HeartArt: Creating a culture of health for people with diabetes
Published: 03 June 2009
Yvonne Coughlan won the 2007 RCN Diabetes and Cardiovascular Disease Award for developing a series of art-based educational workshops about the risks of heart disease, designed for people with type 2 diabetes. Here she describes the rationale for "HeartArt", discusses the workshops in detail and looks at the response of participants to art in the delivery and promotion of health.
First, some background ...
The Bromley by Bow Centre is an exemplar social enterprise organisation in East London, working for over 20 years in one of the most deprived wards in the UK. The general practice based there is a forward-thinking primary care facility with a list of approximately 6,000 patients.
Health and wellbeing are at the core of our activities. Tackling chronic ill-health is a central objective and many of the centre's wider aspirations are underpinned by the need to build a healthier community. Our approach to health and wellbeing is holistic and we continually seek to innovate and support people toward a healthier life.
The centre has used the arts in its delivery of services over many years. We have a long history of embedding creativity in a range of services and an understanding that art can be used effectively to deliver health promotion messages and work with different groups.
The health needs of our community are varied and challenging, with type 2 diabetes being one of the largest problems facing the primary care team: the rate has nearly doubled in the last 10 years. Data available in 2007 showed a national prevalence of diabetes of 4.7 per cent and a prevalence in Tower Hamlets of 6.9 per cent. Many people with type 2 diabetes are undiagnosed and the true prevalence may be much higher, possibly even double the figure of those already diagnosed.
Serving vulnerable ethnic minority groups
At the last census, 48 per cent of the Tower Hamlets population defined themselves as coming from a non-white ethnic group. By far the largest of the non-white ethnic groups is the Bangladeshi population, comprising 34 per cent of the borough population in 2001 and one of the largest single ethnic minority communities in London. The Sylheti community of East London, most of whom reside in Tower Hamlets, is the largest in the world outside Bangladesh.
There is an increased risk of type 2 diabetes in the Asian, African and Caribbean community, and those people who live in the UK are at least five times more likely to have diabetes than the white population. The ethnic profile of the Bromley by Bow general practice reflects this picture.
However, diagnosing and caring for people with type 2 diabetes and raising their awareness is not the only health challenge we face in the locality.
Other health and social issues
Smoking and coronary events are generally higher in Tower Hamlets and the levels of smoking by Bangladeshi males are the highest rates in the country. Statistical evidence shows that the life expectancy here is 10 years less than that of more affluent areas of London, such as Richmond in Surrey.
Poor awareness of the risks of CHD, lack of exercise and the levels of social deprivation are some of the other factors.
Meanwhile the levels of spoken and written English in the Bangladeshi community often compound the problems of accessing health information. There is less use of traditional means such as leaflets and website access to directed sites such as Diabetes UK. Diabetes information and education classes are offered across Tower Hamlets in accordance with NICE recommendations that structured education for diabetes be recommended for all patients with type 2 diabetes.
Why HeartArt?
HeartArt was developed as a response to the objectives of the RCN Diabetes and Cardiovascular Disease Award, developed in collaboration with the College of Pharmacy Practice and Servier Laboratories - that is, to implement innovative educational and clinical initiatives that address the diabetes and cardiovascular needs of patients in addition to the education programmes already being run in the community.
As more arts and health projects are held across the country, there is growing awareness and recognition of their value. Increasingly we realise that arts can be used in facilitation and in practice not only as the means to run groups and workshops, but also as the message itself. HeartArt was developed with this knowledge and understanding.
Attending the workshops
All people with type 2 diabetes on the practice register (around 300 people) were invited to the workshop series.
Colourful invitations were sent out, asking them along to a series of four art workshops that would look at a specific area of coronary heart disease each week - no experience necessary. We enclosed an acceptance slip to encourage their response.
Two series of workshops were planned for December 2007 and January/February 2008, both arranged for Thursday afternoons in a large project room.
The format of the workshops was to deliver structured information alongside the art activities. Participants watched PowerPoint displays that explored the theme of the workshop by presenting factual information and pictures to inform them about their bodies - for example, a diagram of the heart or a cross-s
ection of blood vessels.
These images were interspersed with more abstract slides of textures, colours and shapes. The group would then spend time making art that had its conception or imagery rooted in the workshop information.
The art from the workshops was displayed in the reception area of the centre alongside information about the aims and objectives of the classes and participants were invited to attend a private show and unveiling of their work.
The four weekly workshops used:
- printmaking (mono print and drypoint) to look at the heart and its function
- collage and feltmaking to investigate the effects of smoking and high blood pressure on the circulation and blood vessels
- paper marbling, mixing oils and inks to consider fats and oils
- still life and drawing, taking a traditional approach to think about a composition of fruit and vegetables as the catalyst for discussion that focused on healthy lifestyles.
Week one
We commenced with an overview of the heart, the role of the heart in the body, how it works and ways it has been portrayed in art and literature. A 3D model of the heart was passed around the group to allow them to see the heart size and note its structure.
