Design

Qualitative research conducted comprised observation, focus groups and one-to-one semistructured interviews with clients, volunteers and staff as coresearchers within a collaborative PAR approach.38

Participants

The study recruited an opportunity sample of volunteer participants through information leaflets and contact details in reception. Clients were approached by the researcher using two recruitment criteria: (i) clients had received therapy for at least 2 years prior to the research and had entered the integration stage of the model of integrated care; this meant that though still vulnerable, clients had established a therapeutic relationship of trust enabling them to form safe relationships in the wider community and move forward with their lives; and (ii) they had attended at least one of four CAP groups (art, photography, singing and textiles) for around 2 years. All participants spoke English sufficiently well to participate having attended English classes for about 2 years as part of integrated care. In total, 31 (6 males) participants volunteered for the study and attended focus group comprising 12 (2 males) refugees/asylum seekers, 4 (1 males) volunteers and 15 (3 males) charity staff. Of these, 17 (3 males) participated in interviews comprising 7 (1 males) refugees/asylum seekers, 7 (1 males) volunteers and 3 (1 males) staff.

Patient and public involvement

HBF staff were instrumental in the application for research funding and collaborated with the researcher to determine the study’s objectives. HBF clients were involved in the recruitment process by recommending that other clients join them in the research, though the researcher ensured that they matched recruitment criteria (above). In keeping with PAR, research questions and outcome measures concerning the effects of cultural and creative activities on the psychosocial well-being of refugees/asylum seekers were determined by coresearchers (HFB clients, volunteers and staff) with differing involvement depending on their role at the charity. Focus groups and interviews gave voice to clients’ priorities and preferences but, due to their vulnerability, no personal information was requested as the process of remembering could have been difficult.7 10 Although some participants mentioned personal issues and experiences, they were not encouraged to do so. Data generated by coresearcher involvement in the research collaboration informed focus groups, in turn focus group outcomes led to the development of questions for the in-depth interviews to follow. In addition to participation in focus groups and interviews, a core group of seven coresearchers (three clients, two volunteers, two staff, with one male per category) were involved in design of the interview guides, discussion of emerging themes and dissemination of the research findings to other participants for verification and comments, in accordance with PAR principles.33 The results of the research were fed back to everyone involved with HBF through ongoing communication with the researcher, an internal report lodged at the charity, and an end-of-project event.

Data collection

Data collection carried out by the location-based researcher consisted of three stages: stage 1 (months 1–2) participant observation; stage 2 (months 3–4) focus groups and stage 3 (month 5) semistructured interviews. In stage 1, participant observation was used as a starting point ‘for studying how organisations work, the roles played by different staff and the interaction between staff and clients’ (Pope et al, p32).38 The researcher attended creative classes for clients and spent a day a week working from HBF (12–15 hours per week) to determine the nature of focus groups. In stage 2, four focus groups were held, first and final with clients (n=8, n=4, respectively), second with volunteers (n=4), and third with staff (n=15). In the focus groups, participants were asked to discuss research questions (box 1) involving ways of gathering information on the impact of creative activities, and reasons for attending groups (or in the case of volunteers and staff, reasons for involvement). All focus groups were organised informally to facilitate development of discussion among participants and allow an exchange of experiences and ideas. Ideas that emerged during focus groups laid the basis for first drafts of interview questions, tailored to clients, volunteers or staff (box 2). In line with the collaborative ethos, drafts were circulated to receive feedback from coresearchers prior to the interview stage, and volunteers and staff were consulted and asked to provide comments and suggestions for interview questions. For stage 3, clients (n=7), volunteers (n=7) and staff (n=3) participated in interviews with the researcher using a semistructured format to allow free expression within the research constraints and limit potential research bias.30 39

Data analysis

A first informal thematic analysis was conducted by the researcher while writing field notes consisting of a chronicle of descriptive rather than analytic events both observed and provided by coresearchers as the ‘raw material of the research’ (Kemmis et al, p38).30 The process of transcribing notes was used to identify key points connected to the research question. This preliminary analysis informed focus group topics where points were discussed more in detail. After the first round of focus groups, all notes were compiled into a word document and repeatedly read by the researcher and coresearchers to search for recurring topics and themes. Thematic analysis of focus group outcomes were explored in detail during interviews. All interviews were recorded and transcribed to become familiar with the data and begin the coding process.37 All details in the transcripts were recorded verbatim (eg, sighs, laughter, silences and tears) as their exclusion could have changed the meaning expressed.30 Transcriptions were uploaded into NVivo11 to produce nodes from coding-relevant concepts. NVivo’s word frequency query facilitated the search for keywords (including stem words and synonyms) grouped under the same theme. The text search query provided a comprehensive analysis of data. After coding of data into initial themes,37 a review of themes followed to refine the analysis.

