leaving it an extra day and coming back to it fresh. Tom, male, white

They say that you should try to spend at least 2 hours outside a day, so I try to do that. I also try to look after myself and eat well because I think that helps me to feel like I’m taking care of myself. I also like to see friends, I think that really helps keep me going. Luke, male, white

Connecting with other people was a common feature of activities perceived as being helpful for mental health. This was described in a broad range of activities including tuning into dialogues and narratives in podcasts and reading about characters in books, as well as direct social contact via phone, social media, video and in-person.

When you hear about people talking about their experiences, I find that really interesting and quite helpful. Layla, female, white

I made a big effort to be with other people. I would make efforts to not be alone during the day as it (connecting with others) energised me. Mia, female, white

In addition, participants described that the more absorbing an experience, the greater the benefit, particularly activities that served to completely shift their focus away from their thoughts. Participants described that a shift away from their thoughts was key for separating themselves from negative thought patterns that they might have been experiencing beforehand.

I like content that encourages activity and gives you something to do which can provide a distraction from everything else, so you just get consumed with doing it. Alex, non-binary, white

When I’m reading I do it to get away from the world…it’s nice to sit in the garden and not have to think about my own life. Mia, female, white

During that time, you are only really thinking about that thing, not about what other people think about you or having those sorts of accumulative thoughts that have negative impacts. So I guess it’s kind of a relief from these thoughts and things. It’s the idea of an all-consuming task. Tom, male, white

Online engagement

Subthemes under ‘Online engagement’ were‘Flexible engagment', 'Diverse content', and 'Stories and depth of commentary’. Participants highlighted that online engagement with arts and culture had several advantages over in-person experiences as online content could be accessed regularly, remotely and on demand. Many described that they could access it as and when they felt they needed it, such as when experiencing negative or anxious thoughts, or late at night. They also described how it improved access to younger people who might not have the independent means of getting themselves to a museum or art gallery and whose families might not take them regularly. They explained that online engagement also gives them access to a wider variety of diverse content. In addition, online engagement was seen as being able to offer more detailed descriptions of the humans behind the art, an increased depth and breadth of commentary and more varied perspectives.

However, the important thing is having something that you can just access when you need it. Alex, non-binary, white

You don’t have to go to the place. You can watch it whenever you want. You can watch something in a different country that is at a different time[zone]. It has added value. Jake, male, white

Online can offer the narrative behind the artists that museums don’t do as easily. Nina, female, Asian/British

Participants also described OAC as providing positive alternatives to social media and other typical online content. For example, some spoke about social media and other online experiences as having a negative impact on their mental health, feeling like they got drawn into scrolling online content for unanticipated long periods of time with no purpose. In addition, many described that many online experiences become like ‘echo chambers’ where similar viewpoints and perspectives are shared. They described feelings of nervousness of expressing alternative views that might differ or be perceived as unpopular, whereas they felt that they would benefit from being exposed to a variety of viewpoints, promoting a shift in perspective (see Viewpoints, below).

Especially during lockdown, I didn’t get along well with my phone at all….On your phone there’s this constant thing of checking of messages, seeing what you have or haven’t got, checking who is online, scrolling down Facebook with no real purpose. Because your phone is always with you. …. Your phone sometimes stops you from getting up for things. Then you get that negative realisation that you’ve just laid in your bed for an hour and not made anything of it. Tom, male, white

Human connection

Subthemes under ‘Human connection’ were ‘Human stories’, ‘Alternative viewpoints’ and ‘Representation/diversity’. Human stories of real individuals based on relatable human experiences were identified as an important way in which the mental health benefits of OAC could be optimised. This could be the story of the artist or other individuals whose life journey was connected with art or artefacts. In particular, they wanted to hear the stories of people they could relate to who had experienced challenges. Such challenges included facing transition, not fitting in or experiencing mental health difficulties. Stories describing human experiences (relationships, beliefs, hopes, behaviours and feelings) were seen as having mental health benefits.

How they overcame challenges is important, just as much as hearing about their success. I don’t think it’s helpful to hear about good things about someone as it’s not an accurate perception of their life. Even if they have been really successful they will have had challenges at some point and it’s important to hear about that…….Even if they just seem like an everyday person, you could identify with them more strongly. Sometimes hearing the unheard stories are good as you can feel like your own story is going unheard. It can be comforting. Layla, female, white

However, feeling represented was also seen as essential for mental health benefit. Moreover, under-representation of people by race, gender identity or sexual orientation across a whole cultural experience (such as a museum) was identified as being detrimental to mental health.

