Cultural animation in health research: An innovative methodology for patient and public involvement and engagement

Abstract Background A significant challenge in Patient and Public Involvement and Engagement (PPIE) in health research is to include a wide range of opinions and experiences, including from those who repeatedly find themselves at the margins of society. Objective To contribute to the debate around PPIE by introducing a bottom‐up methodology: cultural animation (CA). Cultural Animation is an arts‐based methodology of knowledge co‐production and community engagement which employs a variety of creative and participatory exercises to help build trusting relationships between diverse participants (expert and non‐experts) and democratize the process of research. Design Three CA full‐day workshops for the research project “A Picture of Health.” Participants Each workshop was attended by 20‐25 participants including 4 academics, 5 retired health professionals who volunteered in the local community and 15 community members. Participants ranged in age from 25 to 75 years, and 80% of the participants were women over the age of 60. Results The CA workshops unearthed a diversity of hidden assets, increased human connectivity, led to rethinking of and co‐creating new health indicators and enabled participants to think of community health in a positive way and to consider what can be developed. Discussion Cultural animation encourages participants to imagine and create ideal pictures of health by experimenting with new ways of working together. Conclusion We conclude by highlighting the main advantages to PPIE as follows: CA provides a route to co‐produce research agendas, empowers the public to engage actively with health professionals and make a positive contribution to their community.

The methodology helps to build trusting relationships between participants by inviting them to work together in a series of workshop activities which may be new to them but which draw on their life-experiences. Rather than relying solely on the written word, ideas are also explored through actions and images. Outputs usually include creative products such as songs, poems, short plays, puppets 11 in addition to a more conventional data set. Consequently, a wider and more diverse audience can engage with the findings of the research.
A typical CA workshop includes a mixture of creative tasks, embodied activities and small group discussions to explore key themes (i.e the topic of the research). The workshop will begin with a series of name games, designed to put people at ease with each other, building on the idea that when people are not static, more participatory ways of approaching and solving problems are possible. These activities along with the creation of various artefacts, to which everyone's contribution is equally important, helps to dissolve hierarchies and traditional barriers associated with professional expertise. By "giving life to" the dynamics of everyday life through these activities, cultural animation encourages participants to reflect on the potential for change within themselves and their own communities. For a more detailed discussion of the theoretical underpinnings and the strengths and limitations of CA, see a recent study on community responses to the 2011 tsunami in Japan. 12 While the benefits of participatory art programmes and initiatives on health and well-being are well documented in the literature, 13,14 participatory arts-based methodologies for researching with public and patients are yet to become mainstream. This article extends the extant discussion by articulating for the first time the opportunities that cultural animation methodologies can bring to PPIE activities in health-focussed research. The methodology has been extensively used by the authors to co-produce knowledge with communities in the UK and abroad (in Japan, Greece, Canada, France, the Philippines) on topics such as food poverty, communities in crisis, marketplace exclusion, disability, volunteering, social innovation, community leadership and health in the community. 15 Here, we discuss the potential and challenges of using CA in health and well-being research, by illustrating how we used this methodology to co-create a health agenda with local communities in Stoke-on-Trent (UK).
According to Public Health England, the health of people in Stoke-on-Trent is generally worse than the average for England.
Stoke-on-Trent is one of the 20% most deprived local authorities in England, and about 26% (13 300) of children live in low-income families. 16 Life expectancy for both men and women is lower than the average for England, and health inequalities have widened in recent years. With residents described by official documents as "leading unhealthy lifestyles", 17 this project aimed to explore the responses of community members to claims such as these to identify what "good health" meant for them and finally what participants might do in response to this situation at a community and individual level. Our research project, A Picture of Health, was funded by the Connected Communities Programme, under a scheme on Knowledge Cocreation and Co-design that sought to "support innovation in the process of co-creation and co-design of research with communities and added value through cross-disciplinary approaches to cocreation and co-design incorporating distinctive arts and humanities perspectives". 18