Focus groups

Focus group data were analysed using thematic analysis (NVivo11). Findings showed consistency in the way all HBF participants (clients, volunteers and staff) articulated their reflections on the impact of creative activities. The benefits of creative activities were highlighted in clusters emerging from around three main overarching themes: ‘skills’, ‘social aspects/friendships’ and ‘mood-personal sphere’; the latter subdivided into ‘brain’ (creative thought processes), ‘routine’, self-expression’ and ‘confidence’. During focus groups, coresearchers were asked to write answers to the questions posed, and a collective discussion followed. Clients responded consistently about benefits of the creative programmes. One client listed ‘Activities help my brain think about other stuff and keep me busy and relaxed. You can’t think about bad things. To learn more skills. I can use skills to help others’.

Learning new or improving existing skills was a key theme emerging out of focus groups, as skill development appeared to change clients’ perceptions of their status; as a female volunteer at HBF for 2 years suggested ‘participants do not feel assessed as clients, they are just learners or artists. These groups paved the way for identifications different from being a victim, a refugee or an asylum seeker’. Clients also mentioned how acquiring new skills was an important factor in improving self-esteem; one client wrote about attending CAP ‘Give me confidence. Make me feel good and useful. Change my mood. Learn new things and meet people. Improve my skills. Give me hope to lead a better life’.

Learning new skills was a benefit connected to the second theme that emerged during focus groups, the social aspect. It allowed people to meet others in similar situations and create friendships and/or a support network; as a client wrote ‘Allows me to feel included. Safe environment. Improves my mood. Learn new skills. Gets me out of the house. Meet new people’. Staff too recognised the social aspect of activities as a major benefit, with one suggesting ‘in these groups, clients learn to have balanced, reciprocal relationships, which they have not experienced before or for a long time given their experience of violence (trafficking). They provide clients with an alternative identity, that is, they are not simply victims here, they are learners, artists, dressmakers, etc.’ Similar themes emerged in the volunteer focus group during which a relatively new male volunteer involved of 4 months was impressed by the solidarity between clients, emphasising the benefits of the ‘feeling of belonging to a group’ and ‘strong support that people receive from other members’.

The third and final theme that emerged when discussing the benefits of CAP the mood-personal sphere. Staff commented on the mood enhancing benefits of CAP for people with PTSD; one staff member observed ‘creative activities allow clients to momentarily leave out their problems or memories, by focusing on a particular activity they cannot think about anything else’. The focus group with staff emphasised that being busy in the company of others allowed clients to feel safe and not to dwell on their own situation. In concentrating on learning new skills, clients blocked out (although for short periods) memories of the past. Importantly, responses illustrated that focus group participants perceived their involvement as beneficial at multiple and overlapping levels. Enhancement of mood appeared to derive from not only meeting new people, forging meaningful relationships and feeling part of a group but also connected to a growing self-confidence and self-esteem experienced as clients acquired new skills.

Interviews

During interviews, clients elaborated on practical and social skills, and commented on the positive effect of attendance on their mood and emotion:

Practical skills: learning new practical skills or improving those previously learnt emerged strongly among asylum seekers without the right to work. As a client pointed out:

I have learned a lot of skills: I’ve learned sewing, now I’m learning art, I can do better, before I didn’t know how to draw a person, to mix colours, you know such things… so you keep on learning, slowly by slowly, then in the end you find yourself, you’re a professional, so that is very great… to me… I like to come, always and attend, and listen to what they tell me, and I do it.

Or, as another client explained:

I’ve learned new skills […] and you can never waste your time learning new skills. New skills always help you in your life, always. So, everything I’ve learned will help me. You think like ‘film club, learning how to edit, etc.’. People pay people on YouTube to edit their films, and I’m, like, I could just do my own, if I wanted to have a YouTube channel, I can do my own.

Skill improvement provided a sense of achievement and improved self-confidence, talking about learning new skills, one client observed:

When you are in this situation it feels like life has, in a way, stopped. And you can’t do anything to change it. But by doing all this activity you feel, or I felt … it was like, you know, that I was learning something in my life, rather than just waiting.[…] For instance, if I go for a job somewhere, where you have to write what skills you have, so I could include all of this. I mean I don’t have a certificate or, like, proper qualifications, but I’ve all those skills, so I feel like, it is, in a way, impressive? Because you feel like, you know, rather than just waiting and not doing anything, you have been learning.

The sense of self-improvement associated with learning skills was linked to the perception that by learning, clients were preparing themselves for a new life when they would be allowed to live and work in the UK, countering the perception that life for them had stopped and giving them something to look forward to. The process of skills learning was not simply a vertical one; peer learning was equally important, stressing the importance of social aspects.

