European paintings at Metropolitan Museum of Art (NYC, USA); Wikimedia Commons, André Lage Freitas

This British Medical Journal study* explored whether receptive arts engagement could have protective associations with survival. We analysed the longitudinal relation between receptive arts engagement and mortality across a 14 year follow-up period in a nationally representative sample of adults aged 50 and older. Results showed a dose-response relation: risk of dying at any point during the follow-up period among people who engaged with cultural activities on an infrequent basis (once or twice a year) was 14% lower than in those with no engagement; for those who engaged on a frequent basis (every few months or more), the risk was 31% lower. The association was independent of all identified confounders, was found across all major causes of death, and was robust to a wide range of sensitivity analyses.

This study had several strengths. We used a nationally representative sample of older adults, applied data linkage to national mortality data, and included a comprehensive list of identified confounders. However, several limitations exist. Firstly, this study was observational, and although we took a number of additional steps to try and test the assumptions of models, causality cannot be assumed. It remains possible that unidentified confounding factors could account for the associations found. However, our E value** suggests that such unmeasured confounders would need to have a considerable effect to account for the associations found. Secondly, most of our data were based on participant self report (eg, existing clinical diagnoses of health conditions), so data might be affected by self report bias. However, participants were unaware of the specific hypothesis of this study. Relatedly, there could be measurement error and misclassification (especially for categorical variables) in our confounders that might result in our analyses not being fully adjusted and leaving residual confounding. Thirdly, in our analyses on cause of death, we focused on four major categories, but owing to insufficient power it remains unclear how results differed for specific subsets of cause of death.

Our results build on previous broad literature on leisure activities and mortality, and more specifically, on the findings from two previous analyses of Scandinavian data. However, our study extends these findings in three key ways. Firstly, the results show the association in another national population. Recognised cross cultural differences exist in the consumption and value of receptive arts engagement, therefore the replication of results in a different country is important because it suggests the association is not confined to one particular cultural context. Secondly, we found no evidence of moderation by sex. Previous research suggests that men and women are affected differently by protective factors. For example, daily reading has been associated with survival in men but not women,  while leisure participation broadly has been found only to be beneficial in men. However, another previous study found that receptive arts engagement was the only leisure activity that did not appear to show a differential survival association by sex. Our study supports this finding and showed no moderating effect and similar protective associations for men and women.

Thirdly, our study identified some of the potential factors that could act as mechanisms that underpin the protective association with mortality. Part of the association is attributable to differences in socioeconomic status among those who do and do not engage in the arts, which aligns with research that suggests engagement in cultural activities is socially patterned. However, the association remains independent of socioeconomic status, so this does not fully explain the association. Some of the other factors that accounted for part of the association included mental health and cognition. This finding is consistent with research that shows that receptive arts engagement can help in preventing and managing depression, and that it can provide support in preventing cognitive decline and in developing cognitive reserve. Our results are also consistent with research that suggests poor mental health and lower cognition can be barriers to engaging in arts activities. Similarly, other social and civic engagement explained some of the association, which ties in with well known literature on social activity and mortality. However, this study also showed that the association is independent of all of these factors, and over half of the association remains unexplained.

When considering what could explain this remaining association, research has suggested that arts engagement builds social capital, which improves people’s access to knowledge and resources, and could help with successful ageing. Further possibilities are that arts engagement improves a sense of purpose in life, helps with the regulation of emotions and thereby enhances coping, supports the buffering of stress, and builds creativity, which improves people’s ability to adapt positively to changing life circumstances. The potential mediating role of these factors remains to be explored further in future studies.