Cultural services and activities: The association with self-rated health and quality of life

Abstract

Background: Previous studies have shown that cultural participation has a positive effect on health and well-being. The aim of this study was to analyse how use of cultural services and participation in cultural activities is associated with self-rated health (SRH) and quality of life (QOL), using validated outcome measurements and key socio-demographic factors. Methods: The study data are drawn from the Regional Health and Well-being Study conducted in 2010 in Finland. (N = 31,000, response rate 48%). The data analysed in this paper consist of 11,905 respondents. Results: Logistic regression models adjusted for key socio-demographic factors showed that use of cultural services was associated with good SRH and good QOL. Also, associations were found between the practice of cultural activities and good SRH and QOL. However, the associations between activities and SRH and QOL were somewhat weaker. Conclusions: Use of cultural services and practicing cultural activities seem to have a positive association with SRH and QOL. Providing citizens with cultural services and activities can be seen as a silent social policy that has the potential to improve SRH and QOL. Further studies with a longitudinal design are needed to examine the causality.

Keywords::

• cultural participation
• cultural activities
• cultural services
• self-rated health
• quality of life

Introduction

Participating in cultural activities has been shown to have a positive effect on self-rated health (SRH) in general populations (Cuypers et al., 2012; Johansson, Konlaan, & Bygren, 2001) as well as in elderly populations (Nummela, Sulander, Karisto, & Uutela, 2009; Nummela, Sulander, Rahkonen, & Uutela, 2008). The association has shown to persist even when health and lifestyle factors such as smoking, drinking, obesity and chronic illness are taken into account (Cuypers et al., 2012; Nummela et al., 2008). Participation in cultural activities is also associated with good quality of life (QOL) (Cuypers et al., 2012; Kim & Kim, 2009) and longer survival (Hyyppä, 2007; Hyyppä, Mäki, Impivaara, & Aromaa, 2006). More specific health and survival outcomes of cultural participation include, for example, reduced levels of stress hormones and lower blood pressure (Konlaan, 2001), lower anxiety and depression (Cuypers et al., 2012), and lower cancer-related mortality (Bygren et al., 2009). However, in certain studies, cultural activities only showed a small impact on QOL, when satisfaction obtained from the activities and also satisfaction on other domains of life were considered (Michalos, 2005; Michalos & Kahlke, 2008, 2010).

It has also been discussed that the positive health and well-being outcomes of cultural participation are mediated by social capital, as for example by education and social relationships (Hyyppä, 2013; Hyyppä & Liikanen, 2005). It has been found that having hobbies, using cultural services, being active and participating is more common among highly educated people (Viitanen, 1999) and people with high socio-economic status (Cuypers et al., 2012).

The aim of this study was to investigate how cultural participation is associated with SRH and QOL when adjusting for key socio-demographic background variables. Both use of cultural services and practice of cultural activities are considered. The outcome variables in this study are constructed of highly validated measurements. SRH is a common health estimate in population studies (Heistaro, Laitikainen, et al. 2001) and has shown to predict possible future health problems (Mailer, Kristensen, & Hollnagel, 1996; Weinberger et al., 1986). Poor SRH has shown to be a strong predictor of mortality in Finnish studies, and the association is only partly explained by medical history, cardiovascular disease risk factors and education (Heistaro, Jousilahti, Lahelma, Vartiainen, & Puska, 2001b).

QOL is a multidimensional construct that refers to subjective well-being and life satisfaction by definition. The WHOQOL-group defines QOL as an “individual's perception of their position in life within the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns”. QOL is measured by asking individuals how they feel about their life in terms of psychological and physical factors, purpose in life, sense of belonging and environmental resources (Schmidt, Mühlan, & Power, 2005; WHOQOL Group, 1998a, 1998b).

SRH has been utilised in prior studies examining the effects of cultural participation (Cuypers et al., 2012; Johansson et al., 2001; Michalos, 2005; Michalos & Kahlke, 2008; 2010; Nummela et al., 2008, 2009), but the measures for QOL have been more diverse and mostly considered a general overall satisfaction with life. In the present study, there is a unique possibility to benefit from using two validated outcome measures. Moreover, the sample size in this study is large, consisting of 11,905 respondents across different age groups.

Materials and methods

Study-design and Data

This study uses data from the Regional Health and Well-being Study conducted in 2010 in Finland. The questionnaire was sent to 31,000 persons over the age of 20 in Turku (N = 9,000), the regions of Kainuu (N = 9,000) and Northern Ostrobothnia (N = 8,000), and a representative sample of the whole of Finland (N = 5,000). Three versions of the questionnaire were prepared for the age groups 20–54, 55–74 and 75+ in four languages Finnish, Swedish, Russian and English. Information on the respondent's main language was obtained from Population Register Centre (VRK), and this information was used in selecting the language of the questionnaire that was mailed to the respondent. The overall response rate was 48% and the data used in this paper consists of 11,905 respondents who had complete answers in questions measuring participation in cultural services and activities.