| CULTUR AL ANIMATI ON A S A PPIE ME THODOLOGY IN HE ALTH RE S E ARCH
Cultural animation is located within the broader field of creative methods 19 and underpinned by an ethos of dissolving hierarchies within mixed-background groups to enable and facilitate the cocreation of knowledge and embodied learning. This is particularly pertinent in the context of health-care research, as it brings together patients, policymakers, health professionals and health-care managers. Through the use of drama exercises, art making, poetry and music, CA aims to create a space in which existing hierarchies are less dominant and boundaries are crossed. By regarding practical skills, experience and expert knowledge as equal, CA exercises embrace the view that knowing and doing are deeply interconnected and equally important in the co-creation of health knowledge and the co-design of health-related solutions. The use of boundary objects, 19,20 such a post-it notes, ribbons, plates, picture frames, cardboard, buttons, fabric, is an integral part of this methodology, for these objects help participants express individual and collective ideas and articulate them through different ways of knowing. 21 The use of boundary objects increases human connectivity and builds up trust between members of the public, academics and health professionals. 22,23 They help redistribute the power between participants, providing both the opportunity and the authority for those involved to exchange different types of knowledge and co-produce shared knowledge as we will see in the case study below (Box 1).
The research project "A Picture of Health" aimed to co-design communities. The interviewees consisted of one retired nurse, one retired GP and 3 retired NHS senior managers along with 10 community members who, in addition to being users of health services in their own right, volunteer and work with asylum seekers and people with disabilities in their local communities. We employed narrative analysis 24,25 to analyse the interviews, the field notes and the visual data. The emphasis was on the co-construction of meaning between the researchers and participants. While being involved in the making of artefacts, contributing and listening to the conversations, we compared what was being said and to our own personal understandings aiming to piece together and make sense of each story in its own context. The process of "data gathering" and "analysis" was therefore concurrent rather than separate, and as such, the story of the researcher was one of the many that have been constructed and orchestrated in the analysis. The

Builds up trusting relationships between participants by in-
viting them to work together in activities which may be new to them but which rely on their life-experiences.

3.
When people move about and complete tasks together, it facilitates new ways of seeing and thinking.

| Workshop 1: what is a healthy community?
The first workshop aimed to co-design the frames of reference for the research by exploring the meanings of a healthy community. The starting point was a presentation of the current health statistics for Stoke-on-Trent given by a retired NHS chief executive. His presentation sparked a debate about how (ill) health is defined and measured by government. Participants took issue with the picture painted by these statistics and did not recognize their communities in these official reports. Participants were then randomly split into 2 groups and asked by the CA facilitator to work together to create an art installation of "a healthy community." As part of this task, they were encouraged to use the objects brought to the workshop by the CA facilitators to convey what health feels, looks, sounds and tastes like in their immediate communities. One group worked with colourful ribbons, buttons and empty frames to create the installation are presented in Figure 1.
This "healthy community" was perceived as a dynamic, openminded, happy community: "this is a messy community which is close knit, having lots of fun together, which is always changing and is open to new members and ideas" (field diary author 1). It was described by a retired NHS manager as a "jewel of a community, with good neighbours, with a thriving industry, vibrant and colourful" (field notes). A member of the local public and NHS-user added: "It is an emergent community: we kept changing it, because the community changes and we wanted to capture this change." The second group created an orderly community out of cardboard, empty packs and straws ( Figure 2). This "healthy community" was a neat locality with terraced houses, allotments, bike paths, a community centre and free parking.

| Workshop 2: ageing well and dying at home
The second workshop comprised of 20 participants, with 5 who did not attend the first workshop. The CA facilitator invited participants to create an ideal community for older people-a theme established in workshop 1-by identifying how such a community would make a difference to their lived experience but also to dying in one's own home.
The workshop started with participants listening to a recorded story about an older woman played out in a reconstructed room.
Participants described the feelings evoked by the story in the following terms: the old woman lives on her own, it is cold in her house; she is a widow, she is frightened and powerless; there is regret; she is lonely; she mentions the weather as an impediment for getting about; her age is a mental construction; she feels isolated; she is reminiscing about old days; her life feels pre-destined; she is frustrated she did not help her friends; there is anxiety on her mind that she will die in hospital and not home (from field notes).
A retired NHS doctor said that in the UK people tend to die in hospitals, yet many people want to die at home and they are not able to. A community member lamented that there are poor end-of-life provisions in place and felt people had no choice in the matter.
After this discussion, participants were asked by the CA facilitator to imagine a community that would make a real difference to the lived experience of older people living and dying in their communities. The ensuing installation about communities that could support people dying at home can be seen in Figure 3.
The arrows point to the human and cultural assets that already exist within communities and would make it possible to die at home with dignity. One retired NHS manager suggested Maslow's hierarchy of needs as a starting point and explained to the others its elements: physiological needs, safety, belonging, esteem and selfactualization. The participants then selected objects to signify the importance of each of these levels. In addition to the various objects chosen to convey the physiological needs, they also selected objects which spoke of the importance of belonging and self-esteem.
These included a message in a bottle and an umbrella to highlight the importance of communication and support and a candle to signify dignity. Unlike the depiction by Maslow, the participants felt these needs should not be seen as hierarchical. The group concluded that all these needs could be met by the community, but that it would require a shift in how people (including themselves) behave towards one another in a highly individualistic world. At the end of the workshop, one CA facilitator commented: "Nobody focused on external services, people spoke about what they themselves can bring to this process. You've all described journeys that are perfectly attainable and do not require external resources." (Field notes).

