The role of cultural involvement of patients for their social welfare

. Cultural involvement takes a significant role on quality of life of patients (QoL) as namely culture is an important domain for health and QoL simultaneously. Paper analyzes the possible connection between culture and health, and, attendance of patients the cultural events as one of the important dimensions of QoL. Research is based on social project “Cultural prescription”, organized by public cultural institution “Mokytojų namai” (Eng. Teacher‟s House) in Vilnius and dedicated to Outpatient Clinic “Centro poliklinika” (Vilnius) patients, who were suffering from chronic disease to improve their QoL. The aim of the paper is to explore the possibilities of innovative social measures to increase social cultural engagement of patients, to contribute to their well-being, and to present the approach of health care practitioners towards the expediency and usefulness of inter-sectorial cooperation for the patients‟ social welfare.


Introduction
Putnam identifies such features of contemporary society as growing sense of fear and isolation, the demise of trust, belonging and support [1]. To a large extent health problems lead to these social phenomena. Social networks, inter-sectorial collaboration become more and more important for the wellbeing of the individuals and groups. Consequently, one of the ways to improve QoL is an aspiration to improve health. There are many approaches how the state in general or social network organizations, in particular, can improve residents health. Culture is between those methods. Actually, in modern society cultural usage for the health and QoL purpose increases rapidly [2][3][4][5]. Moreover, culture is not only a measure to reach better QoL, but it is also a component of QoL. Culture is acknowledged in many social spheres as a social power to influence the particular issue in a right direction, which had not spared the attention of researchers. Sonnenberg [6] indicates that social cultural formal and informal involvement has a positive effect for the wellbeing of individuals.
The paper concentrates on how non-medical factors influence health, welfare and quality of life of patients and presents research approach from the point of health care practitioners view, as intermediaries between social cultural project organizer"s and receivers" (patients") perspective in Lithuania.
The article presents the findings of the social project "Cultural prescription" that was successfully carried out in 2013 in Vilnius when implementing the best practice of social cultural involvement of patients in Turku, Finland (2011). Project was organized by public cultural institution "Mokytojų Namai" (Eng. Teacher"s House) in Vilnius, Lithuania and dedicated to outpatient clinic "Centro poliklinika" patients, who were suffering from chronic disease (cancer, cardiovascular disease and mental health disorders (a predisposition to depression)) to improve their QoL. The idea of that project was participants receiving invitation cards -"Cultural Prescription"to a cultural event or to a cultural institution besides their regular based prescription for medicine. The empiric data was collected by applying a semi-structured interview method. This is an evidence based cross-sectorial cooperation when culture was employed for health care by collaborating cultural and social network enterprises. Precisely, this social project reveals the case when culture enabled for improving patient"s health, welfare and QoL simultaneously.
The aim of the paper is to explore the possibilities of innovative social project to increase social cultural involvement of patients seeking to contribute to their health and QoL and present attitudes of health care practitioners on this issue. Methods of the research: analysis of scientific literature/data, qualitative research, semi-structured interview, qualitative content analysis of the data.

Health related well-being and quality of life
Quality of life (QOL) is a broad multidimensional concept that usually includes subjective evaluations of both positive and negative aspects of life [7]. Researchers of different disciplines have proposed their own definitions of quality of life. Psychologists [8] analyse personal experience based quality of life; economists [9] allocate the biggest focus on objective economical capacity related to living standards; medical scientists [10] analyse QoL from medical perspective and argue with a health-related analysis; sociologists [11,12] dispute individual"s well-being and their reliance to different levels of society. Growing popularity in interdisciplinary studies has led to interdisciplinary of QoL studies. It is important to mention that major studies on QoL has been initiated by such worldwide organizations as UNESCO, World Health Organization (WHO), Organization for Economic Co-operation and Development.
Two historical approaches on QoL based on different scientific fields should be mentioned: Scandinavian and American [13]. American psychological approach is more interested into individual, subjective well-being, strongly related with such concepts as well-being, happiness or life satisfaction and less related with material goods than individual emotional state. While Scandinavian perception developed by sociologists and economists supposed to be more interested in objective living conditions. It considered that happiness and satisfaction may be reached in condition of well-developed welfare state as a state is responsible to create good social conditions and accessible for every resident services. As is noticed by Rapley [14], Scandinavian approach supports believes, that wellestablished welfare system makes people life easier and allow them to reach and have more in their life, enables them integrated in the society which naturally improves their QoL. Even scholars identify different components of QoL, but some domains are agreed by all, such as physical, mental and social health [15,16]. Despite objective purpose of health care services, QoL is still improved through medical care, though possible alternatives in more social or cultural activities, some supplementary activities began to emerge.