A stratified random sampling design was applied. Furthermore, each geographical stratum was subdivided by gender and age groups 20–74 years and 75–99 years. The sampling fractions ranged between 0.1% (younger age groups in the whole of Finland) and 48.6% (older women in the northern Kainuu region). The population sizes were rather small in most of the strata, and thus the sampling was without replacement (WOR). As the sampling fraction was relatively high (up to 48.6%) in some strata, finite population correction (FPC) was incorporated in the analyses. In order to correct for the low response rate, the data were weighted.

Cultural Services and Activities

Cultural participation was measured by two sets of questions. The first one covered use of cultural services. The respondents were asked “How often have you used the following cultural services over the past 12 months?” Eight cultural services were covered: (1) theatre, dance, circus or other performing arts, (2) concert of classical music, (3) concert of popular or rock music, (4) museum or art exhibition, (5) library, (6) cinema, (7) spectator at sports or fitness event and (8) spectator at some other event. The response alternatives were in 4-point-scale (1 or more times per week – not at all during the past 12 months).

Second, the respondents were asked: “Do you yourself practice any of the following cultural activities?” The covered activities were: (1) writing (literature, blogs), (2) reading (not related to profession), (3) music (listening, playing an instrument or singing), (4) acting (amateur drama, etc.), (5) painting, drawing or other visual art, (6) crafts and other practical skills, (7) photography or video and (8) other, please specify. The response alternatives followed a 4-point-scale (3 or more times per week – not at all during the past 12 months).

A total of 6,444 respondents of 14,799 had marked the category “other” and 485 respondents had specified the activity. A thorough recoding was performed in this item, but mostly the specification only added information about the activity that the respondents already had marked in items 1–7. In 10 cases, marking in one of the ordinary items was changed to more frequent following the additional specification. The item “crafts” was recoded to also include different kinds of craftworks often mentioned by male respondents in the category “other”, e.g. repairing old cars or motors.

The associations between cultural participation and outcome variables were first tested separately for each item of cultural services and activities. In prior studies, different cultural items have often been combined to form indices (see e.g. Cuypers et al., 2012; Nummela et al., 2009). Indices were likewise constructed for the present study (see “The Indices of Cultural Services and Activities”).

Outcome Variables

SRH was asked with the question “How would you describe your state of health at present?”, with response alternatives on a 5-point-scale “good”, “rather good”, “moderate”, “rather poor” and “poor”; responses were dichotomised to “good or rather good” versus “moderate or worse” SRH. The question is an item from SF-36 Health Survey version 2, which is a widely utilised survey relying on patient self-reporting used to explain variation in patient outcomes (http://www.rand.org/). In the logistic regression models, the outcome variable is good or rather good SRH.

QOL was measured with EUROHIS-QOL-8, which consists of two items from each domain of the original WHOQOL-BREF (physical, psychological, environmental and social). The overall QOL score is formed by a simple summation of the scores of the eight items, with higher scores indicating better QOL. All responses are on a 5-point Likert scale, ranging from “not at all” to “completely” (Schmidt et al., 2005).

Each respondent's total points in the EUROHIS-QOL-8 were calculated and compared to the mean score of all the respondents. The use of the mean score in EUROHIS-QOL-8 is a common practice also utilised in other studies (eg. da Rocha, Power, Bushnell, & Fleck, 2012; Power, 2003; Skevington, Lotfy, & O'Connell, 2004; WHOQOL Group, 1998b). In the logistic regression models, the outcome variable is a EUROHIS-QOL-8 total score higher than the average.

Control Variables

Age was assessed with register data from the Population Register Centre (VRK) and the variable was categorised into three age groups: (1) 20–54 years, (2) 55–74 years and (3) 75 years and older. Marital status was assessed with register data (VRK) and dichotomised as persons married/in a registered relationship (category 1) and persons cohabiting, separated/divorced, widowed or single (category 2). Family type was dichotomised as families with two or more persons (category 1) and single households (category 2).

The level of education was based on register data from Statistics Finland (TK), and categorised as primary or unknown, secondary and tertiary level education. Main activity was dichotomised as working or elderly retired persons (category 1) and persons in other situations (part-time retirement, unemployed/laid off, studying, housewife/-husband/homemaker/family leave, long-term sick leave/disability pension, switch leave/other1) forming the other category.

Results

Descriptives

In total, 5,269 men and 6,636 women had provided complete answers to each of the cultural service and activity items (i.e. no missing items). Characteristics of the respondents are shown in Table 1. Rather good or good SRH (hereafter referred as “good SRH”) was slightly more usual among women than among men (64% vs. 61%). Women also rated their QOL better than average slightly more often than men (58% vs. 55%). Measurements of the central tendency and skewness in the SRH and QOL are shown in Table 2.

