Objectives - To investigate the possible influence of attendance at
cultural events, reading books or periodicals, making music or singing in a choir as
determinants for survival.
Design - A simple random sample was drawn of 15
198 individuals aged 16-74 years. Of these, 85% (12 982) were interviewed by trained
non-medical interviewers between 1982 and 1983 about cultural activities. They were followed
up with respect to survival until 31 December 1991.
Setting - Swedish
interview survey of living conditions comprising a random sample of the adult Swedish
population.
Subjects - 12 675 people interviewed between 1982 and 1983.
Main outcome measures - Survival of subjects after controlling for eight
confounding variables: age, sex, education level, income, long term disease, social network,
smoking, and physical exercise.
Results - 6301 men and 6374 women were
followed up; 533 men and 314 women died during this period. The control variables influenced
survival in the expected directions except for social network for men; a significant
negative effective was found when the analysis was made separately for men and women. We
found an influence on mortality when the eight control variables were controlled for in
people who rarely attended events compared with those attending most often, the relative
risk being 1.57 (95% confidence interval 1.18 to 2.09).
Conclusion - Attendance at cultural events may have a positive influence
on survival. Long term follow up of large samples with confounders that are well controlled
for and with the cultural stimulation more highly specified should be used to try to falsify
the hypothesis before experiments start.
Introduction
The importance of
stimulating activities is obvious, and there is hardly any need for medical arguments for
attending a theatre, cinema, or sports events, for reading books and periodicals, or for
making music. Cultural activity might be thought to increase resistance to a broad spectrum
of diseases or be the impetus to start dealing with problems.
The mechanism for a
positive effect could perhaps be that it is inspirational for handling everyday social
problems, thus enhancing people's reflection on their life situation and enabling them to
prepare for coming events in their mind. More importantly, such activity provides direct
vicarious emotional arousal without damage or side effects in real life. And we know that
the organism responds with changes in the humoral nervous system-for example, verbal
expression of traumatic experiences through writing or talking improves physical health,
enhances immune function, and is associated with fewer medical visits.(1) In addition,
other gains have been documented in the therapeutic use of music in the treatment of
autistic children,(2) as well as the treatment of cancer and other related
pain.(3) (4) Pictures of works of art have been used to stimulate older
people.(5) Negative effects of cultural activities could be that people lose their
sense of reality and identify with asocial models of behaviour and are themselves encouraged
towards asocial behaviour.(6) (7)
Many of the selective factors determining
attendance at different kinds of events are correlated with survival. Educational level is
one such factor. Furthermore, disease itself influences the ability to take part in
activities and the kinds of activities possible to pursue. Attending cultural events widens
a social network and gives the feeling of belonging to a group, and this in itself could be
the important determinant of survival. Perhaps cultural behaviour is so intermingled with
life as a whole that it is impossible to discern its influence. We investigated the possible
influence of cultural stimulation on survival.
Subjects and methods
A simple
random sample was drawn of 15 198 people aged 16-74 years. Of them, 12 982 people (85%) were
interviewed by non-medical interviewers between 1982 annd 1983 in the Swedish annual survey
of living conditions,(8) which is an interview survey conducted on a random sample of
about 8000 people a year. It covers several components of living conditions such as health,
economic resources, education, employment, and housing. In the years 1982-3 the interview
went into some depth about leisure time activities. Those interviewed were followed up for
survival until 31 December 1991. Risks per person year at each year of follow up were
computed. The interviews were mainly conducted in the interviewees' homes, but about 11%
were telephone interviews.
Overall, 307 people were excluded from the analyses because
they gave only partial responses about leisure time activities, leaving 12 675 (83%) for our
analysis. The interviewees were not aware of our interest in the relation between leisure
time activities and health. In all, 847 respondents, who were aged 16-74 at the time of the
interviews, died during the follow up. Background covariates used for control were age, sex,
educational level, income, disease prevalence, social network, smoking, and physical
exercise. One independent variable was constructed out of attendance at various cultural and
sports events such as cinema, theatre, concerts and live music, art exhibitions, other
exhibitions or museums, sermons, or sports events. Another variable was an index based on
the reading of books or periodicals. The third independent variable reflected making music
and singing in a choir.
Age was controlled for in 10 year age bands. Educational level
was described as at least college level (>12 years at school) or at least high school level
(10-12 years at school). The reference group was those having only a primary education (less than or equal to9
years at school).
The income variable used was the disposable income per adult person in
the family, children being weighted less. Three income levels in approximate quartiles were
contrasted against the lowest (up to about $5400). One question on social network and
support was used to distinguish those who did or did not have weekly contacts with a near
friend outside the family (with whom they could talk about anything). Long term disease,
handicap, complaints after an accident or other ailments were used to distinguish those who
did or did not have such a problem. Exercise was measured with two questions on frequency of
exercise either outdoors or indoors. This was dichotomised into exercise at least once a
month and exercise less often.
