Are variations in rates of attending cultural activities associated with population health in the United States?
© Wilkinson et al; licensee BioMed Central Ltd. 2007
Received: 06 October 2006
Accepted: 31 August 2007
Published: 31 August 2007
Population studies conducted in Sweden have revealed an association between attendance at cultural activities and health. Using data from US residents, we examined whether the association could be observed in the US.
Participants in the current study included 1,244 individuals who participated in the 1998 General Social Survey.
A significant association between cultural activities and self-reported health (SRH) was observed, even after controlling for age, gender, marital status, race, number of children, subjective social class, employment status, household income, and educational attainment. Specifically, the more cultural activities people reported attending, the better was their SRH.
The data confirm that an association between cultural activity and health is present in a US sample. The data do not mean that the association is causal, but they suggest that further longitudinal research is warranted.
Research conducted in Sweden has explored the relationship between attending cultural activities and both mortality and self-rated health (SRH). The Swedish studies suggest that there are health benefits to be gained by participating in different types of cultural activities. Bygren et al.  reported that people who frequentltended cultural activities during a nine-year period had better survival odds than those who rarely attended. Based on the same cohort, but after a 14-year time lapse, the researchers found a higher mortality risk for people who rarely went to the cinema, concerts, museums or art exhibitions compared with those who went frequently . Both analyses controlled for gender, age, education, disposable income, social contacts, presence of a long-term disease, smoking and exercise patterns. In a third analysis the researchers  constructed a cultural attendance indicator that reflected attendance and frequency of attendance at cinemas, theatres, concerts and live music, museums and art galleries, which they used to examine changes in self-reported health associated with changes in attendance of cultural activities over an eight-year period. People who became less active over the eight-year period or who were inactive at both time periods were more likely to report being in poor health compared to people who were active at both time periods or who became more active over the eight years. This analysis controlled for gender, education, home ownership, urbanity, reading, making music, and health status at the first time period.
A Canadian study of police and emergency response workers supported these findings. The more frequently participants attended cultural activities during their leisure time, the better their physical health . Research in the US has hitherto focused on the relationships between health and leisure time physical activity [5, 6], volunteering [7, 8], and religious attendance [9, 10]. To the best of our knowledge, no previous study has examined the association between cultural activity and health in the US population. Given that 1) there are striking differences in social structure and health outcomes between Sweden and the United States [11, 12]; 2) there are few characteristics that are as strongly associated with SES as attendance at cultural activities ; and 3) the well documented relationship between health and socio-economic status (SES) is not fully explained by differences in access to health care , work conditions , social ties , and health behaviors , we examined whether the association between cultural activity and self-reported health could be observed in the US population.
The analysis utilizes public use data from the 1998 General Social Survey (GSS). The GSS is an annual survey of attitudes toward social issues that began in 1972 and comprises a core set of demographic and attitudinal questions as well as rotating topical modules . It is a national area probability sample of non-institutionalized adults residing in the United Status. Data are collected by in-person interviews and verbal informed consent was obtained from all study participants. In 1998 a random sample of 1,435 individuals, 18–89 years old, completed a topical module reporting on the types of cultural activities attended in the previous year. The overall response rate was 75.6%. All aspects of this study received approval from the Institutional Review Board at the University of Chicago.
Outcome variable: Self-Rated Health (SRH)
Participants answered the question "In general how would you rate your health?" Responses were made on a four-point scale: excellent, good, fair, or poor. Consistent with the Swedish study , we combined excellent/good into one category (coded as 1) and fair/poor into a second category (coded as 0).