I think it can help seeing yourself reflected in art. I liked how the British Museum did a presentation of objects (LGBT trail) related to pride. As someone who is LGBT it was nice to see how pride is not necessarily a “new thing” but something that has been researched for a long time. It is nice to feel reflected in people or things that existed hundreds of years ago. Alex, non-binary, white

Sometimes when I am in a museum like the Ashmolean and I see fewer people around Asian and Indian art, it feels personal. Representation in art is important as it shapes how you perceive it. I always feel really moved when I see representation of Indian people because it is so rare. It’s easier to find online. We feel connected to art and artists that represent things that we can relate to. I remember my brother was once so affected by seeing a painting with south Asian people in it that he took a picture of it. Nina, female, Asian/British

Participants said that being able to access different people’s viewpoints was important for optimising the mental health benefit of online cultural content. They valued varied viewpoints from a broad range of people of different ages and backgrounds. They described that often they were only exposed to similar viewpoints, such as from their friendship groups or online forums. They described anxiety of sharing their views in certain forums for fear of being perceived to be saying the wrong thing or ending up on the wrong side of an argument. They described the benefits of different viewpoints which allowed them to see content in a different light. Some said that it could be transiently uncomfortable to see a view that differed substantially from their own but that there was an overall mental health benefit from that experience. They said that online cultural content felt like a safe space to house different viewpoints and that they wanted to have the option of sharing their own viewpoint. They described that seeing a variety of viewpoints could be comforting, could disrupt negative thought patterns and broaden their perspective.

With online resources, the more views and perspectives there are to access the better. It can provide new perspectives that we haven’t heard before. I think it’s nice to see different perspectives and hear someone else’s point of view. You can get stuck in your mind a lot and sometimes it’s beneficial to have someone else’s view bring you out of that. Abi, female, white

It’s interesting with ‘trigger warning’ things, people say that you need to have them for mental health. But this works both ways because my mental health is enhanced by hearing different perspectives. Luke, male, white

Mechanisms of impact

Subthemes under ‘Mechanisms of impact’ were ‘Relatability’, ‘Reflection’, ‘Perspective’, ‘Exploration and discovery’, ‘Learning’, ‘Creativity’ and ‘Escapism’. These mechanisms were interconnected and most commonly related to human connection. However, the gateway to the pathway appeared to be via the relatability of the person to whom the human connection applied.

In order to derive optimal benefit from human stories, participants described the need to be able to relate to the individuals on a human or emotional level, often by being ‘hooked’ by a detail about their everyday life that they could relate to. Everyday ‘quirky’ details such as what a person liked to eat for breakfast were thought to be more important than life events or major achievements. This not only provided benefits by engaging them in the story but also relieved feelings of loneliness.

The hook could be just everyday information about people. How other people live and day to day life. Its immediately relatable to me because that’s my life. Luke, male, white

Participants also wanted to see diverse stories of individuals from global cultures and different periods in history. A true and relatable human experience transcending time and space was seen as having optimal mental health benefits. They described that connecting with those outside of their current context, such as those from a different period in history or global culture was of benefit for which diversity was essential. This was often described as providing a sense of perspective.

It helps relate it to yourself and in some way either empathise with the people at the time or give you some kind of perspective in your life. For example, looking at [cultural] things like the plague and thinking of other people that have experienced a similar kind of pandemic and thinking we will be okay. It’s not the end; knowing it has happened before. Kate, female, white

Human connection through arts and culture provided young people the opportunity to reflect on the experiences, thoughts, feelings and behaviours of other people. This allowed them to understand more, not only about the emotional life of others but also reflect on their own internal experiences.

I enjoy reading about things that resonate with me. I’m interested in people that have had similar struggles. I am interested in learning about people who aren’t straight. As I am not and it took a long time to come out to my parents. It’s powerful to read about people in history that experience this kind of love. I don’t really have a lot of care for celebrities, I don’t follow them and I also don’t really enjoy watching the news as it often makes me feel frustrated. I think being able to understand my own emotions is important for me. Mia, female, white

The process of exploration and discovery when engaging with OAC were seen as beneficial to mental health, particularly in finding untold or hidden stories. This was described both in the absorbing process of ‘getting lost’ in collections and the excitement of serendipitous discovery. Separately and interconnected with these mechanisms were other mechanisms, including creativity, in which participants described the mental health benefits of being inspired to be creative or witnessing creativity in other people which often led to feeling more proactive, in creative and other ways. Learning applied to both learning about art and culture and about the internal experiences of other people and the benefits as being related to using time usefully and of a sense of achievement. Participants also described the mental health benefits of using the experiences of others to imagine being in a different context as a form of escapism.

I like the journey of hunting something down and searching it myself rather than instantly finding it or being handed it really easily. Abi, female, white

Creativity can express things in a way that therapy can’t always do. Abi, female, white

It is about learning new things. I am a quite curious person. I get to see things that I do not normally see. Alex, non-binary, white.

