Bygren, Konlaan and Johansson, 1996

As part of the 1982–3 Swedish Survey of Living Conditions, 12,982 randomly selected individuals aged 16–74 were interviewed about their (passive) attendance at, and (active) engagement in, both individual and social cultural activities. A total of 6,301 men and 6,374 women (97.64 percent of the original sample) were followed up to 31 December 1991, and it was found that 533 men and 314 women died during this period. Taking survival as the main outcome measure, this study used a proportional hazards model to estimate the risk of mortality. The impact of three independent indices was then studied. These were: an attendance index (including cinema, theatre, concerts, art and other exhibitions/museums, sermons and sporting events, the latter of which was analysed separately), a reading index (books/periodicals) and a music-making index (including choral singing). Frequency of attendance was categorised as rarely, occasionally or often, the latter of which (at least 80 visits per year) became the reference group. Potential confounders included were: age, gender, education level, income, long-term disease, social networks, smoking and exercise.

Age, smoking, disease and exercise influenced survival in the expected directions. By contrast, educational level was not found to be an important confounder with respect to mortality, whereas income level was. For men, the possession of a social network was a slight risk factor; for women, the opposite pattern was observed. After adjusting for all of the confounders, it seemed that people attending cultural events occasionally were more at risk of dying than those attending either seldom or often, those attending least found to have a 60% higher risk of death. This led the authors to speculate that ‘Perhaps cultural participation underlies some of the notorious social class differences in survival’ (p. 1580). Nonetheless, no causal conclusion could be drawn. Rather, the study acknowledged that the social element of cultural participation might be an important determinant of survival, suggesting that ‘Perhaps cultural behaviour is so intermingled with life as a whole that it is impossible to discern its influence’ (p. 1578). In terms of follow-up, the team recommended scrutiny of large samples with well-controlled confounders and well-differentiated cultural activities.

The team highlighted some of the flaws in the research design, including the crudeness of the original dataset and the frequency measures derived therefrom, which were lacking in qualitative detail. They also acknowledged possible reverse causation, with disease determining attendance, and it took account of residual confounding, particularly in relation to educational level. Beyond this, the three independent indices – attendance, reading and music-making – enabled a distinction to be made between passive and active and between individual and collective forms of engagement. However, in combining so many forms of attendance within each index, differentiation between art forms and between cultural and sporting or religious events was lost.

Speculating on the possible mechanisms through which cultural participation might improve survival rates, the authors commented that increased self-reflexivity and vicarious emotional arousal might lead to changes in the nervous and immune systems, via innervation of the lymphatic organs, the release of growth hormones and prolactin or the production of neurotransmitters possessing immunological resonance, thereby improving physical health. In relation to psychological health, it was thought that environmental enrichment might increase glucocorticoid receptors in the hippocampal region of the brain, implying a positive impact upon depressive diseases.

Lars Olov Bygren, Boinkum Benson Konlaan and Sven-Erik Johansson, ‘Attendance at Cultural Events, Reading Books or Periodicals, and Making Music or Singing in a Choir as Determinants for Survival: Swedish Interview Survey of Living Conditions’, British Medical Journal, 313, 21–28 December 1996, pp. 1577–80.


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