Group members were asked to make a colour print of the heart, using a technique called mono printing, in response to the slides they had seen. We encouraged them to think about the structure of the heart and its chambers, and how it is a pump.
Week two
This session looked at circulation and how blood vessels connect to the heart. The group saw diagrams of arterial and venous blood flow, and discussed oxygenation and the differences of arteries and veins by looking at cross-section diagrams. They examined the smooth, uninterrupted surface of blood vessels in healthy circulation and compared this with the scaled and pitted surface of arteries and veins damaged by smoking and hypertension .
As in the format of the previous week, we asked them to make a small piece of collage that reflected this changing surface. They used collage materials such as polystyrene rectangles that could be cut into or scooped out and a variety of soft material and textured fragments that could be applied to the surface. The end result was a series of textured panels suitable for display as relief.
A subsequent workshop experimented with collaged feltmaking as an alternative to the polystyrene blocks.
Week three
Then came an investigation of cholesterol and the changes that occur to the cholesterol levels of people with type 2 diabetes. The group looked at a selection of cooking oils (sunflower, rapeseed, olive) and discussed fish oils and the benefits to the heart of mono unsaturated fats in the diet. Our presentation explored the difference between HDL and LDL cholesterol, and also covered triglycerides. Participants then used these cooking oils mixed with oils and inks for the subsequent art activity of paper marbling.
Week four
The final workshop commenced with a presentation of food slides and a discussion about healthy eating and exercise. We set out a table with a colourful display of fruit and vegetables for a still life art activity of drawing and ink painting. Group discussion continued while they were painting and drawing.
Pre-course evaluation
All participants completed a pre-course evaluation to gauge their knowledge of coronary heart disease as a complication of type 2 diabetes, using a score rating from "poor" to "very good" (1-10). These evaluations were anonymised.
- Half of the first group rated their overall knowledge of diabetes as "good" and all but one had discussed diabetes complications with the nurse or doctor.
- Two-thirds of the second group rated their knowledge of diabetes as "poor" or "moderate" and two had never discussed diabetes complications with anyone.
- Two-thirds of the participants rated their knowledge of cardiovascular disease as "poor" or "moderate".
- They rated their knowledge of the effects of high blood pressure in the body as "high" overall, but generally "low" for smoking and cholesterol.
- About half felt they knew the benefits and effects of exercise.
Individuals listed their aims in attending the HeartArt course as getting a better understanding, more knowledge and learning; preventing illness and meeting people.
Results
Out of 100 invitations sent out in the first round, nine participants came forward. We recruited 12 participants from 200 invitations in the second.
The gender and race mix was quite varied. Afro Caribbean women were the most consistent participants in the first group and Bengali men were the biggest user group in the second.
Some of those attending had a poor understanding that they had come to a class that would involve an art activity. Despite this, no one refused to participate. We found a measure of goodwill in both groups and a sense of amusement that everyone was being invited to make art alongside an educative component.
There was an anticipated response at the start of the activities - an incredulous "I can't do that" and "I can't draw", but as we gave a step-by-step demonstration of what was being asked for each activity, this was very transitory.
Each of the session activities expanded on the information that was presented in the PowerPoint demonstrations and the art was successful in expanding conversation and teasing out queries.
Achievements
- Attendance was consistent. An initial dropout rate stemmed in part to a limited understanding of what the course entailed.
- All who attended expressed their surprise and enjoyment from their engagement with art activities. Printmaking and paper marbling were the most popular.
- The mood was light-hearted with plenty of discussion around the table that focused on the topics of the day.
- The groups were generous in their praise of each other's artwork.
- Medical students and a GP trainee assisted the workshops as part of their own training needs.
- The second group worked in conjunction with the local health trainers in the discussion of staying well and healthy lifestyles.
- Language barriers were overcome by using an advocate for all of the sessions.
- For some individuals this was the first time in their lives that they had made art.
- All of the art that was made in the workshops was displayed as a HeartArt exhibition throughout the centre. Participants were invited to attend a private viewing along with their families.
Course outcomes
- All participants said they learned more about their bodies and had been given more information to stay well.
- All said they enjoyed the classes, some saying they enjoyed the classes a lot.
- Both groups took away information on heart health from the British Heart Foundation and Diabetes UK.
- Two men enrolled with the centre's smoking cessation programme.
- Four joined the men's walking group.
- One man took up evening art classes at the centre.
- One lady enrolled in the locally-run diabetes education programme.
General feedback from the group was that the information was put in a way they understood: "good class injoin very well" ... "enjoyed the class a lot" ... "learn how to use different types of art working" ... "amazing what you can do" ... "you can change things over if you try making it look different - you can learn to feel different."
Which way now?
The national agenda is for all patients with type 2 diabetes to be offered and enabled to attend structured diabetes education. HeartArt was developed in this knowledge and should be viewed as an adjunct to and not a substitute for structured diabetes education.
Art and health offers an approach that is different, interesting, enjoyable and engaging. Art and health has value in the armoury of education tools and has tangible outcomes of social inclusion and engagement.
References on request.