Assessing the impact of artistic and cultural activities on the health and well-being of forcibly displaced people using participatory action research

Objective Drawing on a growing body of research suggesting that taking part in artistic and cultural activities benefits health and well-being, the objective was to develop a participatory action research (PAR) method for assessing the impact of arts interventions on forcibly displaced people, and identify themes concerning perceived benefits of such programmes. Design A collaborative study following PAR principles of observation, focus groups and in-depth semistructured interviews. Setting London-based charity working with asylum seekers and refugees. Participants An opportunity sample (n=31; 6 males) participated in focus groups comprising refugees/asylum seekers (n=12; 2 males), volunteers (n=4; 1 males) and charity staff (n=15; 3 males). A subset of these (n=17; 3 males) participated in interviews comprising refugees/asylum seekers (n=7; 1 males), volunteers (n=7; 1 males) and charity staff (n=3; 1 males). Results Focus group findings showed that participants articulated the impact of creative activities around three main themes: skills, social engagement and personal emotions that were explored during in-depth interviews. Thematic analysis of interviews was conducted in NVivo 11 and findings showed that artistic and cultural activities impacted positively by helping participants find a voice, create support networks and learn practical skills useful in the labour market. Conclusions The study expanded on arts and well-being research by exploring effects of cultural and creative activities on the psychosocial well-being of refugees and asylum seekers. By focusing on the relationship between arts, well-being and forced displacement, the study was instrumental in actively trying to change the narrative surrounding refugees and asylum seekers, often depicted in negative terms in the public sphere.

Design: A study was conducted following PAR principles comprising observation, focus 29 groups and in-depth semi-structured interviews. 30 Setting. London-based charity working with asylum seekers and refugees. 31 Participants: Refugees/asylum seekers (n=7), volunteers (n=7) and charity staff (n=8).

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Results: Qualitative data was analysed using NVivo 11. Focus group findings showed that  Conclusions: The study expanded on arts and wellbeing research by exploring effects of 5 cultural and creative activities on the psychosocial wellbeing of refugees and asylum seekers. 6 By focusing on the relationship between arts, wellbeing and forced displacement, the study 7 was instrumental in actively trying to change the narrative surrounding refugees and asylum 8 seekers, [45] often depicted in negative terms in the public sphere. Strengths and limitations of this study: 11 • Focus on collaborative research 12 • Different cultural and artistic activities studied 13 • Researcher spent five months in research setting 14 • Approximately twice as many females participated 15 • Focus groups attracted relatively low numbers 16 17 Introduction: 18 The recent All-Party Parliamentary Group on Arts Health and Wellbeing Inquiry Report 19 shows a growing acknowledgement of the impact of arts and creative practices, stating 'arts 20 engagement has a beneficial effect upon health and wellbeing and therefore has a vital part to 21 play in the public health arena'. [13 p11] More than 70 years ago, the World Health 22 Organisation defined health as a 'state of complete physical, mental and social wellbeing and 23 not merely the absence of disease or infirmity'. [14 p2] As a key element of health, the notion  vitality, resilience, self-esteem and positive functioning) from social wellbeing (supporting 31 relationships, trust and belonging). [17] Other authors emphasise 'resilience and flourishing, knitters to enhanced production of serotonin resulting from repetitive movements and that 27 bilateral processes appeared to engage brain capacity and facilitate a meditative-like state 28 more readily than unilateral ones. 29 The current study was conducted in the light of mental health and arts/museums-and-30 health evidence given the large number of organisations that engage migrants, refugees and 31 asylum seekers in the arts, with nearly 200 of these in the UK. [9] The current research was 32 conducted at one such organisation, Helen Bamber Foundation (HBF), a charity offering 33 support to refugees and asylum seekers as victims of torture and human rights violations. HBF adopts a holistic approach to support its clients that includes cultural and creative 1 activities within a model of integrated care. The model is based on the needs of traumatised 2 asylum seekers and refugees who often require simultaneous assistance on a variety of fronts 3 (e.g. psychological support might not be effective if a person does not have a place to sleep or 4 lives in a dangerous situation, though giving people a place to sleep is not enough to 5 overcome trauma). Their model encompasses services such as legal and health support 6 (psychological and physical), welfare and housing advice, and a creative arts programme 7 (CAP) including art, photography, knitting and textiles, singing, English and computing, led 8 by professional volunteers and attended by nearly 100 clients. By focusing on the relationship 9 between arts, wellbeing and forced displacement, the study aimed to determine why 10 participation in creative arts enhanced the sense of wellbeing experienced by HBF clients, 11 and contribute to the current debate on migration and public health. were placed in reception to encourage participation and clients were recruited directly by the 1 researcher while based at HBF. The criteria for recruitment were that clients had received 2 therapy for at least two years prior to the research and, while still vulnerable, had entered the 3 integration stage of the model of integrated care, and that they attended at least one of the five 4 CAP groups (art, knitting, photography, singing and textiles). Volunteers and staff were 5 recruited via email and personal contact. Co-researchers (n=22: 7m) participated in focus 6 groups comprising clients (n=6), volunteers (n=4) and staff (n=8), and interviews (n=18) 7 comprising clients (n=7), volunteers (n=7) and staff (n=4). Patient and public involvement 10 The development of the research questions and outcome measures about the ffects of cultural 11 and creative activities on the psychosocial wellbeing of refugees/asylum seekers was 12 informed by HFB clients, volunteers and staff taking part in PAR. Focus groups and 13 interviews gave voice to participants' priorities, experience and preferences but, due to the 14 vulnerability of clients, no personal information was requested as the process of remembering 15 could have been difficult for PTSD sufferers, [10,22] and although some participants 16 mentioned personal issues and experiences, they were not encouraged to do so. Participants 17 were involved as co-researchers within the research collaboration and data generated by their 18 involvement informed focus groups and interviews. Participants were indirectly involved in 19 the recruitment process by recommending that other people join them, though the researcher 20 needed to ensure they matched recruitment criteria (above). Participants were directly 21 involved in conducting the study and determining the interview questions. Results were 22 disseminated to participants through an end-of-project event and on-going communication 23 with the researcher, and an internal report will be lodged at HBF.  In stage ii) four focus groups were held, the first and final with clients from arts, 33 photography, singing, and textiles, the second with volunteers, and the third with staff. In the 34 F o r p e e r r e v i e w o n l y 6 focus groups, participants were asked to discuss research questions (Table 1) involving ways 1 of gathering information on the impact of creative activities, and reasons for attending groups 2 (or in the case of volunteers and staff, reasons for involvement). All focus groups were 3 organised informally to facilitate development of discussion among participants and allow an 4 exchange of experiences and ideas. Ideas which emerged during focus groups laid the basis 5 for the first drafts of interview questions, which were tailored to clients, volunteers or staff 6 ( Table 2). In line with the collaborative ethos, drafts were circulated to receive feedback from 7 co-researchers prior to the interview stage, and volunteers and staff were consulted and asked 8 to provide comments and suggestions on the questions. For stage iii) interviews carried out 9 with were semi-structured to allow free expression within the research constraints and limit for key words (including stem words and synonyms) grouped together under the same theme. 30 The text search query provided a comprehensive analysis of data. After coding of data into 31 initial themes,[40] a review of themes followed to refine the analysis. Thematic analysis of focus group data showed consistency in the way all HBF participants 3 (clients, volunteers and staff) articulated their reflections on the impact of creative activities. 4 In discussing the value of engaging in creative arts, participants highlighted the benefits of 5 activities as: 6 7 • Learning new practical skills or improving those previously learnt; 8 • Acquisition of technical, language, social and life skills; 9 • Development of new social relationships based on respect and mutual recognition; 10 • Opportunities to meet people, forge friendships, counter loneliness and develop a sense of 11 belonging in a safe space;