Participants were asked "Next I'd like to ask about some leisure or recreational activities that people do during their free time. As I read each activity, can you tell me if it is something you have done in the past twelve months..." attended 1) art exhibits (37.9%), 2) dance performances (20.4%), 3) operas or classical recitals (17.1%), 4) movies (67.5%), 5) live popular music (39.2%), or 6) plays (theatre) (24.1%) (% endorsements). We also created a variable (Cultural Activity) that reflected cumulative cultural activity during the year by summing the Yes responses. A person who reported attending none of the cultural activities received a score of 0, while somebody who reported attending all of the six activities received a score of 6. Cultural Activity was entered as a continuous variable in analyses (Mean = 2.06, SD = 1.67).
Cultural preferences and activities are influenced by many factors including social class, gender, race, education, and age . SRH also varies with gender, age, marital status, race, employment status and SES [6, 19]. We therefore controlled for age, gender, marital status, race, number of children, subjective social class, employment status, household income and years of education. Age (range 18 – 89), number of children (range 0 – 8+), household income (range $1,000 – $120,000+), and years of education (range 0 – 20) were entered as continuous variables. Gender (female, male), marital status (never married, divorced or separated, widowed, married), race (black, other, white), subjective social class (lower class, working class, middle class, upper class), and employment status (not currently working, retired, homemaker, employed), were entered as class variables (reference category is listed last).
We used univariable logistic regression (proc logistic in SAS) to examine the relationships between each control variable/Cultural Activity and SRH. We used the general linear model (proc glm in SAS) to examine the relationships between control variables and Cultural Activity; for each control variable we report the unstandardized parameter estimate (b).
Multivariable logistic regression analyses were used to establish if there was an association between attending cultural activities and SRH. Models were built for a) each type of activity separately and b) Cultural Activity. The first set of models (I) was adjusted for the demographic characteristics including age, gender, martial status, race, and number of children. The second set of models (II) further adjusted for aspects of SES including subjective social class, employment status, household income, and years of education. In all models, all covariates were entered simultaneously. All statistical tests were 2-tailed and all analyses were conducted in SAS .
Of the 1,435 respondents who completed the topical module, 21 individuals were excluded because of missing data on SRH, age, subjective social class, and number of children. Another 170 individuals were excluded because of missing data on income and education. Thus, the final sample size for analysis was 1,244 (87% of respondents).
Associations with SRH and Cultural Activity
Self-Rated health and cultural activity by demographic characteristics (N = 1,244)
No. of Cultural Activities Attended
1 – 2
3 – 4
5 – 6
No. of Children
Two or more
0 to 8
0 to 8
Subjective Social Class
HH Income ($)
15,000 – 29,999
< High school
No. Cultural Activities
Gender (b = 0.25, Standard Error (SE) = 0.09, p < 0.01), marital status (p < 0.01), race (p < 0.05), subjective social class (p < 0.01), income (b = 0.034, SE = 0.01, p < 0.01), and years of education (b = 0.22, SE = 0.016, p < 0.01) were independently associated with Cultural Activity (in a multivariable model). The never-married had higher cultural activity scores than the married (b = 0.40, SE = 0.12, p < 0.01). Blacks had lower cultural activity scores than whites (b = -0.33, SE = 0.12, p < 0.01). Individuals self-identifying as lower class (b = -0.58, SE = 0.28, p < 0.05), or as working class (b = -0.77, SE = 0.22, p < 0.01) had lower cultural activity scores than those self-identifying as upper class.
Multivariable logistic regression models
Relationships between cultural activities and self-reported health (N = 1,244)
Type of event
OR (95% CI)
OR (95% CI)
Opera or Classical Recital
Predictors of self-reported health (N = 1,244).
95% Confidence Interval
0.96 – 0.99
1.02 – 1.98
0.55 – 1.71
0.46 – 1.09
0.48 – 1.24
0.76 – 1.85
0.34 – 1.04
No. of Children
0.90 – 1.08
Subjective Social Class
0.09 – 0.69
0.24 – 1.47
0.37 – 2.29
0.30 – 0.84
0.33 – 0.95
0.29 – 0.79
HH Income ($)
1.01 – 1.08
1.00 – 1.13
No. Cultural Activities
1.01 – 1.26
The more cultural activities people reported attending, the better was their SRH. This remained true after controlling for several potentially confounding variables such as age, gender, martial status, race, number of children, subjective social class, employment status, household income, and years of education. Confidence in the findings is increased by the fact that similar results have been observed in a Swedish study .