As the dose-response of smoking for total mortality is
grossly linear, we classed smokers from their answers to the questions posed into sizeable
and equal groups for men and women. This grouping was accomplished by the smokers being
classified into two groups-namely, smoking up to 15 g and 10 g of tobacco a day for men and
women respectively and those who smoked more. Non-smokers, including former smokers, were
chosen as the reference group. The above variables were all seen as
confounders.
Our three independent variables were an attendance
index, a reading index, and a music-making index. The cultural events attendance index was
constructed from attending a cinema, theatre, concert and live music, museum, art
exhibition, sermon, or sports events as a spectator. The number of visits at each of these
seven kinds of events was classified into four classes, with more than 20 visits per year
giving four points. These scores in points were used to classify the cohorts into two low
use groups (<9 points and 9-12 points). The most active group scored more than 12 points,
making at least 80 visits per year, and constituted the reference group.
The second
independent variable was constructed out of the questions about reading books or
periodicals. Two classes of low active readers were contrasted against a reference group of
those reading books or periodicals at least once a week. The third independent variable
index was constructed out of questions on how often the respondent played music or sang in a
choir, and they were dichotomised into those doing either at least "now and then" and
those doing it less often than "now and then." The dependent variable was mortality after
the interview. The cohort was followed up till 31 December
1991.
A proportional hazards model was
used to estimate relative risks and 95% confidence intervals.(9) The proportional
hazards model's assumption was analysed by inspecting the log of the negative log of
survival curves for parallelism, which they showed. Furthermore, age stratification resulted
in the same estimates as including age in the model. Analysis of the first five and second
four years separately resulted in roughly the same estimates. The null hypothesis was tested
for the model and variables with the chi (2) test using the Wald criterion.
Results
In total, 6301 men and 6374 women aged 16-74 years at the interview in
1982-3 were followed up for survival until the end of 1991; 533 men and 314 women died
during the period. The total person years at risk for both sexes was about 111 000 years.
Table 1 shows the distribution of the different variables and numbers of deaths and risk
years.
| Table 1 - Distribution of variables and numbers of deaths and risk years |
| Variable |
Percentage (n = 12 675) |
No of deaths |
No of risk years |
| Sex: |
| Female |
50.1 |
314 |
56 329 |
| Male |
49.9 |
533 |
54 690 |
| Age (years): |
| 16-44 |
56.0 |
77 |
65 027 |
| 45-64 |
30.5 |
306 |
32 595 |
| 65-74 |
13.5 |
464 |
13 397 |
| Education (years): |
| <9 |
41.8 |
532 |
45 729 |
| 10-12 |
41.6 |
254 |
46 730 |
| >12 |
16.6 |
59 |
18 560 |
| Disposable income: |
| Low |
22.3 |
162 |
25 616 |
| Fairly low |
24.1 |
324 |
26 534 |
| Moderate |
26.8 |
205 |
99 801 |
| High |
26.8 |
156 |
29 068 |
| Social network: |
| Weekly contact with friends |
59.0 |
420 |
65 888 |
| Seldom has contact/no friends |
41.0 |
427 |
45 132 |
| Long term disease: |
| Yes |
37.7 |
629 |
40 199 |
| No |
62.3 |
218 |
70 821 |
| Smoking: |
| No smoking |
68.9 |
529 |
76 883 |
| 1-15 g/day* |
12.6 |
141 |
13 851 |
| >15 g/day* |
18.4 |
175 |
20 285 |
| Exercise: |
| Inactive |
51.0 |
681 |
55 119 |
| At least once a month |
49.0 |
166 |
54 691 |
| Reading books or periodicals: |
| Rarely |
26.7 |
316 |
29 370 |
| Occasionally |
29.0 |
232 |
32 322 |
| At least once a week |
44.3 |
299 |
49 327 |
| Making music: |
| Sometimes |
20.2 |
104 |
22 769 |
| Rarely |
79.8 |
743 |
88 251 |
| Attending cultural events: |
| Rarely (7-8 points) |
23.6 |
399 |
24 941 |
| Occasionally (9-12 points) |
53.0 |
381 |
59 392 |
| Often (>12 points) |
23.5 |
67 |
26 687 |
| *Women 1-10 g/day and >10 g/day. |
Of the control variables, age, smoking, long term disease, and exercise had an
influence in the expected directions. As the influence of education on survival has long
been known, it was included as a confounder. In the seven dimensions of our analysis the
influence of education was not significant in the final model, although income was. Income
and education might be correlated, and we investigated the importance of this correlation
for our analysis. When we removed income, education did not influence survival, but when
education was removed the influence of income was still significant. It seems, therefore,
that education is not an important confounder. To control for social circumstances from the
generation before, the father's occupation was introduced in the model; but the results
hardly changed at all. For men having a social network was a slight risk factor, and for
women a lack of a social network was a slight risk factor. The interaction was analysed and
found to be of no importance for the coherence of cultural consumption and survival.