Employment of culture for social involvement of patients
Researchers agree that cultural experience and impressions from culture have physical, mental and social effects [17]. Health care practitioners are often skeptical about health related researches if they do not measure solid medical facts. Phillips [18] implies, that nontraditional treatment activities or methods such as cultural or social initiatives frequently does not convince medics as important or having value for objective health status, because, they rather rely on medicine technologies and laboratory tests. Despite this approach of medical practitioners, various activities have been implemented and researches have been still conducted, which proved the great interest in the topic in scientific and social levels. Considering a linkage between QoL and culture the Canadian research [19] outcome may be presented as method of direct correlation between culture and QoL visualization in society, as overwhelming majorities of research participants (province of Ontavio) states, that culture enrich their quality of life and they value culture as important part for it. Augustinsson (2011) added, that all kind of cultural experience helps people to express themselves in daily life regardless of objective living conditions, in this way culture is suggested to be understood as resource of human well-being which directly matters to quality of life. Cuypers et al. [20] notice that even low-level cultural activity may have a protective effect on health during the time. Culture has individual and community levels of influence on QoL. Even, if culture or its attendance is presented as entertainment, culture by nature provides more social and individual values. As culture is an integral part of every society, it can help individual to adapt themselves in society.
At individual level it is stated that cultural experience improves mental health by relieving stress, anxiety and depression and its symptoms, therefore it stimulates positive feelings, experiences and minds. Culture may contribute to the human life and humanity improvement, individual self-esteem and happiness; help for individual to maintain their health, improve daily routine and empower human to use personal potential (capacity). The mechanism of community level influence is presented by Guetzkow [21].
Firstly, culture may have positive effect on building of the social capital, as it is dedicated to community or society. Secondly, culture improves the economy through promoting peoples" capacity, health and QoL which allow them and society in common reach better economical results; traditional attending increase general consumption, in particular cases of social initiative or project, it may have positive economic side for single person or family unit, to attend free of charge cultural events and save money for other purposes. Thirdly, is claimed that the culture is advantageous to community through single individual in holistically approach. Social cultural formal and informal involvement of patients into health care programmes does not only look after health risk factor"s prevention but also take into account leisure participation in social, cultural and religious activities as part of their concerns. In this respect cultural engaged governmental or non-governmental social programs and projects traditionally divided into two main categories: active and passive participation, which leads to direct or indirect impact. Active kind of participation guarantees direct impact for a participant, because this kind of programs directly include participants into process of producing art (culture) and belief in the inherent healing power of the creative process of art making. Therefore, this kind of art participation in most cases is called art therapy. Art therapy may be provided as part of regular treatment and as intervention to social issues, but it is always required for a group of active people, who would have determined to participate without being afraid of being supervised by therapist [22]. Individuals directly involved in creating or organizing artistic activity may learn skills that they did not previously have and may demonstrate greater creativity not even in cultural nature, but in daily life and solutions of problems as well [23].
Therefore, it is important to highlight, that art therapies have deeper traditions and history of occurance in societies and has a greater acceptance among medical communities. Passive participation guarantees indirect impact for persons who attending this programs or projects. This kind of initiatives do not include people into culture producing process, rather it invites participants to revel cultural events together with other people despite they are participants of initiative or not, in other wordsbe part of natural audience. Despite active or passive participation in culture strengthens feeling of belonging to community, stimulates positive experience and feelings [24], any kind of relation between person and culture has a health benefits, despite of participating or attending culture. Cultural engaged social initiatives addressing health and QoL are found throughout the world: in Great Britain prescription of culture (2004) later (2010) recalled "Social Prescription" linked patients to participate in particular social actions (membership in social networks, volunteering clubs, etc.) [25]; in Sweden, Region Skane in 2009-2011 culture was prescribed as supplemented method to long term sick leave patient"s rehabilitation [26]; particular Lithuanian case "Cultural prescription" (2013) brought from Turku, Finland, where it was implemented in 2011 while Turku was European Capital of Culture and aimed to uncover the comprehensive role of culture for individuals and communitieswell-being providing a valuable perspective. As it was already presented, Lithuanian case Cultural prescription was not linked to art therapy, but it aimed to improve health and QoL through participation in cultural events of those who suffered chronic diseases. A solid number of cultural prescriptions were prescribed (3420 units), which evidence health care practitioner"s determination to this social project.

