Arts, mental distress, mental health functioning & mental wellbeing: fixed-effects analyses of a nationally-representative panel study

Arts engagement within communities is ubiquitous across cultures globally and previous research has suggested benefits for mental health and wellbeing. However, it remains unclear whether these benefits are due to the confounding impact of factors such as socio-economic status (SES), childhood arts engagement, previous mental health, personality, or self-selection bias. So this study used fixed effects models that account for even unidentified time-constant confounding measures to examine the longitudinal association between arts (frequency of both arts participation and cultural attendance), mental distress, mental health functioning, and mental wellbeing. Methods from Changes in frequencies of art engagement were related to changes in health within individual whilst

However, there are a number of other factors that could explain this association. For example, arts engagement is socially patterned, with engagement in adult life related to broader social and cultural capital as well as education, income, engagement in childhood and the engagement of parents and wider peer groups [22,23]. Similarly, arts engagement has been shown to vary based on childhood engagement and the engagement patterns of friends and family as an individual transitions to adulthood [24], and based on previous mental health [25]. Personality too has been shown to affect attitudes towards arts engagement [26]. As these factors are all themselves associated with mental health, it is possible that associations between arts and mental health could in fact be due to individual confounding factors [27,28]. This is the case both for intervention studies, for which self-selection bias is likely to predispose individuals with higher levels of cultural capital, greater past experience, better previous mental health and open personality types to take part, and for analyses of observational data, which have, to date, largely involved cross-sectional associations [29]. Even longitudinal analyses that adjust for such factors still may not entirely remove their effects [30]. Therefore, to address these issues we analyzed data from a large-scale nationallyrepresentative longitudinal cohort study using a sophisticated statistical technique commonly used in causal inference research that automatically accounts for all timeinvariant factors (even if unobserved) as well as allowing the modelling of time-varying confounders.

Participants
This study used data from Understanding Society: The UK Household Longitudinal Study (UKHLS), which provides high-quality longitudinal panel data comprising a stratified and clustered General Population Sample of around 40,000 households. These analyses used data from wave 2 (2010-2012) and wave 5 (2013-2015) when questions on arts activities/cultural events were included. Of 54,554 respondents in wave 2, 37,389 were followed up in wave 5, and 25,051 of these (around 67%) responded to self-completion questionnaires on health and arts. After deleting 1,391 cases with missing information (around 5%), the final analytic sample includes 23,660 respondents and 47,320 personwave observations. Longitudinal weights provided by the UKHLS were used to adjust for the complex survey design, non-response rate, unequal selection probabilities and nonrandom attrition across waves.