Table 1 Socio-demographic characteristics and SRH and QOL in participants in the ATH-study. (n = 11,905)

	Men (n = 5,269)		Women (n = 6,636)
	N	%	N	%
Age groups
19–54	2490	68.2	3346	65.1
55–74	1953	26.4	2139	27.3
75-	826	5.4	1151	7.6
Marital status
Married/in a registered relationship	3262	49.0	3339	45.2
Other	1993	51.0	3286	54.8
Family type
Two or more persons	3995	72.4	4468	69.6
Single household	1199	27.6	2061	30.4
Education
Lowest	1933	36.3	2470	37.6
Middle	1659	34.8	2012	31.9
Highest	1538	28.9	1964	30.5
Main activity
Working/retired (old age)	3164	66.9	3827	65.7
Other	1223	33.1	1592	34.3
Perceived health
Rather good or good	2783	61.3	3777	64.1
Moderate – poor	2424	38.7	2775	35.9
EUROHIS-QOL-8
Higher than average	2877	54.6	3773	57.5
Lower	2392	45.4	2861	42.5

Table 2 Measurements of central tendency and skewness in SRH and QOL.

	Male	Female
Perceived health	(n: 5207)	(n: 6552)
Mean	2.45	2.37
Median	2.00	2.00
Standard deviation	1.01	1.01
Skewness	0.31	0.43
EUROHIS-QOL-8	(n: 5269)	(n: 6634)
Mean	2.13	2.12
Median	2.00	2.00
Standard deviation	0.62	0.62
Skewness	0.67	0.75

Use of different cultural services and activities is shown in Table 3. The table shows the most popular cultural services to be library and cinema for both men and women. In Finland, the public library network is very comprehensive, so the availability of free-of-charge library services is good in all regions. Libraries have many services, including books, magazines, newspapers, reading rooms, PCs, music, dvds and games, for both adults and children. In the use of other cultural services, few differences were seen according to gender. However, men were more active in going to sports events than women, whereas women more often went to theatre or classical concerts than men. The most popular cultural activities were music and reading for both men and women, and photography/video for men and crafts for women.

Table 3 Use of different cultural services and practicing of activities in men and women. (%) (N = 11 905).

Men (n = 5269)					Women (n = 6635)
Services	≥ 1 times a week	1–3 times a month	A few times in the year	Not in past 12 months	≥ 1 times a week	1–3 times a month	A few times in the year	Not in past 12 months	Pearson p-value
Theatre/dance	3.2	2.2	35.3	59.3	1.6	3.6	50.0	44.8	0.00#
Classical concert	4.5	0.9	12.3	82.3	1.9	1.8	20.8	75.5	0.00#
Pop/rock concert	3.2	3.5	32.6	60.7	2.0	2.4	37.2	58.4	0.00#
Museum/art	3.4	1.9	27.9	66.8	1.8	2.7	36.4	59.1	0.00#
Library	9.6	21.3	32.9	36.2	9.5	32.8	32.4	25.3	0.00#
Cinema	2.6	8.0	44.6	44.8	1.6	10.7	48.4	39.3	0.00#
Sports event	5.0	9.7	34.9	50.4	3.2	4.6	26.8	65.4	0.00#
Other event	3.9	1.9	31.4	62.8	2.2	1.8	39.3	56.7	0.00#
Activities	≥ 3 times a week	1–2 times a week	1–3 times a month	Not in past 12 months	≥ 3 times a week	1–2 times a week	1–3 times a month	Not in past 12 months	Pearson p-value
Writing	2.2	1.4	4.9	91.5	1.8	2.0	6.8	89.4	0.01#
Reading	27.1	15.3	28.3	29.3	40.6	17.5	28.5	13.4	0.00#
Music	39.9	19.2	18.5	22.4	45.0	21.5	18.5	15.0	0.00#
Acting	1.1	0.2	0.6	98.1	0.5	0.2	0.7	98.6	0.01#
Painting	2.5	1.6	6.6	89.3	2.4	2.7	10.1	84.8	0.00#
Crafts	4.3	5.6	18.3	71.8	15.1	10.6	28.4	45.9	0.00#
Photo/video	3.7	6.0	24.0	66.3	3.3	6.2	25.2	65.3	0.56

Note: #p < 0.05.

Use of cultural services and participation in cultural activities was also analysed by key socio-demographic factors. Age categories of 20–54 years, 55–74 years and 75 years or older were analysed, where the oldest group was the least active in using cultural services. Compared with their youngest counterparts, only attending classical concerts was as frequent for both groups. The oldest group was also the least active in the activities of music, painting and photography/video.

Comparing married and non-married respondents, the married more often attended the theatre, cinema and sports events and did more crafts. However, the non-married more often went to pop concerts or to the cinema and did more writing, music and painting.

Households' size had an impact on the use of cultural services: households including at least two persons more often attended the theatre, library and sports events than single households. They also practiced more photography/video than the single households, whereas writing was more common among the single households.

For education categories, the lowest educated were the least active group in using cultural services and practicing activities, except in the case for acting and crafts. Analysed by respondent's main activity, those who were not working or retired by age more often attended the library, or did writing, music and painting, while going to the theatre, classical concerts, sports events or other cultural events was more common among the working group.

The distribution of use of cultural services and participation in activities across the background variables is shown in Tables A1 and A2.