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• Value of peer-learning and mutual support; 13 • Improvement in mood and self-confidence; and 14 • Freedom of expression and developing a new identity other than refugee/asylum seeker.

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Thematic clusters emerged from around three main overarching (and overlapping) themes 17 from these benefits: 'social aspects-friendships', 'skills', and 'mood-personal sphere'; the 18 latter was sub-divided into 'brain' (how creative activities helped the brain), 'routine', self-19 expression' and 'confidence'. During the interviews, respondents tended elaborated on skills, both practical and social, and 23 also commented on the effect that attendance had on their mood and emotion.

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Learning new practical skills: One of the themes which emerged strongly during interviews 26 was that creative arts groups allowed participants to learn new skills and/or to improve prior 27 skills. Skill improvement was important for asylum seekers without the right to work. As a you're a professional, so that is very great... to me... I like to come, always and attend, 1 and listen to what they tell me, and I do it. 2 Or, as another client explained:  The improvement of skills was a benefit that provided a sense of achievement and improved 9 self-confidence, illustrating the overlapping nature of themes that emerged. Talking about 10 new skills learnt, one client observed: 11 When you are in this situation it feels like life has, in a way, stopped. And you can't do 12 anything to change it. But by doing all this activity you feel, or I felt…it was like, you 13 know, that I was learning something in my life, rather than just waiting. [ 17 feel like, you know, rather than just waiting and not doing anything, you have been 18 learning. 19 Self-improvement was seen not only as a result of learning from professionals, but also from 20 peer-learning; several clients commented on the fact that they learnt from friends as well as 21 volunteers, pointing to the importance of social aspects of the classes.