| Workshop 3: the relationship between the communities and the government
In the final workshop, participants were asked to draw on the activities and reflections from the first 2 workshops to communicate their own "picture of health" to the rest of the world, including government. This was achieved by completing 2 activities: (i) using social media as a framework to convey their findings to a general audience and (ii) producing a presentation to government in the form of a human tableaux.
For the social media, exercise participants were asked to construct a 3-dimensional Facebook page. One groups' creation can be seen in Figure 4, in which the heart signified "friendship," the candle "hope," the stethoscope "access to the GP" and the sunglasses "leisure and rest time" as elements of health in the community.
The selection of objects to create the installation allowed people to find and express a creative self which led to increased levels of energy in the room and to productive discussions and effective problem-solving. After the 3-dimensional Facebook page was constructed, the group was asked to produce their first "post." To encourage the group to distil their thoughts into concise wording, they were asked to create their post in the form of a Haiku. These are 2 "posts" written by the groups: The candle helps us to go in the right direction, it is a community for different ages, we offer money advice to people, our dreams can come true. The GP practice has a participatory group. We organise events such as youth clubs, coffee mornings, mother and toddler, learn how to cook" (field notes).
In the final part of the workshop, each group was invited to enact these poems as if presenting their findings to a government (played by other participants). One group chose to do this by holding hands and reciting the poems together (see Figure 5).
The aim of the presentation was to convince the fictional government that what is going on in the community is worth supporting.
The narrative of one of the groups went as follows: One of four people will suffer mental illness at some point in their life but you don't know who is going to be. It could be anyone, it could be you. We think we have the answer in our community.
(field notes) They then sang a song in a very upbeat rhythm: "There was a sad man called Joe, who did not know where to go. Who are we?
Community, creativity, diversity, equality, inclusivity in Stoke on Trent, all in our backyard" (field notes).
One of the participants approached the table where those playing the part of the government were sitting and said: "Here is an advance payment of what we saved you so far (fake money is handed over). But doing this with your support will save you half a million per year. And that's just a start. If it works for mental health, it will work for all health." The participants playing the government role then agreed to support the proposed community-based health initiatives.
Despite the negative indicators of health for Stoke-on-Trent, at the end of the research project, participants agreed that their own communities could make a difference to their own health. New health indicators were co-created such as creativity, connectivity,

| Feedback on cultural animation
At the end of the final workshop, the CA facilitator asked participants for feedback on the process and the techniques of cultural animation. Participants said that CA "sets people to open up as they are not overwhelmed by words." The methodology also "visualises change, you feel like you've already started the process of change." The process was also described as "truly democratic," "empowering," "honest," "practical" and "valuable" (field notes organizations and clubs that could support people in need; access to IT in public spaces and so on. One of the retired nurses who currently volunteers in the community said in a follow-up interview: "Refugees and asylum seekers have so much to offer but we don't let them. I can point people in the right direction, teach them how to get into the system and use their skills and knowledge, in return they teach me how to cook and one of them even babysat my grandson." Cultural animation also led to increased human connectivity between diverse parties, as these 2 interview quotes from community  is crucial that more studies are conducted on the workings and impact of CA on PPIE processes to distil best practices and develop conceptual insights that could refine and extend existing theoretical frameworks.

ACK N OWLED G EM ENTS
We would like to thank Sue Moffat from the New Vic Theatre and her team of theatre practitioners for conducting the Cultural Animation Workshops.

CO N FLI C T O F I NTE R E S T
The authors have no conflict of interest to declare.