Associations Between Cultural Services, Cultural Activities, SRH and QOL

To test for associations between different cultural services and activities and SRH and QOL, logistic regressions were used for each service and activity item separately. Due to small cell proportions in the categories in frequent use/activity, the items were categorised as 0 = no usage/activity in past 12 months (reference category, OR = 1) and 1 = use/activity in past 12 months. The results are shown in Table 4. Altogether, 12 items were positively associated with both SRH and QOL: all items of cultural services and items reading, music, crafts and photography of activities. In activities, the item painting was only associated positively and significantly with SRH and the item crafts with QOL. However, the association between crafts and SRH was positive, so the item was included to the analyses. The item painting was rare, only practiced by 11% of men and 15% of women, and negatively associated with QOL, so it was not included in the analyses.

Table 4 Associations of items of cultural service use and cultural activities with SRH and QOL (EUROHIS-QOL 8 item index).

	Self-rated health rather good or good		EUROHIS-QOL 8 item index better than average
	Use in past 12 months	95% confidence interval	Use in past 12 months	95% confidence interval
Theatre/dance	1.63^#	1.48–1.80	1.71^#	1.55–1.89
Classical concert	1.37^#	1.21–1.55	1.63^#	1.45–1.85
Pop/rock concert	1.81^#	1.63–2.01	1.31^#	1.18–1.45
Museum/art exhibition	1.51^#	1.36–1.67	1.44^#	1.30–1.60
Library	1.70^#	1.53–1.88	1.20^#	1.08–1.33
Cinema	2.50^#	2.27–2.76	1.62^#	1.47–1.78
Sports event	1.62^#	1.47–1.79	1.48^#	1.34–1.64
Other event	1.36^#	1.23–1.50	1.40^#	1.26–1.54
	Activity in past 12 months	95% confidence interval	Activity in past 12 months	95% confidence interval
Writing	1.14	0.96–1.36	0.76^#	0.64–0.90
Reading	1.31^#	1.16–1.47	1.30^#	1.15–1.46
Music	1.73^#	1.54–1.94	1.22^#	1.09–1.37
Acting	0.77	0.52–1.13	0.75	0.51–1.10
Painting	1.23^#	1.05–1.44	0.72^#	0.62–0.84
Crafts	1.05	0.96–1.16	1.13^#	1.02–1.24
Photography/video	1.37^#	1.24–1.52	1.12^#	1.01–1.24

Notes: Logistic regression with odds ratios and 95% confidence intervals. ^# p < 0.05. Reference category = no service use/activity in past 12 months (OR = 1).

The Indices of Cultural Services and Activities

To build indices of cultural participation, a factor analysis was performed for the items that were positively associated with both SRH and QOL. In rotated (Varimax rotation) factor analysis, two factors were spontaneously extracted. The first factor included all eight items of cultural services. The second factor included the items reading, music, crafts and photography/video. Thus, two indices were built: one index of cultural services and one of cultural activities. The results of the factor analysis are shown in Table 5.

Table 5 Rotated factor analysis of items of cultural services and activities.

	Factor 1	Factor 2
Museum/art exhibition	0.727	0.198
Classical concert	0.715
Pop/rock concert	0.714
Other event	0.714	0.108
Theatre/dance	0.692	0.109
Cinema	0.662
Sports event	0.575
Library	0.390	0.340
Reading		0.735
Music		0.544
Crafts		0.321
Photography	0.167	0.247

The means for both indices were between index scores 4 and 5, so the chosen cutting point for the indices was 4. Thus, one of the categories consists of the respondents using services/practicing activities more than average (in the table “Proportion of observations with an index score of 5 or higher (%)”) and the other category of the respondents using services/practicing activities up to the average or less (in the table “proportion of observations with an index score of 0–4 (%)”). Crohnbach's α was used to analyse the internal consistency and reliability of each formed index. (see e.g. Santos, 1999). For the index of services, Crohnbach's α was very high, 0.84. For the index of activities, the α was 0.51. To examine the effect of dropping the negatively associated items in the index of activities, an α was also calculated for an index including all the seven original items. The α for this index was 0.57. Thus, the reliability of the index was not weakened by dropping the negatively associated items. The characteristics of the built indices are shown in Table 6.

Table 6 Characteristics of the indices of cultural services and cultural activities. (N = 11 905)

	Min/max	Mean	Proportion of observations with index score 0–4 (%)	Proportion of observations with index score 5 or higher (%)	Crohnbach's α for the index
Index of services^a	0/24	4.7	54.2	45.8	0.84
Index of activities^b	0/12	4.2	54.8	45.2	0.51

a Items theatre/dance, classical concert, pop/rock concert, museum/art exhibition, library, cinema, sports event, other event.

b Items reading, music, crafts, photography/video.

The Analyses

As the socio-demographic factors discussed in the “Descriptives” section seemed to correlate with cultural participation, it was decided to use them as control variables in the final regression models examining associations between cultural participation and the outcome variables (SRH and QOL). Logistic regressions at a 0.05 significance level for the indices were performed with the control variables entered stepwise. The reference category in cultural services and activities is “use/activity up to average or less” (OR = 1). The regression models, odds ratios and 95% confidence intervals are shown in Table 7.

Table 7 Odds ratios (OR) and 95% confidence intervals for good SRH and QOL by sum indices of cultural services and cultural activities.