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Acquisition of technical, language, social and life skills: One of the benefits of being engaged 24 in creative activities that emerged was that participants had the opportunity to overcome 25 social isolation and create a social network. As one client pointed out: 26 The groups changed me because you know when I come, I feel lonely and doesn't have 27 anybody, I was lonely I don't even know whether there will be a home from morning to 28 live in. But when I started coming these groups, I told you I feel active, I feel coming to 29 see people, that I speak to, I don't even know how to communicate with people before. I 30 told you because of my coming here I now feel to communicate to people. Before I never 31 communicate to people, I don't know how to do it. And I don't know how to play with 32 people. But these groups make me now taught me: play with people, to meet me. The social aspect was an important point reiterated in all interviews; fellow clients were 1 described as 'friends' but also as 'brothers and sisters'. Arts activities allowed clients to 2 create a community characterised by solidarity, as one client explained: 3 If you're in a situation where you've been completely isolated from people for a while 4 and you just don't know who to trust, or to be around people, it's one of those spaces 5 where you can get to meet people, socialise, and actually make friends. [ 9 just understand what you've possibly been through. 10 This remark connects with the observation that 'engagement in participative creative arts 11 activities in communities can help to build social capital, address loneliness and social 12 isolation, and build personal confidence and a sense of empowerment'.[25 p32] The 13 awareness of experiencing similar situations makes clients feel free to share their own 14 experiences with one another but also not to, if they do not feel like opening up: 15 There is a sense of community: you know you go there, you know there are people like 16 you in the same situation you're not going to be judged, so it's that sense of community: 17 we know what's going on, we don't have to talk about it. [...] It's a distraction from 18 immigration and we know we are all going through it, but we don't have to talk about it. 19 There are other things going on in life, and we talked about, for example in the art 20 group, the works we produced and what we could do, what we could achieve and get 21 inspired by each other's work. 22 Again, this remark introduced the third broad theme which emerged out of the interview 23 analysis, which was the impact of creative arts on personal mood and emotion.

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Mood and Emotion: Learning or improving skills while forging long-lasting relationships 26 in a context deep social isolation (outside of HBF), inevitably has a substantial impact on 27 mood and emotion. In discussing this aspect of creative arts, interviewees focused 28 particularly on how groups allowed them to have a routine, a 'luxury' a client said 'when 29 you can't do nothing but waiting for the government to decide on your right to stay in the 30 country', and this routine combined with skills learning/improving was thought to have a 31 positive impact on their mental health condition. 'Having something to do' and 'something 32 to look forward to' were recurrent expressions during interviews. As one client noted:  1 have anywhere to go, so I just come here, and I attached myself to the groups, we met, we 2 talk, we...then I've gone to knit, I've gone to do computer, reading, many things I learnt 3 here, so I just like it. 4 Another client elaborated further: 5 It's something that I look forward to. One thing you have to bear in mind is that I am not 6 working, and I am not studying, you know, so it was the only thing that I would look 7 forward to because it was something to do, otherwise I would just be at home, doing 8 nothing, you know, feeling very sorry for myself, getting upset all the time. I mean I still 9 feel that way but at least there's something to look forward to, when you don't have 10 hope or something to look forward to, it increases your depression levels, so for me it's 11 helped me greatly. 12 The benefits of having a routine were increased because it involved creative activities: 13 There is nothing else for you and it's also a way of, like, using your time wisely, 'cause 14 at the end of the day most of the time you're just sitting down doing nothing, and doing 15 nothing slowly begins to affect your mind, your brain, you know you become lazy, you 16 know you literally are just in a four-squared room […] 17 According to clients and volunteers, creative activities had a positive impact on mood 18 because they allowed people to exercise their brain and find a voice to express themselves. Creative and cultural activities carried out over a sustained period of five months provided 2 refugees and asylum seekers with new skills, that included practical and technical skills, and 3 social and life skills involving language acquisition obtained partly through informal peer 4 learning and mutual support. Learning new skills contributed to the sense of wellbeing and 5 empowerment experiences by HBF clients. Furthermore, activities appeared to positively 6 enhance mood and emotion both for clients and volunteers. The time spent by the researcher 7 at the HBF was vital to become familiar with the context, get to know people involved in the 8 organisation, and explain the research to make it possible to recruit co-researchers from 9 among clients, volunteers and staff for focus groups and interviews. Moreover, the fact that 10 several clients often attended more than one group a week (in certain cases all five groups) 11 made it possible to forge trusting relationships and recruit co-researchers, allowing them to 12 feel comfortable in speaking their mind regarding the research. 13 In keeping with previous research, creative and cultural participation lead to improved 14 social health [30] and aligned with a growing body of evidence [13] to suggest that the five 15 selected CAP activities enhanced mental wellbeing [1][2][3][4][5][6][7][8]31] helping clients to develop self-16 confidence and resilience.
[3] A possible issue here was that the number of groups attended by 17 clients, that varied from one to three throughout the week, was not taken into account, so it is 18 not evident as to whether increased participation would have enhanced positive aspects of 19 wellbeing at a higher or faster level. Although passive participation was not compared,[32] 20 active and creative participation in the CAP groups specifically benefited refugees and 21 asylum seekers, as their status in the UK would not have permitted alternative occupation or 22 employment, so may not have left their homes and met other people on a regular basis.

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In terms of study weaknesses, the greater number of female participants (approximately 24 twice that of males) was due to the fact that most creative arts groups were led by female 25 volunteers (only two of ten volunteers were male) and most participants in these groups were 26 also female except for the singing group, where numbers were roughly equal. Consequently, 27 it was easier for the female researcher to forge relationships with women rather than with 28 men. With the singing group, while one male choir member took part in one focus group, it 29 was difficult to engage male participants in the research; given the nature of the activity, 30 conversation was limited to the first minutes before arrival as once rehearsals started, it 31 became difficult to forge meaningful relationships with participants.

