Impact on public attitudes of a mental health audio tour of the National Gallery in London

Abstract Aim The arts have the potential to increase public awareness about mental health and reduce stigma. However, arts‐based projects to raise awareness have been small‐scale. In this study, a mental health‐awareness audio tour of The National Gallery in London was co‐produced and narrated by young adults with relevant lived experience. The study investigated the acceptability of the tour to the public and evaluated its impact on public attitudes about mental health. Methods Participants were Gallery visitors over four consecutive days. The tour led visitors on 10 stops through the Gallery. Each stop focused on artworks and Gallery spaces, challenged common myths about mental health, and invited visitors to consider their personal views. Participants completed measures of mood and attitudes about mental health pre‐ and post‐tour and provided narrative feedback. Results Pre‐tour, participants (N = 213) reported high levels of happiness, compassion towards people with mental health conditions, comfort talking about mental health, and positive attitudes about mental health. Post‐tour, participants (N = 111) reported significant increases in happiness, comfort, and positive attitudes. In feedback, participants (N = 85) reported that strengths of the tour were the music, inclusion of lived experience, art and mental health links, and reported that the tour was informative, innovative, and improved mental health awareness. Conclusions The tour increased positive attitudes, despite positive baseline attitudes, indicating the feasibility of arts‐based interventions in major venues to reduce stigma. Sampling limitations and participant retention suggest that arts‐based projects to raise awareness should target more diverse audiences and consider data collection strategies in large venues.

reported that strengths of the tour were the music, inclusion of lived experience, art and mental health links, and reported that the tour was informative, innovative, and improved mental health awareness.
Conclusions: The tour increased positive attitudes, despite positive baseline attitudes, indicating the feasibility of arts-based interventions in major venues to reduce stigma. Sampling limitations and participant retention suggest that arts-based projects to raise awareness should target more diverse audiences and consider data collection strategies in large venues.

| INTRODUCTION
Mental health stigma is characterized by discriminatory behaviours, prejudicial attitudes, and biased social structures towards those with mental health conditions (Corrigan, 2000). Misconceptions and negative attitudes about mental health conditions are highly prevalent (Kaur et al., 2016), which can have wide-ranging consequences for individuals experiencing these conditions, often considered to be worse than the condition itself (Thornicroft et al., 2016). Among individuals with mental health conditions, public stigma is associated with social disadvantages and negative outcomes, representing a major health inequality (Pedersen & Paves, 2014;Clement et al., 2011). The World Health Organization have prioritized reductions in mental health stigma and discrimination (World Health Organization, 2013). However, despite antistigma campaigns, such as the UK Time to Change campaign, mental health stigma remains a significant issue (Evans-Lacko et al., 2014) and further interventions are necessary. Meta-analysis evidence suggests direct, face-to-face campaigns are the most impactful anti-stigma approach for meaningful behaviour change .
The arts have the potential to increase public awareness about mental health and reduce stigma (Gronholm et al., 2017) by inviting reflection, discussion, and eliciting empathy (Ho et al., 2017). Galleries are enhancing public engagement by using technologies to create more interactive, immersive experiences (Falco & Vassos, 2017; and co-producing art projects with people with lived experience for a more authentic and personal experience Ho et al., 2017). Despite these advances, projects have been small-scale and generally outside mainstream settings.
The present study evaluated a mental health-awareness audio tour of The National Gallery in London. The tour was co-produced with young adults with lived experience of mental health issues through workshops based in the Gallery (Riches et al., n.d.). The aim of this study was to investigate the acceptability of the tour for Gallery visitors and evaluate its impact on public attitudes about mental health. Hypotheses were that participants would find the tour acceptable, and that it would increase understanding and improve attitudes about mental health.

| Design, participants and setting
A cross-sectional within-subjects design was used to evaluate the impact of the mental health audio tour on public attitudes about mental health. The National Gallery is a large, free-admission art gallery in central London; and is one of the most visited galleries in the world (www.nationalgallery.org.uk). Participants were visitors to the National Gallery from the general public who undertook the audio tour. This project was an audit of the audio tour conducted with the approval of the National Gallery; therefore, no ethical approval was obtained. However, the study was conducted in accordance with The Declaration of Helsinki (1964).