Studies investigating social activities have repeatedly demonstrated that such activities have health benefits. Frequently these health benefits are assumed to derive from increased activity levels that result in improvements in cardiovascular functioning [21, 22]. However, some researchers report that the health benefits gained from social activities that do not directly improve physical fitness may be as great as those gained from physical activities that directly increase fitness . Although this study did not directly assess mechanisms linking attending cultural activities with health, it seems plausible that the benefits derived from attending cultural activities are related, partly at least, to social aspects of the activities. People frequently attend cultural events with friends; being part of a social group that provides social, emotional and instrumental support has positive health benefits . That said, cultural stimulation likely has an effect on health in its own right. Results from an animal experiment demonstrate that environmental stimulation from social interactions has a different effect on the brain than that from inanimate aspects of the environment . This could be analogous to the stimulation from viewing art in the company of friends, and speaks to potential pathways through which cultural activities may influence health.
Indeed, the arts have been used for several decades as a therapeutic health-enhancing tool for individuals with no reports of adverse effects on the health and well-being of the participants. Studies that have evaluated the potential of the arts as a therapeutic health-enhancing tool have demonstrated that music, art, and mental imagery can have a beneficial impact on both mental and physical health [26–29]. For example, results from a case-control intervention with elderly women found that compared to the controls, women who had received an art intervention reported improvements on several self-reported indicators of health status and decreased systolic blood pressure .
It is possible that the reported health benefits associated with art therapies are related to reduced levels of stress. Stress reduction decreases oxidative DNA-damage and the formation of 8-hydroxydeoxyguanosine, elevated levels of which are linked to the development of disease, including cancer . Participating in leisure time activities is an effective mechanism of coping with stress and engaging in activities that are perceived to be meaningful may be particularly important during periods of stress . Therefore it also is possible that attending cultural activities serves as a buffer against harmful stress, thereby lowering disease risk.
The study had a number of limitations. First, the data are cross-sectional, meaning that the direction of causality is uncertain. It is possible that good health increases motivation and the ability to attend cultural activities. Second, the data were exclusively based on self-report. It would be helpful if future studies reported a clinical health endpoint as well as SRH. Third, the cultural activities examined were limited to those assessed in the GSS. This may have resulted in the misclassification of people who attended cultural activities that were not assessed by the GSS. In future research it will be helpful to use a broader range of cultural events (e.g. visiting museums, zoos, and aquariums, as well as attending ethnic festivals and sporting events). Fourth, information was not available on how frequently participants attended each event. The Swedish studies included an assessment of intensity and demonstrated that changes in the intensity of cultural consumption were associated with changes in health status . Fifth, none of the fully-adjusted models that investigated each type of event separately demonstrated a significant relationship between any one event and SRH. The results therefore are silent as to whether attending each type of event is particularly strongly associated with better health. Sixth, the analysis did not include several important confounding variables, such as exercise patterns and dietary behaviors which influence SRH , and the presence of serious illness , which influences SRH and could also influence attendance at cultural activities. Last, the Cultural Activity effect was attenuated when more confounders were included in the models (Table 2). We do not know what residual confounding remains.
In conclusion, despite these limitations, our results suggest that further research is warranted on the relationship between cultural activities and health. Such research should use longitudinal experimental methods and clinical end-points. If such future research suggests that participating in cultural activities does have health benefits, this may have implications for socio-cultural policies designed to improve health.