Good self-rated health
Cultural services^a	Model 1		Model 2		Model 3		Model 4
	OR	95 % CI	OR	95 % CI	OR	95 % CI	OR	95 % CI
Use up to average/less	1		1		1		1
Use more than average	2.07#	1.87–2.29	2.06#	1.86–2.28	1.81#	1.62–2.01	1.81#	1.62–2.01
	Model 5		Model 6		Model 7
	OR	95 % CI	OR	95 % CI	OR	95 % CI
Use up to average/less	1		1		1
Use more than average	1.81#	1.62–2.01	1.64#	1.47–1.83	1.57#	1.39–1.77
Cultural activities^b	Model 1		Model 2		Model 3		Model 4
	OR	95 % CI	OR	95 % CI	OR	95 % CI	OR	95 % CI
Activity up to average/less	1		1		1		1
Activity more than average	1.26#	1.14–1.39	1.24#	1.12–1.37	1.26#	1.14–1.40	1.26#	1.14–1.40
	Model 5		Model 6		Model 7
	OR	95 % CI	OR	95 % CI	OR	95 % CI
Activity up to average/less	1		1		1
Activity more than average	1.26#	1.13–1.40	1.19#	1.07–1.33	1.24#	1.10–1.39
Good quality of life
Cultural services^a	Model 1		Model 2		Model 3		Model 4
	OR	95 % CI	OR	95 % CI	OR	95 % CI	OR	95 % CI
Use up to average/less	1		1		1		1
Use more than average	1.66#	1.50–1.83	1.65#	1.49–1.82	1.67#	1.51–1.85	1.68#	1.52–1.86
	Model 5		Model 6		Model 7
	OR	95 % CI	OR	95 % CI	OR	95 % CI
Use up to average/less	1		1		1
Use more than average	1.68#	1.52–1.86	1.55#	1.40–1.73	1.48#	1.32–1.66
Cultural activities^b	Model 1		Model 2		Model 3		Model 4
	OR	95 % CI	OR	95 % CI	OR	95 % CI	OR	95 % CI
Activity up to average/less	1		1		1		1
Activity more than average	1.16#	1.05–1.28	1.14#	1.03–1.26	1.14#	1.03–1.26	1.14#	1.03–1.26
	Model 5		Model 6		Model 7
	OR	95 % CI	OR	95 % CI	OR	95 % CI
Activity up to average/less	1		1		1
Activity more than average	1.15#	1.04–1.27	1.09	0.99–1.21	1.09	0.98–1.22

Notes: #p <  0.05.

Model 1: Straight associations; Model 2: Adjusted for gender; Model 3: Adjusted for gender and age; Model 4: Adjusted for gender, age and marital status; Model 5: Adjusted for gender, age, marital status and family type; Model 6: Adjusted for gender, age, marital status, family type and education; Model 7: Adjusted for gender, age, marital status, family type, education and main activity

Reference category = use/activity up to average or less. (OR = 1)

a Items theatre/dance, classical concert, pop/rock concert, museum/art exhibition, library, cinema, sports event, other event.

b Items reading, music, crafts, photography/video.

Logistic regressions showed that more than average use of cultural services was positively associated with good SRH and the association was evident even when the control variables of gender, age, marital status, family type, education and main activity were entered in the model. Model 7 showed that the odds ratio was 1.57 for having good SRH for respondents who have used cultural services more than average; this is compared with an odds ratio for 1.00 for respondents who had used services up to average or less. The effect of more than average use of cultural services seemed to be lower on QOL than on SRH. The odds ratios for good QOL were lower than the odds ratios for good SRH. Nevertheless, the positive association between more than average use of cultural services and good QOL was evident even when the control variables gender, age, marital status, family type, education and main activity were entered into the model.

The associations between cultural activities and good SRH and QOL seemed to be weaker than the associations between cultural services and good SRH and good QOL. However, a positive association between more than average activities and good SRH was evident even when all of the control variables were entered into the model. The association between cultural activities and QOL did not persist when the control variables education and main activity were entered into the model.

Discussion

The main result of this study was that use of cultural services and involvement in cultural activities were significantly associated with good SRH. The association was evident even when gender, age, marital status, family type, education and main activity were controlled for. This result was expected and in accordance with previous research on the topic (Cuypers et al., 2012; Johansson et al., 2001).

Use of cultural services also had a significant association with good QOL. Also Kim and Kim (2009) found that cultural participation was associated with good QOL. However, the difference with the present study was that QOL was here measured multidimensionally,2 while in Kim and Kim it was assessed with two questions about satisfaction in life and happiness in general. In Michalos (2005), cultural activities only showed a small impact on QOL when satisfaction from other domains of life – partner, housing and finances – were taken into account. In the present study, the measurement of QOL also considered these aspects.