I find that it is a form of escapism. When you watch a play you are watching other people’s lives and perspectives. Nina, female, Asian/British

Mental health outcomes

Subthemes under ‘Mental health outcomes’ were ‘Reduce negativity’, ‘Lift mood’, ‘Calming’ and ‘Proactivity’. Participants described that OAC could impact on their mental health in a variety of ways. They described a positive impact on mental health that came with the disruption of negative thought patterns especially when absorbed in activities or engaged with diverse stories or viewpoints. They also described a mood lifting aspect, which also related to looking outwards and adjusting a negative mindset, which could also lead to feeling of proactivity. Many talked about the promotion of feelings of calm that came with engaging with cultural content which was also described by some as helping with insomnia and was even sought out when having problems with sleep.

I tend to think in black and white and have polarising thoughts. Doing these things gives me another way of thinking. Alex, non-binary, white

I just think we need to see more content that makes us happy and smile to lift our mood in that moment, and just be a reminder that we don’t have to feel sad or stuck in the mind-set we are in. Abi, female, white

Dark emotive imagery can be calming. It can show darkness that perhaps the artist felt or that others relate to and feel that you are not alone in sometimes having those feelings. You step out of yourself, which helps to make things that are currently going on in your life not seem so bad. Nina, female, Asian/British

A major advantage was seen as encouraging proactivity and motivation, both for creative activities and social activism. Often this was after transient distress at witnessing social inequalities but overall was viewed as a positive experience with mental health benefit.

If you have done something nice it can be uplifting and inspire you to do other things that day. It can make you feel more motivated and proactive. Eve, female, white

Some people there are now taking action and taking ownership of their heritage. I see this as very positive. It is them turning over information which is commonly perceived as true. Jo, non-binary, white

Engagement optimisation

Subthemes under ‘Engagement optimisation’ were ‘Regular’, ‘Familiar’, ‘Optionality’ and ‘Not ‘targeted’ at mental health’. Many participants described that the mental health benefits of arts and culture were greater with regular use and familiarity. Some said that they had been introduced to arts and culture at an early age and that this familiarity meant that they felt more comfortable accessing it at times of need. Many expressed that they would also recommend an early introduction for others.

The more you’re doing it regularly the more your anxiety doesn’t build up again so it’s good to keep using it. Layla, female, white

We should promote [online cultural content] more in schools. Not everyone has parents that are interested in culture. Getting them interested from an early age could help them develop a lifelong interest which in turn would benefit them. Abi, female, white

Many preferred to engage with OAC regularly to maximise the benefits and then to dip into it when they felt particularly in need, for example, when feeling low, anxious or unable to sleep. Optionality around engagement preferences was seen as important. Some also described that it was not that they benefitted from regular engagement but rather experienced negative consequences when they could not do it.

These are effects that are like a domino effect, it comes up again and again, so I will regularly feel the benefit and this gets stronger with time. Jo, non-binary, white

While a few participants thought they would access content that was explicitly targeted at mental health, many were more cautious. Many participants expressed being particularly cynical about mindfulness being promoted online in relation to arts and culture.

I find that hearing something that I’m interested in reading in is so much more helpful as you are engaged and distracted. I know others do like mindfulness, but I just don’t connect with it. Sometimes it feels like it is done to tick a box and so people move away from it. Layla, female, white

Discussion

This study contributes to a gap in the literature by examining the use and potential benefit of OAC for mental health in young people. Overall, it highlights that OAC for young people has several advantages over in-person experiences as well as providing positive alternatives to social media and other typical online content. Of note, human connection (through diverse human stories and alternative viewpoints) was universally described as the feature of OAC most likely to optimise a mental health impact and the importance of representation was highlighted within that. Furthermore, we identify several mechanisms through which this optimisation might occur—including through reflection on experiences, providing a sense of perspective and the process of exploration and discovery, as well as perceived mental health outcomes, including proactivity, disruption of negative thoughts and lifting mood. In particular these findings have significant implications for further research targeting approaches of OAC for mental health.

A number of participants described and articulated the ways in which culture and the arts could support their mental health, and that benefits were more likely to be derived with greater familiarity and regular use. Participants described some advantages of online versus in-person engagement. This included being able to use it regularly, remotely and on demand, as well as containing deeper and broader commentary and more diverse content. Features of OAC that participants thought were most likely to benefit their mental health were diverse human stories and alternative viewpoints via human connection, providing opportunities to reflect on the experiences of others and providing a sense of perspective. Perceived impacts on mental health were disrupting negative thought patterns, lifting mood, an increased sense of calm and increased proactivity.

All participants were able to speak about their own mental health and efforts they make to support their mental health. Many studies5 6 8 10 11 39 40 have attempted to understand conventional forms of help-seeking in young people. In contrast this study allowed young people to describe alternative ways of supporting their mental health on their own terms.²⁹

Regular attendance of cultural events in the community has been shown to be associated with a multitude of health benefits including increased longevity^41–44 and previous commentary has described the potential of the cultural heritage sector as providing sites for public health interventions.²² OAC from cultural institutions such as museums, arts galleries and libraries, has enormous potential for enabling wider access and more frequent and flexible engagement for optimal public health impact.