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A further weakness was the low level of attendance for focus groups. As a result of quickly, consequently, not all of those who expressed an interest in participating were able to 1 do so but most were nevertheless happy to informally discuss the topics debated afterwards; 2 other clients expressed an interest in being kept in the loop regarding the progress of the 3 research. As for volunteers, while at least one volunteer per group was involved in the 4 research at any point, it was difficult to organise focus group times convenient for everyone, 5 so again themes and research methods were discussed in more informal ways with the 6 researcher based at HBF during weekly meetings with clients. This study expanded on arts and wellbeing research by exploring the effects of cultural and 10 creative activities on the psychosocial wellbeing of refugees and asylum seekers. The 11 activities at HBF provided opportunities for clients to meet people and develop new social 12 relationships based on respect and mutual recognition. In turn, these opportunities countered 13 loneliness and allowed refugees and asylum seekers to develop a sense of belonging in a safe 14 space. The opportunities further supported freedom of expression and the possibility of 15 developing a new identity to counter the negative stereotype of being viewed as a refugee or 16 asylum seeker, leading to sustainable improvements in positive mood and self-confidence, 17 countering anxiety and depression, and other mental health issues. By focusing on the 18 relationship between arts, wellbeing and forced displacement and in keeping with PAR, the 19 study has been instrumental in actively trying to change the narrative surrounding refugees 20 and asylum seekers,[42] often depicted in negative terms in the public sphere. Refugee and 21 asylum seeker organisations should consider commissioning PAR to involve their clients, 22 volunteers and staff in appraising and improving the current provision for migrants to the 23 UK, particularly in terms of broad-ranging skill sets and psychosocial support.  work. All authors agree to be accountable for all aspects of the work. We would like to thank 31 the clients, volunteers and staff who were co-researchers in the project. The study gained approval from UCL Ethics Committee (Ethics Application 4526/002 Co-6 developing a method for assessing the psychosocial impact of cultural interventions with 7 displaced people: Towards an integrated care framework) to carry out the research with 8 potentially vulnerable participants. Competing interests 11 The authors have no competing interests.
▸ The explanation and elaboration document provides specific examples of well-written SQUIRE items and an in-depth explanation of each item. ▸ Please cite SQUIRE when it is used to write a manuscript.

Text section and item name Page/line no(s). info is located
Title and abstract 1. Title 1/1-2/1 Indicate that the manuscript concerns an initiative to improve healthcare (broadly defined to include the quality, safety, effectiveness, patient-centredness, timeliness, cost, efficiency and equity of healthcare). Manuscript concerns an initiative to improve healthcare for forcibly displaced people. 2. Abstract 21/1-9/2 a. Provide adequate information to aid in searching and indexing.
b. Summarise all key information from various sections of the text using the abstract format of the intended publication or a structured summary such as: background, local problem, methods, interventions, results, conclusions. The structure abstract summarises all key information under headings of: objective, design, setting, participants, results, and conclusions. Introduction: Why did you start? 3. Problem description -Nature and significance of the local problem. b. Description of the approach to the ongoing assessment of contextual elements that contributed to the success, failure, efficiency and cost. 5/29-6/7 c. Methods employed for assessing completeness and accuracy of data. 6/7-6/11 11. Analysis a. Qualitative and quantitative methods used to draw inferences from the data.
6/18-6/26 b. Methods for understanding variation within the data, including the effects of time as a variable. 6/26-6/32 12. Ethical considerations -Ethical aspects of implementing and studying the intervention(s) and how they were addressed, including, but not limited to, formal ethics review and potential conflict(s) of interest. showed that artistic and cultural activities impacted positively on participants by helping 2 them to find a voice, create a support network, and learn practical skills useful in the labour 3 market.

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Conclusions: The study expanded on arts and wellbeing research by exploring effects of 5 cultural and creative activities on the psychosocial wellbeing of refugees and asylum seekers. 6 By focusing on the relationship between arts, wellbeing and forced displacement, the study 7 was instrumental in actively trying to change the narrative surrounding refugees and asylum 8 seekers, often depicted in negative terms in the public sphere.  Research conducted in the field of forced displacement and mental health shows that 32 'asylum seekers and displaced people report high rates of pre-migration trauma', [6 p275] and social and emotional isolation, racism and hostility, experience of detention, and uncertainty 4 related to the asylum application process.[7-9, 12] If, as authors suggest, [13][14][15][16][17] there is a 5 strong link between mental health and socioeconomic conditions in terms of employability, 6 income and housing, then the mental health of unemployed asylum seekers living on low 7 incomes in poor quality housing is likely to be worse than that of the general population. Arts-and-health practitioners believe that 'aesthetics act upon our senses to make us feel 9 more, hear more and see more than we otherwise might… feelings are intertwined with and mutual support (improving social wellbeing) and enhance self-esteem and self-10 confidence (increasing personal wellbeing).