An interesting finding in this study was that not all cultural activities were positively associated with good SRH and QOL. In fact, writing and painting were negatively associated with good QOL. On the other hand, they were relatively unpopular activities too. Painting was slightly more common among women (15%) than among men (11%) and the same seemed to be true for writing (11% vs. 9%). Acting was very rare, only being reported by 1–2% of the respondents. Perhaps the lack of positive associations was due to the small amount of practitioners, or maybe acting, writing and painting are activities that are used to express or relieve negative feelings. In contrast, reading and music were very clearly positively associated with both good SRH and QOL. Thus, one might say that practicing these activities probably enhances SRH and QOL. Therefore, it can be considered important to make libraries and concerts available to citizens. A strength of this study was the relatively large data-set covering the general population. Further, validated outcome-measurements and a systematically constructed measurement of cultural participation were used. Regarding future studies, it would be interesting to examine whether the association between cultural service use and SRH remains when occurrence of chronic diseases, functional capacity and health behaviours such as smoking, drug use and nutritional habits are controlled for. A limitation of this study is the cross-sectional design that makes it impossible to make undisputable conclusions on causality. Especially when it comes to the SRH, it might be possible that people with limitations in health and functional capacity have difficulties in accessing cultural services. Another limitation of the study was the low response rate (48%) and the lack of complete answers in cultural items in 20% of the respondents. In order to correct for the effect of a low response rate, the data have been weighted. It is still possible that some selection bias remains such that healthy individuals have been more eager to participate in the study than those who have health problems.

A national follow-up is being carried out between 2013 and 2014, consisting of 150,000 persons. In the follow-up, the cultural participation measurement has been improved and extended based on experience provided by the 2010 data.3 During 2011, Turku was the capital of Culture and citizens gained access to many cultural services, events and activities. Turku was one of the regions in the data collected in 2010. It will be interesting to study the possible change in cultural participation and in the outcome variables in Turku compared to the other regions. Thus, with the broad national follow-up data, there will be a possibility to study the effects of this cultural intervention and to perform more thorough analyses of people's cultural participation, even separately for different age groups.

Conclusion

The main result of this study was that use of cultural services was significantly associated with good SRH and good QOL. Moreover, involvement in cultural activities was associated with good SRH and QOL, even though the associations were weaker than for use of services. Especially, the activities for reading and music were very clearly positively associated with both good SRH and QOL. Thus, one might say that practicing these activities probably enhances SRH and QOL. Therefore, it can be considered important to maintain and promote easy access to libraries and concerts for citizens. In a broader context, one can say that the results indicate that culture can be seen as a silent social policy that brings highlights in life and has the potential to improve health.

In further studies, it would be profitable to examine whether the association between cultural service usage and SRH remains when occurrence of chronic diseases, functional capacity and health behaviours such as smoking, drug use and nutritional habits are controlled for. Moreover, longitudinal studies are needed to study the causality of associations between cultural participation and SRH. In Finland, broad national follow-up data is being collected between 2013 and 2014, making it possible to study causality, differences in age groups and the effect of a significant cultural intervention that took place in Turku in 2011.

Notes

^1. Switch leave is a voluntary leave for 90–359 days during which an employee receives unemployment benefit and an unemployed person is hired as a substitute.

^2. In Eurohis-8 QOL is measured by asking individuals how they feel about their life in terms of different dimensions: psychological and physical factors, purpose in life, sense of belonging and environmental resources (WHOQOL Group, 1998a; 1998b; Schmidt, Mühlan, & Power, 2005)

^3. For example, new items have been created based on the answers in the activity category “other” in the 2010 data.

The Regional Health and Well-being Study was approved by the Ethics Review Board at the National Institute for Health and Welfare located in Helsinki.

Table A1

Use of different cultural services and practicing of activities according to age and education (%) (n = 11 905).