| National Gallery Mental Health audio tour
This project was a collaboration between staff and Young Producers from the National Gallery, young people with lived experience of mental health issues, technologists who produce audio guides, and academics from King's College London. The aim of the project was to develop an audio tour of the National Gallery that raised awareness and debunked myths about mental health by promoting the voices of young adults with lived experience of mental health issues. Development stages of the tour included workshops in the Gallery with young adults with lived experience of mental health issues, writing the audio tour script, creation of a progressive web app that could be accessed by mobile devices, and recording the tour narration. Further details of the development of the tour are provided in Riches et al. (under review). The tour was launched on 10th October 2019 and was free to all Gallery visitors for 6 months in the first instance. The tour comprised 10 stops, each focusing on artworks or Gallery spaces, identified and challenged common myths about mental health, and invited listeners to consider their personal views and reflect on their wellbeing. The tour was narrated by two young adults who were part of the National Gallery's Young Producer's programme and included excerpts of four young adults with relevant lived experience reflecting on their own personal experiences and the artworks. See Table 1 for a description of all stops, artworks, and myths.
T A B L E 1 Summary of the stops included in the National Gallery mental health audio tour Audio stop and myth Artworks/gallery space Link between myth and artworks/gallery space 1. Mental health issues are a modern phenomenon-young people are too sensitive nowadays.
The Sainsbury Wing of the Gallery, room 51.
This is the newest wing of the Gallery but houses the oldest paintings thus mirroring how mental health issues have been around for centuries even though they may appear to be a modern phenomenon because people are more comfortable talking about them now.
2. Everyone experiences mental health issues in the same way.
Two paintings of 'The Virgin & Child' by Giovanni Battista Cima da Conegliano, room 57.
The two paintings depict the same subject but from different perspectives. In the same way, experiences of the same mental health issues are often different and vary between people.
3. Hearing voices and seeing things are rare and a sign of mental illness.
'The Vision of the Blessed Gabriele' by Carlo Crivelli, room 57.
Historically, having visions and hearing voices, such as depicted in this painting, were experiences that were celebrated and indicated that someone was special rather than unwell. Many people in the general population without mental illnesses have these experiences. This is one of the very few paintings depicting people of colour in the Gallery. In the same way that ethnic minorities initially seem 'missing' from classical art, mental health issues can also seem less visible among those from ethnic minorities or low-income countries because of a reluctance to speak out due to fear of stigmatization or institutional barriers to accessing care.
6. People with mental health issues are lazy, attention seeking and manipulative.
Boris Anrep Mosaics, in the Portico, main entrance of the Gallery.
The Mosaics include depictions of Virginia Woolf and Winston Churchill, who both achieved great things while battling their mental health issues.
7. An artist needs to have mental health issues in order to be creative.
Paintings by Van Gogh, Henri de Toulouse-Lautrec, and Claude Monet, Impressionists Gallery, room 43.
Although some artists, such as those whose paintings are featured in this room, have experienced mental health issues, they had periods when they were too unwell to paint. The 'tortured artist' stereotype can be damaging as it may prevent or delay people in creative jobs from seeking the help that they need, which may make their mental health issues much worse. This painting depicts a ship attempting to cross a turbulent sea with the sky overhead threatening to unleash a storm at any minute reflecting the common myth that people with mental health issues are unpredictable and may be dangerous or violent. Whereas they are actually more likely to experience violence from others and hurt themselves.