Empirical research of social project Cultural prescription
The research was conducted on 18-31 October 2013 in four different departments of Outpatient Clinic "Centro Poliklinika" in city Vilnius, Lithuania where prescriptions for the attendance of cultural events were prescribed.
The research was aimed to evaluate health care practitioners "comprehension about prescribing culture and their experience in familiar practices. Informants provided answers verbally during an interview. The empiric data was collected by applying a semi-structured interview method that induced more relaxed communication atmosphere, better adjustment to the research environment, and provided information contributing to an in-depth discussion of the problem analysis. Five doctors and five nurses were selected by Gatekeeper method of sampling.
Health care practitioners participated in the research were family doctors (n = 5) and nurses (n = 5), average work experience 17 years. The focus during the interview was given to understanding of specific moment of prescribing culture, better understanding of informants "attitudes and comprehension on actual practise.
The data has been collected until a certain degree of theoretical "satiation" has been achieved. Questionnaire contained twenty questions grouped in five blocks, which covered questions on common information about informants; familiar experience, participation and participants in social project Cultural Prescription; possible influence on health and QoL; evaluation of the project; and health care practitioner"s role in the process of prescribing culture.
Research has been conducted following the scientific research ethics: voluntary approach, goodwill, privacy and respect. To ensure confidentiality of respondents, their names have been replaced with number and letter that indicates participant and occupation (D = doctor, N = nurse).
Results were processed using qualitative processing method distinguishing categories and subcategories. Inductive category approach was used. Data derived categories raises attention to the data, which also means information gained from the interviewees. In this case, then voices of health care practitioners are hoping to raise, this approach of categorization is agreed as most suitable to apply, because the actual content of the text is much richer than it could be predicted in advance. The qualitative content analysis presents wider understand to date and more information than only it"s content [27].
Analysis of the data obtained during the research revealed the following main categories: General perception, Experience and knowledge, Process, Outcomes, Final evaluation establishing health care practitioners experience in prescribing culture process, attitudes and related practise. Practitioners identified different perceptions of social project culture prescription.

Category
General perception of cultural prescription Subcategories Art therapy, Entertainment, Charity It was established that health care practitioners equate cultural prescription to art therapy, that itself associated to medical terminology and health. Cultural involvement in Lithuania is related to art therapy because of being most known term as a term but not by its meaning.

-D: "<…> not unnecessarily various art therapies occur, so <…> Cultural Prescription also exist".
However, this assign deeper understanding of cultural events and health interrelation, because another understanding as entertainment and charity supports an idea, that health care practitioners do not recognise health and cultural event interaction as medically important. Association with entertainment informs us that because of access to the cultural event health care practitioners automatically ascribe it as entertainment without any medical willingness.

-D: "<…> it is beneficial for everyone to have fun sometimes". 6 -D: "<…> culture cannot harm people <…>, it is good that this project exist". so exist".
An expression of charity also responds to cultural events and health interrelations acknowledgement.
3 -D: "<…> if social status is high, <…> they do not need for this charity".

-N: "<…> those who like <…> this charitable initiative makes them very happy <…>".
Thus, information was found as important due to present how the health care practitioners perceived this project. First category revealed three interpretations of the one phenomenonculture prescription. Many causal indicators can be behind these different perceptions ( Table 2). Obtained direct or indirect experience, scientific knowledge or even absence of interest gained during lifetime may influence presumption of a phenomenon as well as disclose surrounding circumstances of health care practitioner"s perception of Cultural Prescription. It was established that most often health care practitioners mentioned art therapy practises as direct experience of culture and health most relevant to the prescribed culture. In this order seems more meaningful, that health care practitioners who had direct experience tend to associate Cultural prescription with art therapy. Health care practitioners also indicated Cultural Prescription as a first social project that they were involved as a part of implementers" team. Although they knew about familiar initiatives, they had limited experience of culture applications in their working environment. It was also established, that only a minority (n=2) have encountered with scientific literature.

-D: "<...> I remember at the study times I had a course about art therapies for mental disorder patients". 10 -N: "Had to take interest in the scientific literature, because I had to write internship assignments, and there was much to do on this topic".
Interviewees who stated about scientific literature had less than ten years working practice, which also means that studies were graduated later. Time aspect is relevant to be mentioned because in Lithuanian context exist significant differences between the decades due to countries historical development as well as art therapy as a source of cultural engaged social projects. It stresses the importance of the research, to highlight health care practitioner"s attitudes and perceptions because health care system is the one that needs to be convinced about the worth to join forces. Moreover, interviewees perception on Cultural prescription are varied as well as their experience and interest are various, which naturally concludes, that current state of knowledge influence the perception of the subject and process of its realization. It was established, that process may vary from fail to succeed and also can be neglected (Table 3). Table 3. Domains of Culture prescription"s process.