Age
	19–54 years (n = 5836)				55–74 years (n = 4092)				75- years (n = 1977)
Services	≥ 1 times a week	1–3 times a month	A few times in the year	Not in past 12 months	≥ 1 times a week	1–3 times a month	A few times in the year	Not in past 12 months	≥ 1 times a week	1–3 times a month	A few times in the year	Not in past 12 months	Pearson p-value
Theatre/dance	2.2	2.6	42.9	52.3	2.5	3.9	45.6	48.0	4.1	1.7	27.9	52.0	0.00^#
Classical concert	3.0	0.7	14.8	81.5	3.2	2.6	21.6	72.6	5.0	2.2	14.0	78.8	0.00^#
Pop/rock concert	2.0	3.9	42.8	51.3	3.3	1.2	22.2	73.2	5.2	0.2	6.3	88.3	0.00^#
Museum/art	2.4	2.2	32.5	62.7	2.7	2.3	33.6	61.3	4.5	1.4	22.6	71.5	0.00^#
Library	10.2	30.6	35.0	24.2	8.7	22.0	30.9	38.3	6.0	12.0	16.2	65.9	0.00^#
Cinema	1.6	12.5	54.0	32.0	2.8	3.7	36.0	57.5	4.7	0.8	13.8	80.7	0.00^#
Sports event	3.8	8.7	33.5	54.0	4.6	4.5	28.7	62.2	4.8	1.6	12.5	81.1	0.00^#
Other event	2.7	2.0	34.9	60.4	3.3	1.8	39.7	55.1	4.6	0.8	21.3	73.2	0.00^#
Activities	≥ 3 times a week	1–2 times a week	1–3 times a month	Not in past 12 months	≥ 3 times a week	1–2 times a week	1–3 times a month	Not in past 12 months	≥ 3 times a week	1–2 times a week	1–3 times a month	Not in past 12 months	Pearson p-value
Writing	2.0	1.9	6.4	89.6	1.9	1.2	5.2	91.8	2.5	1.8	3.1	92.6	0.00^#
Reading	28.8	17.4	31.9	21.9	41.4	15.1	23.6	19.9	54.4	11.2	12.0	22.4	0.00^#
Music	45.9	21.3	18.5	14.3	35.7	19.2	19.6	25.5	34.7	15.5	14.0	35.8	0.00^#
Acting	0.8	0.2	0.6	98.5	0.8	0.3	0.7	98.3	1.1	0.2	1.2	97.5	0.36
Painting	2.7	2.5	10.4	84.4	2.0	1.6	4.6	91.8	1.9	0.6	3.0	94.4	0.00^#
Crafts	6.8	7.4	24.9	60.9	15.9	10.2	21.6	52.3	14.6	7.0	15.1	63.3	0.00^#
Photo/video	3.6	7.1	27.1	62.1	3.6	4.7	22.7	69.1	1.8	1.4	7.4	89.5	0.00^#
Education
Lowest (n = 4403)					Middle (n = 3671)				Highest (n = 3502)
Services	≥ 1 times a week	1-3 times a month	A few times in the year	Not in past 12 months	≥ 1 times a week	1–3 times a month	A few times in the year	Not in past 12 months	≥ 1 times a week	1-3 times a month	A few times in the year	Not in past 12 months	Pearson p-value
Theatre/dance	2.8	2.0	32.0	63.3	2.6	2.7	43.2	51.5	1.7	4.2	56.2	37.9	0.00^#
Classical concert	3.7	0.4	9.7	86.3	3.0	0.8	14.8	81.4	2.8	3.0	27.3	66.8	0.00^#
Pop/rock concert	3.1	2.2	28.9	65.8	2.4	3.1	37.9	56.6	2.0	3.8	40.2	54.0	0.00^#
Museum/art	3.1	1.3	19.7	75.9	2.7	2.0	31.6	63.7	1.8	3.8	48.9	45.5	0.00^#
Library	8.1	21.5	29.8	40.5	9.6	27.7	33.9	28.7	11.3	33.5	35.6	19.5	0.00^#
Cinema	2.4	7.0	38.5	52.1	2.2	9.6	49.2	39.0	1.6	12.4	54.5	31.6	0.00^#
Sports event	4.4	6.3	27.5	61.8	4.3	8.9	32.4	54.4	3.4	6.5	33.5	56.7	0.00^#
Other event	3.7	1.3	26.5	68.5	2.9	1.7	37.6	57.7	2.3	2.7	44.3	50.7	0.00^#
Activities	≥ 3 times a week	1–2 times a week	1–3 times a month	Not in past 12 months	≥ 3 times a week	1–2 times a week	1–3 times a month	Not in past 12 months	≥ 3 times a week	1–2 times a week	1–3 times a month	Not in past 12 months	Pearson p-value
Writing	1.5	1.4	3.3	93.8	2.1	1.5	6.0	90.4	2.6	2.4	9.2	85.9	0.00^#
Reading	28.8	14.7	27.4	29.1	32.7	17.0	29.4	20.9	41.4	17.9	28.7	12.0	0.00^#
Music	39.9	18.7	17.1	24.3	43.6	20.8	19.0	16.6	44.8	21.8	20.3	13.2	0.00^#
Acting	0.7	0.2	0.7	98.5	1.0	0.2	0.5	98.2	0.7	0.3	0.8	98.3	0.59
Painting	2.4	2.0	7.0	88.6	2.6	2.1	8.5	86.8	2.3	2.5	10.0	85.3	0.06
Crafts	10.3	8.3	21.9	59.5	9.5	7.6	22.9	59.9	8.9	8.6	26.1	56.4	0.01^#
Photo/video	2.9	5.0	19.9	72.2	4.0	5.9	25.1	65.0	3.7	7.8	30.4	58.1	0.00^#

Note: ^# p <  0.05.

Table A2 Use of different cultural services and practicing of activities according to marital status, family type, and main activity (%) (N = 11 905).