- Bygren LO, Konlaan BB, Johansson SE: Attendance at cultural events, reading books or periodicals, and making music or singing in a choir as determinants for survival: Swedish interview survey of living conditions. BMJ. 1996, 313: 1577-1580.View ArticlePubMedPubMed CentralGoogle Scholar
- Konlann BB, Bygren LO, Johansson SE: Visiting the cinema, concerts, museums or art exhibitions as determinant of survival: a Swedish fourteen-year cohort follow-up. Scandinavian Journal of Public Health. 2000, 28: 174-178. 10.1080/140349400444869.View ArticleGoogle Scholar
- Johansson SE, Konlaan BB, Bygren LO: Sustaining habits of attending cultural events and maintenance of health: a longitudinal study. Health Promotion International. 2001, 16: 229-234. 10.1093/heapro/16.3.229.View ArticlePubMedGoogle Scholar
- Iwasaki Y, Mannell RC, Smale BJA, Butcher J: Contributions of leisure participation in predicting stress coping and health among police and emergency response workers. Journal of Health Psychology. 2005, 10: 79-99. 10.1177/1359105305048557.View ArticlePubMedGoogle Scholar
- Santiago MC, Coyle CR: Leisure-time physical activity and secondary conditions in women with physical disabilities. Disability and Rehabilitation. 2004, 26: 485-494. 10.1080/09638280410001663139.View ArticlePubMedGoogle Scholar
- Lorraine PJ, Hammonk RL, Blanton JM: Predictors of self-rated health status among Texas residents. Prev Chronic Dis. 2005, 2 (4): A12-. 10.1191/1479972305cd059ed.PubMedGoogle Scholar
- Harris AH, Thorensen CE: Volunteering is associated with delayed mortality in older people: analysis of the longitudinal study of aging. Journal of Health Psychology. 2005, 10: 739-752. 10.1177/1359105305057310.View ArticlePubMedGoogle Scholar
- Musick MA, Herzog AR, House JS: Volunteering and mortality among older adults: findings from a national sample. Journal of Gerontology B Psychological Science Social Science. 1999, 54: S173-S180.View ArticleGoogle Scholar
- Hummer RA, Ellison CG, Rogers RG, Moulton BE, Romero RR: Religious involvement and adult mortality in the United States: Review and Perspectives. Southern Medical Journal. 2004, 97: 1223-1230. 10.1097/01.SMJ.0000146547.03382.94.View ArticlePubMedGoogle Scholar
- Hill TD, Angel JL, Ellison CG, Angel RJ: Religious attendance and mortality: an 8-year follow-up of older Mexican Americans. Journal of Gerontology B Psychological Science Social Science. 2005, 60: S102-S109.View ArticleGoogle Scholar
- OECD Health Data 2006: How does the United States compare?. [http://www.oecd.org/dataoecd/29/52/36960035.pdf]
- Jackson A: Canada beats USA but loses gold to Sweden: Twenty-five indicators of social development. Canadian Council on Social Development. [http://www.ccsd.ca/pubs/2002/olympic/indicators.htm]
- Katz-Gerro T: Cultural consumption and social stratification: leisure activities, musical tastes, and social location. Sociological Perspectives. 1999, 42: 627-646.View ArticleGoogle Scholar
- Veugelers PJ, Yip AM: Socioeconomic disparities in health care use: Does universal coverage reduce inequalities in health?. Journal of Epidemiology and Community Health. 2003, 57: 424-428. 10.1136/jech.57.6.424.View ArticlePubMedPubMed CentralGoogle Scholar
- Marmot MG, Bosma H, Hemingway H, Brunner E, Stansfiled S: Contribution of job control and other risk factors to social variations in coronary heart disease incidence. Lancet. 1997, 26: 235-239. 10.1016/S0140-6736(97)04244-X.View ArticleGoogle Scholar