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To provide voice and agency for participants, the study used a collaborative approach to 12 explore client experiences of creative activities with HBF clients, staff and volunteers acting 13 as co-researchers. The research was operationalised according to the principles of   The study recruited an opportunity sample of volunteer participants through information 9 leaflets and contact details in reception. Clients were approached by the researcher using two 10 recruitment criteria: i) clients had received therapy for at least two years prior to the research 11 and had entered the integration stage of the model of integrated care; this meant that though 12 still vulnerable, clients had established a therapeutic relationship of trust enabling them to 13 form safe relationships in the wider community and move forward with their lives; and ii) 14 they had attended at least one of four CAP groups (art, photography, singing and textiles) for 15 around two years. All participants spoke English sufficiently well to participate having 16 attended English classes for about two years as part of integrated care. In total, 31(6m) 17 participants volunteered for the study and attended focus group comprising 12(2m) 18 refugees/asylum seekers, 4(1m) volunteers, and 15(3m) charity staff. Of these, 17(3m) 19 participated in interviews comprising 7(1m) refugees/asylum seekers, 7(1m) volunteers, and 20 3(1m) staff.  with the researcher, an internal report lodged at the charity, and an end-of-project event. participants were asked to discuss research questions ( Table 1)   transcribing notes was used to identify key points connected to the research question. This 5 preliminary analysis informed focus group topics where points were discussed more in detail. 6 After the first round of focus groups, all notes were compiled into a Word document and 7 repeatedly read by the researcher and co-researchers to search for recurring topics and 8 themes. Thematic analysis of focus group outcomes were explored in detail during 9 interviews. All interviews were recorded and transcribed to become familiar with the data and 10 begin the coding process [37]. All details in the transcripts were recorded verbatim (e.g.   that clients perceived their involvement as beneficial at multiple and overlapping levels. 1 Enhancement of mood appeared to derive from not only meeting new people, forging 2 meaningful relationships and feeling part of a group but also was connected to a growing 3 self-confidence and self-esteem experienced as clients acquired new skills.

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The focus group with HFB staff emphasised that being busy in the company of others 5 allowed clients to feel safe and not to dwell upon their own situation. As one staff member 6 observed 'Creative activities allow clients to momentarily leave out their problems or 7 memories; by focusing on a particular activity, they cannot think about anything else'. Staff 8 recognised the social aspect of activities as a major benefit, with one suggesting 'in these 9 groups, clients learn to have balanced, reciprocal relationships, which they have not 10 experienced before or for a long time given their experience of violence (trafficking). They Practical skills: Learning new practical skills or improving those previously learnt emerged 25 strongly among asylum seekers without the right to work. As a client pointed out: learning. 13 The sense of self-improvement associated with learning skills was linked to the perception 14 that by learning, clients were preparing themselves for a new life when they would be 15 allowed to live and work in the UK, countering the perception that life for them had stopped 16 and giving them something to look forward to. The process of skills learning was not simply 17 a vertical one; peer learning was equally important, stressing the importance of social aspects.

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Social skills: The opportunity to overcome social isolation and create a social network 20 emerged as one of the benefits of creative engagement. As one client indicated: people. But these groups make me now taught me: play with people, to meet me. 28 The client expressed the difficulties of establishing new relationships and the feeling that the 29 group was a place in which they could regain this ability to connect with other people. The 30 social aspect was an important point reiterated in all interviews; fellow clients were described 31 as 'friends' but also as 'brothers and sisters'. Arts activities allowed clients to create a 32 community characterised by solidarity, as one client explained: involved in the organisation, and explaining the research to recruit participants from among 10 clients, volunteers and staff. The fact that several clients attended more than one group per 11 week (2-4) made it possible to forge trusting relationships and recruit co-researchers, 12 allowing them to feel comfortable in speaking their mind. A possible issue here was that the 13 number of groups attended by clients was not accounted for, so it was not evident as to 14 whether increased participation furthered benefits at a higher/faster level. Once recruited, 15 participants remained with the study in their co-researcher roles and continued to attend 16 activities on a weekly basis for the five months (except for rare absences due to illness). 17 Activities appeared to positively enhance mood and emotion both for clients and on the popularity of activities, and although the order was the same as that of clients, they 1 were not asked their opinion on which were most beneficial.

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The current study bridged the gap between two research disciplines: arts-in-health and 3 forced displacement and mental health. It contributed to existing literature by demonstrating 4 beneficial effects of creative activities on the wellbeing of refugees/asylum seekers and that 5 PAR was an appropriate method to use for collaboration between displaced communities and 6 academics. The PAR approach was particularly useful when conducting research with 7 refugees/asylum seekers suffering from PTSD and other mental health issues because the 8 process of involvement as co-researchers helped to counter client isolation and build social 9 capital through regular meetings. In helping to interpret findings, clients acquired research 10 methods skills (e.g. drafting interview guides, conducting focus groups, discussing data) and 11 organisational skills (event/exhibition). Participating in the research and disseminating 12 findings gave clients a sense of agency and ownership of the project that enhanced self- 13 confidence and feelings of empowerment and provided a positive means of expression 14 countering their refugee/asylum seeker status that effectively placed them powerless.

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In terms of study weaknesses, the greater number of female than male participants was 16 probably due to the fact that most creative groups were led by female volunteers (2m, 8f). 17 Most clients attending these groups were also female except for singing, where numbers were 18 approximately equal (although only one male choir member took part in a focus group).