| Procedure
The tour was promoted on the Gallery website and social media. Promotion described a free mental health-themed audio tour exploring art and mental health myths. The evaluation was conducted on the first four consecutive days after the tour was launched (i.e., 10th-13th October 2019). On entry to the Gallery, visitors on these days were approached by a researcher and invited to undertake the mental health audio tour and complete a brief survey before and after the tour. Researchers used tablets to administer surveys that were designed on the online software program Qualtrics. Following completion of the pre-tour survey, participants accessed the tour by connecting to the free Gallery Wi-Fi and using the web-based app (https://tour.aiwebservices.com/c/ngmentalhealth) on their mobile phone. They wore headphones to listen to the audio. Researchers checked that they were able to access the tour and assisted with technical issues. Participants were advised to listen to the Introduction audio for the tour first before setting off to explore the Gallery. They were provided with a map of the Gallery indicating the relevant room for each stop and were free to choose the order in which they visited the stops. Participants were told by researchers that they could remove their headphones at any time if they felt uncomfortable. A clinical psychologist was always present in the Gallery to monitor visitors for distress and address concerns. Participants were asked to find researchers to complete the post-tour survey once they had finished listening to all stops. Researchers were positioned near the main entrances and exits to maximize the likelihood of engaging with visitors as they entered the Gallery to invite them to take part and also to prompt participants leaving the Gallery to complete the post-tour survey. Participant anonymity was ensured by using a unique four-digit participant ID number for data collection which was provided on a sticker that participants were asked to affix to their clothing. This meant that the same number could be entered by a researcher into the tablet for the post-tour survey to ensure it could be linked with their pre-tour survey responses. A prize draw for a £50 shopping voucher incentivized participation each day. and 'the mentally ill' were adapted to 'people with mental health conditions' throughout, and the original item 'A woman would be foolish to marry a man who has suffered from mental illness' was adapted to 'People would be foolish to begin a relationship with someone who has had a mental health condition'. See Table 2 for all pre-tour items.

| Measures
Post-tour, participants were invited to recomplete all pre-tour VAS, the Attitudes to Mental Illness items and five additional VAS on attitude change, enjoyment, amount learned, the extent to which they thought differently about their own mental wellbeing, and how understandable they found the tour. See Table 2

| RESULTS
Two-hundred and thirteen participants took the tour and completed the pre-tour survey. Table 3 reports their demographic characteristics.
One-hundred and twenty-nine (60.6%) were female, 145 (68.1%) were ≤35 years of age, and 64 (30.0%) were of White British ethnicity. One-hundred and eleven pre-tour survey participants (52.1%) returned to complete the post-tour survey. and ethnicity were not significant (see Table 3). Table 2 reports preand post-tour mood and attitudes. There were significant increases in happiness and comfort, and decreases in stress, all with small effects.  Table 4 reports themes, explanations, and illustrative quotes. Participants reported that strengths of the tour were the integration with music, inclusion of lived experience, the art and mental health links, and reported that the tour was informative, innovative, and improved mental health awareness. A weakness was the tangential links between artworks and audio tour content for some of the stops.

| DISCUSSION
This study aimed to evaluate the impact on public attitudes of a mental health audio tour of the National Gallery in London. As hypothesised, participants found the tour acceptable, it increased understanding and led to more positive attitudes about mental health. High scores for enjoyment and how understandable participants found the tour indicate that participants had a positive and engaging experience and highlight the potential for future public engagement and anti-stigma campaigns in large-scale cultural spaces. Large effects for reducing negative attitudes about fear and exclusion of people with mental health conditions and enhancing positive attitudes on integration of such individuals into the community are comparable to findings from similar art-based anti-stigma interventions (Aldam et al., 2017;Kosyluk et al., 2018), and positive effects on happiness, stress, and comfort are consistent with other interactive arts-based experiences . The experiential dimension to the tour and inclusion of the voices of people with lived experience enabled visitors to engage with complex topics and reflect on their social and personal meaning. This appears to be crucial to instigating attitude change given that experiential learning theory suggests active engagement is more valuable and effective than many other educational approaches (Kolb et al., 2001).
Strengths of the study included the novel arts-based approach in a world-renowned art gallery, co-production with people with lived experience, and a relatively large sample from the general population.
The study provides evidence in favour of using art galleries as spaces for raising awareness about mental health in creative and engaging ways. This has important public health benefits as better mental health awareness is linked to lower levels of stigma and discrimination against those experiencing psychological difficulties (Evans-Lacko et al., 2014), which in turn may lead to those with mental health conditions seeking help earlier and potentially improving their prognosis (Clement et al., 2015;Schnyder et al., 2017).
Limitations include lack of diversity in the sample, use of some  national galleries, which has been reported by researchers involved in the tour (Riches et al, under review). Future arts-based projects on this scale may need to consider alternative strategies for data collection.
In conclusion, this study indicates that a mental health-themed audio tour of the National Gallery in London, which was co-produced with young adults with lived experience, was a novel and effective way to raise public awareness about mental health and reduce stigmatizing attitudes. Future arts-based anti-stigma projects should aim to replicate this impact on broader and more diverse audiences.