Marital status
Married/in a registered relationship (N = 6,601)					Other (N = 5,279)
Services	≥ 1 times a week	1–3 times a month	A few times in the year	Not in past 12 months	≥ 1 times a week	1–3 times a month	A few times in the year	Not in past 12 months	Pearson p-value
Theatre/dance	1.9	2.6	46.5	49.0	2.8	3.1	39.4	54.8	0.00#
Classical concert	2.6	1.4	18.4	77.6	3.8	1.3	14.8	80.1	0.00#
Pop/rock concert	2.2	1.4	31.3	65.0	2.9	4.3	38.1	54.7	0.00#
Museum/art	2.3	1.5	33.3	62.9	2.9	3.0	31.0	63.2	0.00#
Library	7.4	28.5	34.3	29.8	11.5	25.8	31.2	31.5	0.00#
Cinema	1.8	5.8	45.8	46.8	2.3	12.3	47.3	38.0	0.00#
Sports event	3.9	6.9	32.8	56.5	4.2	7.3	29.1	59.4	0.02#
Other event	2.4	1.7	36.6	59.3	3.5	1.9	34.1	60.4	0.01#
Activities	≥ 3 times a week	1–2 times a week	1–3 times a month	Not in past 12 months	≥ 3 times a week	1–2 times a week	1–3 times a month	Not in past 12 months	Pearson p-value
Writing	1.8	1.3	4.9	92.0	2.2	2.1	6.8	89.0	0.00#
Reading	35.7	16.2	27.4	20.8	32.4	16.4	29.2	22.0	0.04#
Music	35.0	21.4	21.5	22.1	48.9	19.4	16.0	15.8	0.00#
Acting	0.5	0.2	0.7	98.6	1.0	0.3	0.6	98.1	0.08
Painting	1.8	1.4	6.3	90.5	3.0	2.8	10.2	84.0	0.00#
Crafts	10.8	8.7	23.6	56.9	8.8	7.6	23.2	60.3	0.00#
Photo/video	3.4	6.6	25.3	64.7	3.5	5.5	24.1	66.8	0.16
Family type
2 or more persons (N = 8463)					Single household (N = 3260)
Services	≥ 1 times a week	1–3 times a month	A few times in the year	Not in past 12 months	≥ 1 times a week	1–3 times a month	A few times in the year	Not in past 12 months	Pearson p-value
Theatre/dance	2.1	2.5	44.7	50.6	3.1	3.6	37.7	55.5	0.00#
Classical concert	2.8	1.0	16.6	79.6	4.2	2.0	16.3	77.4	0.00#
Pop/rock concert	2.3	2.3	35.9	59.5	3.4	4.3	33.0	59.3	0.00#
Museum/art	2.3	2.0	32.1	63.6	3.3	2.8	32.8	61.1	0.02#
Library	8.4	27.8	34.6	29.2	12.2	25.7	28.5	33.7	0.00#
Cinema	1.8	8.7	48.8	40.7	2.9	11.1	41.8	44.3	0.00#
Sports event	3.9	7.7	32.8	55.7	4.5	5.9	26.2	63.4	0.00#
Other event	2.7	1.7	35.7	59.9	3.8	2.2	34.4	59.7	0.11#
Activities	≥ 3 times a week	1–2 times a week	1–3 times a month	Not in past 12 months	≥ 3 times a week	1–2 times a week	1–3 times a month	Not in past 12 months	Pearson p-value
Writing	1.8	1.4	5.3	91.4	2.5	2.4	7.1	88.0	0.00#
Reading	32.6	16.5	29.2	21.7	37.1	15.8	26.4	20.7	0.00#
Music	39.1	21.3	20.4	19.2	50.7	18.0	14.3	17.1	0.00#
Acting	0.7	0.2	0.6	98.5	1.1	0.3	0.8	97.8	0.22
Painting	2.3	2.1	7.9	87.8	2.8	2.3	9.3	85.5	0.17
Crafts	9.2	8.3	24.0	58.5	10.8	7.8	21.6	59.8	0.03#
Photo/video	3.5	6.5	25.8	64.2	3.6	5.1	22.2	69.2	0.00#
Main activity
Working/retired (old age) (N = 6991)					Other (N = 2815)
Services	≥ 1 times a week	1–3 times a month	A few times in the year	Not in past 12 months	≥ 1 times a week	1–3 times a month	A few times in the year	Not in past 12 months	Pearson p-value
Theatre/dance	2.3	3.0	47.7	46.9	2.1	2.9	36.2	58.8	0.00#
Classical concert	3.0	1.5	18.2	77.3	3.2	0.9	14.2	81.7	0.00#
Pop/rock concert	2.4	2.6	38.3	56.7	2.3	4.2	34.7	58.7	0.01#
Museum/art	2.6	1.6	33.8	62.0	2.2	3.7	31.1	62.9	0.00#
Library	7.3	26.9	35.7	30.2	14.7	31.1	30.2	24.1	0.00#
Cinema	1.8	8.8	50.6	38.9	2.0	12.4	46.1	39.6	0.00#
Sports event	4.1	7.8	34.1	54.0	3.7	7.0	28.4	60.9	0.00#
Other event	2.8	1.7	39.1	56.4	3.1	2.3	31.1	63.4	0.00#
Activities	≥ 3 times a week	1–2 times a week	1–3 times a month	Not in past 12 months	≥ 3 times a week	1–2 times a week	1–3 times a month	Not in past 12 months	Pearson p-value
Writing	1.6	1.3	5.1	92.0	2.7	2.5	8.0	86.8	0.00#
Reading	33.0	16.3	29.6	21.2	31.6	17.5	29.4	21.5	0.61
Music	38.7	21.4	21.1	18.7	51.3	19.4	14.4	14.8	0.00#
Acting	0.6	0.2	0.7	98.5	1.2	0.3	0.4	98.2	0.03#
Painting	1.7	1.5	7.0	89.9	4.1	3.8	12.3	79.8	0.00#
Crafts	9.3	8.8	23.5	58.4	9.4	7.2	24.8	58.6	0.20
Photo/video	3.0	5.6	26.8	64.6	4.7	8.2	24.3	62.9	0.00#

Note: #p <  0.05.