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Given the nature of the singing activity, conversation was limited to the first minutes before 20 arrival; once rehearsals had started it was difficult for the researcher to form relationships 21 with clients. It was also possible that some activities were seen by clients as gender-neutral 22 (e.g. photography or singing), but others such as working with fabrics and soft materials (e.g.

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wool and cloth) may have been seen as a predominantly female activity; male participants 24 might have been more comfortable working with harder materials (e.g. wood and metal This study expanded on arts-in-health and collaborative research approaches by exploring the 2 effects of cultural and creative activities on the health and wellbeing of refugees and asylum 3 seekers. Creative activities at HBF provided opportunities for clients to socialise and develop 4 new relationships based on respect and mutual recognition. In turn, these opportunities 5 countered loneliness and allowed refugees/asylum seekers to develop a sense of belonging in work. All authors agree to be accountable for all aspects of the work. We would like to thank 28 the clients, volunteers and staff who were co-researchers in the project.      c. Methods employed for assessing completeness and accuracy of data. 6/24-29 11. Analysis a. Qualitative and quantitative methods used to draw inferences from the data. 7/1-17 b. Methods for understanding variation within the data, including the effects of time as a variable. 6/11-13 and 7/9-13 12. Ethical considerations -Ethical aspects of implementing and studying the intervention(s) and how they were addressed, including, but not limited to, formal ethics review and potential conflict(s) of interest.   Setting. London-based charity working with asylum seekers and refugees.

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Participants: An opportunity sample (n=31; 6m) participated in focus groups comprising 28 refugees/asylum seekers (n=12; 2m), volunteers (n=4; 1m) and charity staff (n=15, 3m). A subset 29 of these (n=17; 3m) participated in interviews comprising refugees/asylum seekers (n=7; 1m), 30 volunteers (n=7; 1 m) and charity staff (n=3; 1m).  focusing on the relationship between arts, wellbeing and forced displacement, the study was 10 instrumental in actively trying to change the narrative surrounding refugees and asylum seekers, 11 often depicted in negative terms in the public sphere.   likely to be worse than that of the general population. 13 Arts-and-health practitioners believe that 'aesthetics act upon our senses to make us feel 14 more, hear more and see more than we otherwise might… feelings are intertwined with mental, The authors attributed the positive mood of knitters to enhanced production of serotonin 27 resulting from repeated movements, and that bilateral processes appeared to engage brain 28 capacity and facilitate a meditative-like state more readily than unilateral ones. Although creative 29 activities are seen to provide major benefits for refugees and asylum seekers, researchers have  The current study was conducted in the light of mental health and arts-in-health/museums-in-2 health evidence, and the large number of organisations that engage migrants, refugees and 3 asylum seekers in the arts, with nearly 200 of these in the UK.
[29] The current research was 4 conducted at the Helen Bamber Foundation (HBF), a charity offering support to refugees and 5 asylum seekers as victims of torture and human rights violations. HBF adopts a holistic approach 6 to support its clients that includes cultural activities within a three-phase model of integrated care  By offering equal weight to client contributions focusing on the relationship between forced 2 displacement and arts participation, the study aimed to empower participants by developing their 3 sense of ownership in the project. Through collaborative working between the charity, displaced 4 people and academics, the purpose of the research was to co-develop a methodological approach 5 to address the needs of refugees/asylum seekers and to co-produce interview questions that could 6 be applied in UK and international settings. The objectives were to expand on arts-in-health and  The study recruited an opportunity sample of volunteer participants through information leaflets 20 and contact details in reception. Clients were approached by the researcher using two recruitment process by recommending that other clients join them in the research, though the researcher 5 ensured that they matched recruitment criteria (above). In keeping with PAR, research questions 6 and outcome measures concerning the effects of cultural and creative activities on the 7 psychosocial wellbeing of refugees/asylum seekers were determined by co-researchers (HFB 8 clients, volunteers and staff) with differing involvement depending on their role at the charity. 9 Focus groups and interviews gave voice to clients' priorities and preferences but, due to their week working from HBF (12-15 hours per week) to determine the nature of focus groups. In

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Stage 2, four focus groups were held, first and final with clients (n=8, n=4 respectively), second 30 with volunteers (n=4), and third with staff (n=15). In the focus groups, participants were asked to 31 discuss research questions ( Table 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, 2 reasons for involvement). All focus groups were organised informally to facilitate development 3 of discussion among participants and allow an exchange of experiences and ideas. Ideas that 4 emerged during focus groups laid the basis for first drafts of interview questions, tailored to 5 clients, volunteers or staff (Table 2). In line with the collaborative ethos, drafts were circulated to 6 receive feedback from co-researchers prior to the interview stage, and volunteers and staff were  Focus group data were analysed using thematic analysis (NVivo11). Findings showed 5 consistency in the way all HBF participants (clients, volunteers and staff) articulated their 6 reflections on the impact of creative activities. The benefits of creative activities were 7 highlighted in clusters emerging from around three main overarching themes: 'social 8 aspects/friendships', 'skills', and 'mood-personal sphere'; the latter sub-divided into 'brain' 9 (creative thought processes), 'routine', self-expression' and 'confidence'. During focus groups, 10 co-researchers were asked to write answers to the questions posed, and a collective discussion