Category
Process Sub-category Neglect, Fail, Succeed Prescribing cultural prescription is more complex and liable process than it may seem. Complexity depends on bothpatients and health care practitioners sides. Research revealed that health care practitioners neglected cultural prescriptionsconceptually appropriate patient came to owns doctor, not necessarily, one gets a cultural prescription. Neglect occurs via the complexity of reasons. First, established is a low level of project popularity between patientsit leads to an absence of patients recall about a possibility to get a cultural prescription, which, according to health care practitioners would be helpful. Also when a person is unaware of the project, it becomes more time consuming to answer all questions and explain all information. Second is the requirement of firmly scheduled health care and patient appointment. It was even more problematic if practitioner once had a practise when patient refused or it took too long to prescribe cultural prescription, practitioners enthusiasm about process reduces. Health care practitioner"s efforts were necessary to reach this number equally as they had to strive for every patient to get pleasure and benefits from this project. Research revealed that health care practitioners had experienced positive emotions among their workloads and rush that indicate mutual outcomes, for practitioners and patients. Established emotional, social and economic subcategories that reflect findings (Table 4). Was established that prescribed culture play a role in patient"s social life and increase their social welfare.
According to the research, emotional, social and economic factors consist of Prescribed culture outcomes. Successful cases incurred practitioners"good emotions because of being the one who could make patient pleased.
1 -N: "<...> they are really happy about it". Simultaneously patients provided positive emotions when received cultural prescription. Emotions are important to daily life because it allow people feel better in daily routine and easier to access social networks. Moreover, relationships are important with those people or networks that can provide emotional or material support for people: patients, who received Cultural prescription, noticed health care practitioner friendly and favourable themselves and noticed relations as important. Social factor is equally important, because importance of being in society and communicating to other people are agreed indicators of quality of life between scholars [18,19]. Established relation of Cultural prescription with economic factor: linking possibility to save money for those people, who were generally attending cultural events as well as for those who postponed their attendance due to a shortage of money. Considering, that Cultural prescription as socially engaging project has positive influence on improving social relations, activating social participation and so reducing social isolation, made it important to evaluate and generalize this social project in general. To reach this, advantages and disadvantages (Table 5) were aimed to gain information about what is done right and what may be improved in the future due to pursuit the best version of the project. Advantages and disadvantages were asked to identify only for cultural prescription as a social project by nature not its outcomes on patient"s health or QoL. Two tickets free of charge allow the patient to take a company together which increases emotional and social ties between close persons. Therefore, enable less determined patients, who do not like to participate in active initiatives also gain social project benefits. That means that this method of providing cultural benefits is more suitable for individuals who are not determined to take part in active cultural initiatives. Limited repertoire, agency between health care institutions and cultural events and timing were established as disadvantages.
1 -N: "<...> cannot choose those concerts <...> limited choice <...>" 2 -N: "<...> that they have to go to pick up their ticket 9 -N: "<...> question of time should be considered <...>". List of possible cultural institutions or events did not respond to everyone who gave cultural prescription needs. Informants highlighted that prescribing direct tickets to cultural events could be more productive, especially for those, who received cultural prescription more than once. Thus, opposition to intermediaries is linked to time consuming to patients and health care practitioner simultaneously. Therefore, health care practitioners stressed, that type should be considered in advance.

Conclusion
Cultural involvement of patients means an active or passive their participation, as within models of social engagement individuals undertake part and through practical projects provide a rich recourse for development community wellbeing. Study present health care practitioner"s attitude toward socially engaged cultural project "Cultural prescription" where chronically ill patients together with medical prescription received tickets to cultural events in order to improve their health, social relations, and quality of life.
Although the current study poses some limitations, to the authors knowledge this is the first research examining the health care practitioner"s perspective of such social engaged cultural projects in Lithuania. The findings of study suggest that health care practitioners do not deny benefits of attending culture, but also do not recognize it as capable to have medical significance. The meaning health care practitioners gave to social project Cultural prescription depends on their personal interest in a subject as well as knowledge and experience.
Considering organizational disadvantages and displeasure at occupied time founded, generally health care practitioners have a positive attitude toward this particular initiative for their patients. Following the success of the project took one additional year with corrections based on research results that made project run easier for health care practitioners. The current study and project were presented at the stakeholder"s conference where it made a discussion toward cooperation health care and cultural sectors for a common welfare of the residents. It was jointly agreed that Cultural prescription plays a role for improvement of health, social relationships, social participation and QoL in general and makes influence at community level through reducing social isolation, and increasing social connections also promotes interpersonal interactions.