- Seeman T, Syme L: Social networks and coronary artery disease: a comparison of the structure and function of social relations as predictors of disease. Psychosomatic Medicine. 1987, 49: 341-354.View ArticlePubMedGoogle Scholar
- Marmot MG, Smith GD, Stansfeld S, Patel C, North F, Head J, White I, Brunner E, Feeney A: Health inequalities among British civil servants: the Whitehall II study. Lancet. 1991, 337: 1387-1393. 10.1016/0140-6736(91)93068-K.View ArticlePubMedGoogle Scholar
- General Social Survey: GSS study description, 2004. [http://www.norc.uchicago.edu/projects/gensoc1.asp]
- Idler EL, Benyamini Y: Self-rated health and mortality: a review of twenty-seven community studies. Journal of Health and Social Behavior. 1997, 38: 21-37. 10.2307/2955359.View ArticlePubMedGoogle Scholar
- SAS: SAS Version 8. 2000, Cary, NC, SAS Institute IncGoogle Scholar
- Blair SN, Kampert JB, Kohl HW, Barlow CE, Macera CA, Paffenbarger RS, Gibbons LW: Influences of cardiorespiratory fitness and other precursors on cardiovascular disease and all-cause mortality in men and women. JAMA. 1996, 276: 205-210. 10.1001/jama.276.3.205.View ArticlePubMedGoogle Scholar
- Kaplan GA, Strawbridge WJ, Cohen RD, Hungerford LR: Natural history of leisure-time physical activity and its correlates: associations with mortality from all causes and cardiovascular disease over 28 years. American Journal of Epidemiology. 1996, 144: 793-797.View ArticlePubMedGoogle Scholar
- Glass TA, de Leon CM, Marottoli RA, Berkman LF: Population based study of social and productive activities as predictors of survival among elderly Americans. BMJ. 1999, 319: 478-483.View ArticlePubMedPubMed CentralGoogle Scholar
- Berkman LF: The role of social relations in health promotion. Psychosomatic Medicine. 1995, 57: 245-254.View ArticlePubMedGoogle Scholar
- Schrijver NCA, Pallier PN, Brown VJ, Wurbel H: Double association of social and environmental stimulation on spatial learning and reversal learning in rats. Behavioural Brain Research. 2004, 152: 307-314. 10.1016/j.bbr.2003.10.016.View ArticlePubMedGoogle Scholar
- Beck SL: The therapeutic use of music for cancer-related pain. Oncology Nursing Forum. 1991, 18: 1327-1337.PubMedGoogle Scholar
- Hughes JR, Daaboul Y, Fino JJ, Shaw GL: The Mozart effect on epileptiform activity. Clinical Electroencephalography. 1998, 29: 109-119.View ArticlePubMedGoogle Scholar
- Wikström BM, Theorell T, Sandström S: Medical health and emotional effects of art stimulation in old age. Psychotherapy and Psychosomatics. 1993, 60: 195-206.View ArticlePubMedGoogle Scholar
- Walsh SM, Minor-Schork D: Suicidal adolescent perceptions after an art future image intervention. Applied Nursing Research. 1997, 10: 19-26. 10.1016/S0897-1897(97)80045-6.View ArticlePubMedGoogle Scholar
- Irie M, Asami S, Nagata S, Miyata M, Kasai H: Psychological mediation of a type of oxidative DNA damage, 8-Hydroxydeoxyguanosine, in peripheral blood leukocytes of non-smoking and non-drinking workers. Psychotherapy and Psychosomatics. 2002, 71: 90-96. 10.1159/000049351.View ArticlePubMedGoogle Scholar
- Manderbacka K, Lundberg O, Martikainen P: Do risk factors and health behaviors contribute to self-ratings of health?. Social Science and Medicine. 1999, 48: 1713-1720. 10.1016/S0277-9536(99)00068-4.View ArticlePubMedGoogle Scholar
- Manor O, Matthews S, Power C: Self-rated health and limiting longstanding illness: inter-relationships with morbidity in early adulthood. International Journal of Epidemiology. 2001, 30: 600-607. 10.1093/ije/30.3.600.View ArticlePubMedGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/7/226/prepub