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Learning new or improving existing skills, the second theme to emerge during focus groups, appeared to 20 be an important factor in improving self-esteem; another client noted that attending CAP 'Give me from not only meeting new people, forging meaningful relationships and feeling part of a group but also 6 was connected to a growing self-confidence and self-esteem experienced as clients acquired new skills. Practical skills: Learning new practical skills or improving those previously learnt emerged 13 strongly among asylum seekers without the right to work. As a client pointed out: The sense of self-improvement associated with learning skills was linked to the perception that 4 by learning, clients were preparing themselves for a new life when they would be allowed to live 5 and work in the UK, countering the perception that life for them had stopped and giving them 6 something to look forward to. The process of skills learning was not simply a vertical one; peer 7 learning was equally important, stressing the importance of social aspects.   11 Again, this remark introduced the third broad theme which emerged out of the interview 12 analysis, which was the impact of creative arts on personal mood and emotion. 13 14 Mood The benefits of a routine were increased by inclusion of creative activities that according to 11 clients and volunteers, had a positive impact on mood because they exercised the brain and 12 allowed clients to find a new language to express themselves. As a client stated:   activities, and although the order was the same as that of clients, they were not asked their 2 opinion on which were most beneficial.

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The current study bridged the gap between two research disciplines: arts-in-health and forced 4 displacement and mental health. It contributed to existing literature by demonstrating beneficial 5 effects of creative activities on the wellbeing of refugees/asylum seekers and showed that PAR refugee/asylum seeker status that otherwise, rendered them effectively powerless.

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In terms of study weaknesses, the greater number of female than male participants was 28 probably due to the fact that most creative groups were led by female volunteers (2m, 8f). Most 29 clients attending these groups were also female except for singing, where numbers were 30 approximately equal (although only one male choir member took part in a focus group). Given 31 the nature of the singing activity, conversation was limited to the first minutes before arrival; was also possible that some activities were seen by clients as gender-neutral (e.g. photography or 3 singing) but others such as working with fabrics and soft materials (e.g. wool and cloth) may 4 have been seen as a predominantly female activity; male participants might have been more 5 comfortable working with harder materials (e.g. wood and metal). It was generally more difficult 6 to engage male participants in the research; a possible reason for this was female clients might 7 have found it easier to relate to the female researcher. A further weakness was low attendance for 8 focus groups possibly due to difficulties of organising these at convenient times for everyone, 9 given changing client circumstances (e.g. interviews for benefits, housing etc.). More clients 10 expressed an interest than those who participated, nevertheless were happy to informally discuss 11 topics debated. Others wanted to be kept in the loop without participating in focus groups and 12 interviews, so research methods were discussed informally during meetings between researcher 13 and clients.  and other government and non-government agencies.  All authors agree to be accountable for all aspects of the work. We would like to thank the 11 clients, volunteers and staff who were co-researchers in the project. Due to the confidential nature of the human participant data, it will not be freely available via 28 free access databases. Any request for data should be addressed to the corresponding author.  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59 1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59 1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59 1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y   22 14.If you could compare the way you were feeling before joining any of these activities and the way you feel now, would you say you feel any different? Explain 15.Creative activities of course are part of the support that HB offers to its clients. Do you think that you would feel the same about yourself today even without attending these creative activities groups? Why?
16.Do you think that taking part in these creative activities has had any influence on the way you see yourself? And the way you see yourself in London?
▸ The explanation and elaboration document provides specific examples of well-written SQUIRE items and an in-depth explanation of each item. ▸ Please cite SQUIRE when it is used to write a manuscript.

Text section and item name Page/line no(s). info is located
Title and abstract 1. Title 1/1-1/2 Indicate that the manuscript concerns an initiative to improve healthcare (broadly defined to include the quality, safety, effectiveness, patient-centredness, timeliness, cost, efficiency and equity of healthcare). Manuscript concerns an initiative to improve healthcare for forcibly displaced people. 2. Abstract 1/21-2/9 a. Provide adequate information to aid in searching and indexing. 1/21-2/9 b. Summarise all key information from various sections of the text using the abstract format of the intended publication or a structured summary such as: background, local problem, methods, interventions, results, conclusions. 1/21-2/9 The structure abstract summarises all key information under headings of: objective, design, setting, participants, results, and conclusions. 1/21-2/9 Introduction: Why did you start?
3. Problem description -Nature and significance of the local problem. c. Methods employed for assessing completeness and accuracy of data. 7/11-7/17 11. Analysis a. Qualitative and quantitative methods used to draw inferences from the data. 7/2-7/10 b. Methods for understanding variation within the data, including the effects of time as a variable.
6/14-6/17 and 7/10-7/17 12. Ethical considerations -Ethical aspects of implementing and studying the intervention(s) and how they were addressed, including, but not limited to, formal ethics review and potential conflict(s) of interest.  were explored during in-depth interviews. Thematic analysis of interviews was conducted in 2 NVivo 11 and findings showed that artistic and cultural activities impacted positively by 3 helping participants find a voice, create support networks, and learn practical skills useful in 4 the labour market.