While it might be assumed that pleasing and agreeable content might maximise the mental health benefits of OAC, the findings of this study suggest that the mechanisms for mental health benefit rely on human connection and descriptions of challenges and the divergence of viewpoints. Participants described that cancel culture⁴⁵ and trigger warnings were unhelpful. This is consistent with recent studies demonstrating that even young people with relevant traumas do not avoid triggering material and the effects of triggering material appear to be short-lived, even in those with post-traumatic stress disorder (PTSD).⁴⁶ Taking this a step further, the participants in this study felt that a lack of divergent views was detrimental to mental health. These findings suggest that future OAC initiatives could benefit from, rather than seek to avoid, material which is perceived as ‘triggering’. Instead, such material could potentially be included—in consultation with users and relevant stakeholders.

In this current study, those from traditionally marginalised groups described the benefits of representation and how they felt that under-representation was detrimental to mental health. Participants described the benefits of diversity in the cultures and histories presented in bringing a sense of perspective. Opportunities for people to ‘speak for themselves’ have been accelerated by new media and technological tools, but those contributions tend to nevertheless remain heavily mediated by institutions.⁴⁷ Options to comment on and co-produce content might allow young people to feel empowered and motivated to engage.⁴⁸ However the current inequalities in representation in cultural institutions⁴⁹ must be reversed in order to realise the public health potential of OAC for mental health insome of those with the greatest unmet mental health need.⁵⁰

Limitations

While providing a useful insight into young people’s perspectives on OAC for mental health, this study focused on a sample of 13 participants aged between 18 and 24 years, 9 of whom were already users of OAC content. While this allowed an exploration of the perceived mental health benefits of OAC and how to optimise these, a limitation of this study was that it did not fully explore barriers to engagement. The focus of this study, to fully explore the benefits and potential for optimisation of OAC for mental health in young people, meant that the potential harms while touched on were not explored in detail. In addition, this study was conducted during COVID-19 restrictions, which brought into sharp focus the usefulness of OAC for mental health, due to the physical closure of cultural institutions and heightened mental health difficulties in young people. This context must be remembered when considering some of the findings such as the benefits of online engagement which may have been more obvious at the time of COVID-19 restrictions than at other times.

Implications

The results of this qualitative interview study suggest that connection to cultural assets on a personal level has potential mental health benefits for young people. For cultural institutions to produce online content that benefits mental health for young people, there must be increased efforts to draw out, present and engage people in the human stories and alternative viewpoints behind the collections’ arts and artefacts. For young people, it is not necessarily the quantity or illustriousness of the objects presented, but the emotional power of the human narratives behind these objects that has the greatest potential impact on mental health. Thus, future OAC projects could consider integrating human stories, as well as diversity and representation and alternative viewpoints into their catalogue of offerings—as their inclusion could help to optimise online and cultural resources for mental health (even where that is not the primary aim of the OAC being offered).

Future research should expand to include an increasingly diverse study sample—including more perspectives from more under-represented young people from ethnically diverse backgrounds and those from deprivation, including digital poverty, who might also have lower levels of help seeking from health services as well as lower levels of community engagement, including OAC. Such research could increase understanding of the potential barriers to engagement. In addition, this research focused on the potential positive impacts, however further research is needed into the potential harms of OAC for mental health. As with implications for practice this has important implications for an age targeted approach to research. Given the preference of young adults for the proactive use of such resources, on the importance of human connection in optimisation for mental health and the scepticism of resources targeted at mental health, this has important implications for the testing of cultural resources for mental health in this age-group. Further mixed methods research is needed to fully elucidate these research gaps in an age targeted way with attention to under-represented groups.

Conclusion

Many of those interviewed for this study self-reported levels of psychological distress indicating clinically significant depression and/or anxiety. Therefore, these results have public health implications with potential applicability to clinical populations. Moreover, this study suggests new and innovative ways of unleashing culture to broader audiences online with previously underused ways of enriching engagement and mental health impact. This study demonstrates that young people believed that OAC could be an engaging and efficacious way of supporting mental health. Of note is the importance of representation and equitable access which must be addressed to realise the full public health potential of OAC.⁵¹ OAC has the potential to reach the volumes of young people with threshold and subthreshold CMDs who currently do not seek help. In addition, these methodologies can be used to elucidate the potential utility of other community-based resources for mental health.

Data availability statement

No data are available.

Ethics statements

Patient consent for publication

Not applicable.

Ethics approval

The Oxford University Research Ethics Committee (CUREC) granted ethical approval for this study prior to its commencement (Ethics reference R70187/RE005). Participants gave informed consent to participate in the study before taking part.