Social skills: the opportunity to overcome social isolation and create a social network emerged as one of the benefits of creative engagement. As one client indicated:

The groups changed me because you know when I come, I feel lonely and doesn’t have anybody. I was lonely I don’t even know whether there will be a home from morning to live in. But when I started coming these groups, I told you I feel active, I feel coming to see people, that I speak to. I don’t even know how to communicate with people before. I told you because of my coming here I now feel to communicate to people. Before I never communicate to people, I don’t know how to do it. And I don’t know how to play with people. But these groups make me now taught me: play with people, to meet me.

The client expressed the difficulties of establishing new relationships and the feeling that the group was a place in which they could regain this ability to connect with other people. The social aspect was an important point reiterated in all interviews; fellow clients were described as ‘friends’ but also as ‘brothers and sisters’. Arts activities allowed clients to create a community characterised by solidarity, as one client explained:

If you’re in a situation where you’ve been completely isolated from people for a while and you just don’t know who to trust, or to be around people, it’s one of those spaces where you can get to meet people, socialise, and actually make friends.[…] And these friendships do last. A life-time, because you understand what the person has gone through, you don’t have to explain a lot, you know, they just know that you’ve been through something terrible.[…] So, it’s easier when you have people here who just understand what you’ve possibly been through.

This remark connects with the observation that ‘engagement in participative creative arts activities in communities can help to build social capital, address loneliness and social isolation, and build personal confidence and a sense of empowerment’ (Staricoff, p32).25 The awareness of experiencing similar situations makes clients feel free to share their own experiences with one another but also not to, if they did not feel like opening up:

There is a sense of community: you know you go there, you know there are people like you in the same situation you’re not going to be judged, so it’s that sense of community: we know what’s going on, we don’t have to talk about it.[…] It’s a distraction from immigration and we know we are all going through it, but we don’t have to talk about it. There are other things going on in life, and we talked about, for example in the art group, the works we produced and what we could do, what we could achieve and get inspired by each other’s work.

Again, this remark introduced the third broad theme which emerged out of the interview analysis, which was the impact of creative arts on personal mood and emotion.

Mood and emotion: learning or improving skills while forging long-lasting relationships in a context of deep social isolation (outside of HBF), inevitably had a substantial impact on mood and emotion. In discussing this aspect of creative arts, interviewees focused particularly on how groups allowed them to have a routine, a ‘luxury’ one client said ‘when you can’t do nothing but waiting for the government to decide on your right to stay in the country’. Routine combined with skills learning/improving was thought to have a positive impact on clients’ mental health; ‘having something to do’ and ‘something to look forward to’ were recurrent expressions during interviews. As one client noted:

I used to come here every day of my life: Monday, Tuesday, Wednesday… because I don’t have anywhere to go, so I just come here, and I attached myself to the groups, we met, we talk, we… then I’ve gone to knit, I’ve gone to do computer, reading, many things I learnt here, so I just like it.

Another client elaborated further:

It’s something that I look forward to. One thing you have to bear in mind is that I am not working, and I am not studying, you know, so it was the only thing that I would look forward to because it was something to do, otherwise I would just be at home, doing nothing, you know, feeling very sorry for myself, getting upset all the time. I mean I still feel that way but at least there’s something to look forward to, when you don’t have hope or something to look forward to, it increases your depression levels, so for me it’s helped me greatly.

This statement describes the social and emotional isolation as part of postmigration living difficulties. The routine of classes, together with an awareness that others in similar situations would attend, provided comfort to clients, countering feelings of isolation:

There is nothing else for you and it’s also a way of, like, using your time wisely, ‘cause at the end of the day most of the time you’re just sitting down doing nothing, and doing nothing slowly begins to affect your mind, your brain, you know you become lazy, you know you literally are just in a four-squared room[…]

The benefits of a routine were increased by inclusion of creative activities that according to clients and volunteers, had a positive impact on mood because they exercised the brain and allowed clients to find a new language to express themselves. As a client stated:

[Attending creative groups] gives you a lot of confidence, you know. And it allows your brain to think outside of the box because I think we are just in that box and… but when you attend these classes, your mind, you know, opened and you learn new things and you want to then learn other things as well.

This comment highlights an important link between arts and feelings; as another stated:

It is more of expressing, more of letting go, it’s like getting a spirit out of you, and you don’t have necessarily have to tell someone ‘I’ve done this because of that and that, and this’, you know. Because sometimes you just don’t find the voice to talk about it and, I, as a person am really shy and, you know, I feel easily embarrassed, you know.[…] So… that’s why I’m into arts, yes I’m doing arts really.

Clients agreed that the possibility of self-expressing without having to articulate their feelings, helped them grow emotionally and gain confidence. It was not only clients who benefited from CAP; findings also pointed to the positive impact on volunteers, a point stressed by all volunteers when discussing personal experiences.