Measures
Arts engagement was measured using 28 separate questions that were categorised into "activities" or "events". Arts activities included dance (including ballet), singing to an audience or rehearsed for a performance (not karaoke), playing a musical instrument, writing music, rehearsing/performing in a play/drama, opera/operetta or musical theatre, taking part in a carnival/street arts event, learning or practising circus skills, painting, drawing, printmaking or sculpture, photography, film or video making as an artistic activity, using a computer to create original artworks or animation, taking part in textile crafts, wood crafts or any other crafts such as embroidery, knitting, reading for pleasure (not newspapers, magazines or comics), writing any stories, plays or poetry, or being a member of a book club where people meet up to discuss and share books. Cultural events included attending a film at a cinema or other venue, an exhibition or collection of art, photography, sculpture or a craft exhibition, an event which included video or electronic art, an event connected with books or writing, street arts or a public art display or installation, a carnival or cultural specific festival, a circus (not animals), a play/drama, pantomime or musical, an opera/operetta, a classical music performance, a rock, pop or jazz performance, a ballet, a contemporary dance performance, or an African people's dance or South Asian and Chinese dance. For each question frequency of arts engagement was measured using five categories for arts participation (never, once/twice per year, once per month, once per week, more than once per week), and four categories for cultural attendance (never, once/twice per year, once per month, once per week or more).
Given the well-known distinctions between mental health and multidimensional wellbeing [31], we explored three aspects of mental health. Mental distress was measured with GHQ-12 (General Health Questionnaire); a well-validated scale derived from 12 items to measure the levels of respondents' psychiatric illness. Items include depressive and anxiety symptoms, sleeping problems, and overall happiness [32]. UKHLS converts the answers to GHQ-12 questions to a single continuous scale ranging from 0 (the least distressed) to 12 (the most distressed), with a lower score indicating better mental health.
Functioning as a result of mental functioning was measured using SF-12 (12-Item Short Form Health Survey); a widely used and reliable instrument that measures respondents' general quality of life that focuses both on mental and physical health, with a particular emphasis on the implications of any problems for ability to function as normal in everyday life [33]. The survey contains eight indicators formed of 12 items: physical functioning (2 items), role limitations due to physical health problems (2 items), bodily pain (1 item), general health (1 item), vitality (1 item), social functioning (1 item), role limitations due to emotional problems (2 items), and mental health (2 items) [33]. UKHLS calculates the SF-12 Mental Component Summary (MCS) score by assigning higher weights to mental health related items (the latter six items). The MSC score ranges from 0 (the lowest mental functioning) to 100 (the highest mental functioning).
Subjective wellbeing comprises both affective aspects (such as happiness and pleasure in daily life and being free from negative affect) as well as cognitive-evaluative aspects (such as life satisfaction) [34]. We focused specifically on life satisfaction. This was measured using a single-item "overall, how satisfied are you with your life nowadays?" Responses ranged from 1 (completely unsatisfied) to 7 (completely satisfied) [35].
We controlled for a wide range of variables, which were shown to influence both mental health and participation in arts activities or events. Demographic characteristics included age, age squared, marital status (never married, married/cohabited, divorced/separated/widowed), presence of children in the household (no children, preschool children aged 0-4, primary school children aged 5-11, middle school children Data were strongly balanced. A Hausman test to confirm the selection of a fixed effects over a random effects model. The modified Wald test for group-wise heteroscedasticity was significant so sandwich estimators were applied. Coefficients for all years were not jointly equal to zero, so time-fixed effects were included in the model.

Results
Decriptive statistics Table 1

Mental distress
When adjusting for all identified confounders, significantly lower levels of mental distress were found amongst those who participated in arts activities more than once a week (coef.

Discussion
This study showed a significant relationship between both frequent arts participation and cultural attendance and lower levels of mental distress and higher levels of life satisfaction. This result was particularly strong for life satisfaction, for which there were associations also from less frequent cultural attendance.
Our results confirm that the relationship between arts engagement and multiple different aspects of mental health is not merely an artefact of time-constant socio-economic factors. This suggests that while arts engagement is associated with broader aspects of social and cultural capital and socio-economic status (which are themselves associated with health) [27], the relationship cited in previous studies is independent of these factors. Further, our analyses automatically accounted for other time-constant factors such as personality, previous arts engagement, and previous mental health. But it confirmed that the relationship with mental health is not explained by these either.
In considering, therefore, how arts activities can affect mental health, arts engagement can be considered as a 'complex' or 'multi-modal' health-promoting activity in that it combines multiple health-promoting or risk-reducing factors such as gentle physical activity, social interaction, relaxation, emotional expression, and cognitive stimulation [37]. But our analyses shed further light onto the causal mechanisms that could link arts and mental health. We found a relationship with higher mental health functioning only with arts participation; not cultural attendance. As cultural attendance is associated with improved mental distress and wellbeing directly but not functioning, this suggests a direct relationship with affective symptoms (such as reductions in negative feelings and stress hormones and enhanced feelings of happiness) but not with an ability to alter psychological or behavioural factors relating to coping with affective symptoms. However, arts participation does show a relationship with mental functioning. As the only major distinction between the two types of arts engagement is the participation itself, as other elements of the two types of activities (e.g. aesthetic engagement, gentle physical activity, social interaction etc) are consistent, this suggests it is participation that supports coping. In support of this, intervention studies have identified improvements in aspects of functioning such as self-efficacy, agency and purpose as a result of arts participation [38].
Our results are limited due to only having data across two waves of UKHLS which do not permit lagged analyses, and it is possible that residual confounding for time-varying factors remains. But as all time-constant factors are automatically considered and the data allowed us to include all identified confounders, remaining unobserved heterogeneity should be small. Our analyses also focused on broad categories of arts engagement.