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Conclusions: The study expanded on arts and wellbeing research by exploring effects of 6 cultural and creative activities on the psychosocial wellbeing of refugees and asylum seekers.

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By focusing on the relationship between arts, wellbeing and forced displacement, the study 8 was instrumental in actively trying to change the narrative surrounding refugees and asylum 9 seekers, often depicted in negative terms in the public sphere. Research conducted in the field of forced displacement and mental health shows that 33 'asylum seekers and displaced people report high rates of pre-migration trauma', [6 p275] and social and emotional isolation, racism and hostility, experience of detention, and uncertainty 5 related to the asylum application process.[7-9, 12] If, as authors suggest, [13][14][15][16][17] there is a 6 strong link between mental health and socioeconomic conditions in terms of employability, 7 income and housing, then the mental health of unemployed asylum seekers living on low 8 incomes in poor quality housing is likely to be worse than that of the general population. 9 Arts-and-health practitioners believe that 'aesthetics act upon our senses to make us feel 10 more, hear more and see more than we otherwise might… feelings are intertwined with  and mutual support (improving social wellbeing) and enhance self-esteem and self-11 confidence (increasing personal wellbeing).

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The current study bridged the gap between two research disciplines: arts-in-health and 13 forced displacement and mental health. conducting focus groups, discussing data) and organisational abilities (event/exhibition).

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Participating in the research and disseminating findings gave clients a sense of agency and 34 ownership of the project that enhanced self-confidence and feelings of empowerment, one of  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  In terms of study weaknesses, the greater number of female than male participants was 5 probably due to the fact that most creative groups were led by female volunteers (2m, 8f). 6 Most clients attending these groups were also female except for singing, where numbers were 7 approximately equal (although only one male choir member took part in a focus group).

8
Given the nature of the singing activity, conversation was limited to the first minutes before 9 arrival; once rehearsals had started it was difficult for the researcher to form relationships 10 with clients. It was also possible that some activities were seen by clients as gender-neutral 11 (e.g. photography or singing), but others such as working with fabrics and soft materials (e.g. nevertheless were happy to informally discuss topics debated. Others wanted to be kept in the 20 loop without participating in focus groups and interviews, so research methods were 21 discussed informally during meetings between researcher and clients.  Nations Refugee Agency, World Health Organisation, and other government and non-10 government agencies.    Due to the confidential nature of the human participant data, it will not be freely available via 34 free access databases. Any request for data should be addressed to the corresponding author. 3. Which creative arts classes have a positive impact on the lives of refugees? Circle the option(s) that you think work best or add another one.
Arts and crafts Drawing Films Knitting Photography Singing Textiles. Volunteers: 1. Why do you volunteer at the HBF?
2. How do you think your group benefits clients?
3. How would you collect evidence on the effects of participating in artistic activities? Staff: 1. Why do you recommend clients to attend Creative Arts groups?
2. What do you think are the benefits of attending arts groups?
3. How would you collect evidence on the effects of participating in artistic activities?   ▸ The SQUIRE guidelines are intended for reports that describe system level work to improve the quality, safety and value of healthcare, and used methods to establish that observed outcomes were due to the intervention(s). ▸ A range of approaches exists for improving healthcare. SQUIRE may be adapted for reporting any of these. ▸ Authors should consider every SQUIRE item, but it may be inappropriate or unnecessary to include every SQUIRE element in a particular manuscript. ▸ The SQUIRE glossary contains definitions of many of the key words in SQUIRE.
▸ The explanation and elaboration document provides specific examples of well-written SQUIRE items and an in-depth explanation of each item. ▸ Please cite SQUIRE when it is used to write a manuscript.

Text section and item name Page/line no(s). info is located
Title and abstract 1. Title 1/1-2/1 Indicate that the manuscript concerns an initiative to improve healthcare (broadly defined to include the quality, safety, effectiveness, patient-centredness, timeliness, cost, efficiency and equity of healthcare). Manuscript concerns an initiative to improve healthcare for forcibly displaced people. 2. Abstract 1/20-2/9 a. Provide adequate information to aid in searching and indexing. 1/21-2/9 b. Summarise all key information from various sections of the text using the abstract format of the intended publication or a structured summary such as: background, local problem, methods, interventions, results, conclusions. 1/21-2/9 The structure abstract summarises all key information under headings of: objective, design, setting, participants, results, and conclusions. 1/21-2/9 Introduction: Why did you start?
3. Problem description -Nature and significance of the local problem. a. Description of the intervention(s) in sufficient detail that others could reproduce it. 5/4-5/6 and 5/9-5/21 b. Specifics of the team involved in the work. 5/24-5/27 9. Study of the intervention(s) a. Approach chosen for assessing the impact of the intervention(s). 5/27-6/8 6/11-6/23 b. Approach used to establish whether the observed outcomes were due to the intervention(s). c. Methods employed for assessing completeness and accuracy of data. 7/11-7/17 11. Analysis a. Qualitative and quantitative methods used to draw inferences from the data. 7/2-7/10 b. Methods for understanding variation within the data, including the effects of time as a variable.