Fig 1 - Estimated survival of people attending cultural events often, occasionally, or rarely. Eight confounders were controlled for (age, sex, weekly contacts with close friends, education, income, long term disease, smoking and physical exercise)
The
above mentioned variables are seen here as confounders; our focus of interest was on
cultural stimulation measured by our three indices: attendance at events, reading, and
making music. We found an influence on mortality when we controlled our seven control
variables for rare attendance at events and a trend towards influence for occasional
attendance compared with often attending events. Relative risks were 1.57 (95% confidence
interval 1.18 to 2.09) and 1.24 (0.95 to 1.63) respectively (table 2, fig 1). As some of the
sports events included in attendance at events might be negatively socioeconomically skewed,
going to sports events was analysed separately. The risk ratio was 0.86 (0.72 to
1.02).
| Table 2 - Relative risks for mortality (95% confidence intervals) in proportional hazards models* |
| Variable |
Model 0 |
Model 1 |
| Education (years): |
|
|
| 9 and under |
1 Reference |
1 Reference |
| 10-12 |
0.80 (0.68 to 0.93) |
0.92 (0.79 to 1.08) |
| >12 |
0.57 (0.43 to 0.75) |
0.93 (0.68 to 1.26) |
| Disposable income: |
|
|
| Low |
0.88 (0.73 to 1.06) |
0.85 (0.70 to 1.03) |
| Fairly low |
1 Reference |
1 Reference |
| Moderate |
0.76 (0.64 to 0.91) |
0.82 (0.68 to 0.98) |
| High |
0.60 (0.49 to 0.73) |
0.73 (0.59 to 0.90) |
| Social network: |
|
|
| Weekly contact with friends |
1.06 (0.93 to 1.22) |
1.10 (0.96 to 1.26) |
| Seldom has contact/ no friends |
1 Reference |
1 Reference |
| Long term disease: |
|
|
| Yes |
2.28 (1.94 to 2.67) |
2.10 (1.78 to 2.46) |
| No |
1 Reference |
1 Reference |
| Smoking: |
|
|
| No smoking |
1 Reference |
1 Reference |
| 1-15 g/day** |
1.96 (1.62 to 2.36) |
1.76 (1.45 to 2.12) |
| >15 g/day** |
1.83 (1.53 to 2.18) |
1.69 (1.42 to 2.02) |
| Exercise: |
|
|
| Inactive |
1 Reference |
1 Reference |
| At least once a month |
0.60 (0.50 to 0.72) |
0.78 (0.65 to 0.94) |
| Reading books or periodicals: |
|
|
| Rarely |
1.41 (1.20 to 1.65) |
1.05 (0.88 to 1.25) |
| Occasionally |
1.13 (0.95 to 1.34) |
0.94 (0.79 to 1.14) |
| At least once a week |
1 Reference |
1 Reference |
| Making music: |
|
|
| Sometimes |
0.77 (0.63 to 0.94) |
0.89 (0.72 to 1.10) |
| Rarely |
1 Reference |
1 Reference |
| Attending cultural events: |
|
| Rarely (7-8 points) |
2.38 (1.83 to 3.09) |
1.57 (1.18 to 2.09) |
| Occasionally (9-12 points) |
1.60 (1.24 to 2.08) |
1.24 (0.95 to 1.63) |
| Often (>12 points) |
1 Reference |
1 Reference |
| *Model 0 was adjusted for sex and age (in 10 year bands) with one variable at a time; model 1 was adjusted for sex, age (age span 16-74), education, disposable income, social network, long term illness, smoking, exercise, reading books or periodicals, making music, and attending cultural events. **Women 1-10 g/day and >10 g/day |
Discussion
Our results show that people attending cultural events
seem to live longer than those who attend rarely. Our analysis of the influence of cultural
stimulation, however, took advantage of a standard of living study that was not originally
designed for such a purpose. Therefore the frequencies of visits or activities could be seen
as only crude measures of such stimulation because the emotional responses to or perceptions
of the visits are unknown. Much of the culture may not give inspiration for handling the
everyday problems of life. Neither will it stimulate the immune system or whatever other
mechanisms might influence mortality. Some films and television programmes are suspected to
stimulate violence instead.(6) (7) These objections are obviously valid, and the
to ignore them risks not detecting true influences of cultural stimulation. Many of the
confounders were crudely measured. Long term disease was measured with only one question in
the interview and social network with only two. It would have been of benefit if the
dependent variables, the classification of low and high consumers of cultural stimulation,
had been conformed among the three indices; but this was not possible with the data at hand.
The reference group of the index for visits to cultural events could be viewed as
extreme. The people in this group attended events at least 80 times a year-more than every
fourth day. Perhaps they were extremely healthy, and therefore the index possibly measures
only an active-passive personality trait responsible for the covariation we found. However,
they comprised nearly a quarter of the sample, and physical exercise was among the
confounders we controlled for. We could have anticipated a more distinct influence in the
groups that were more active making music or singing in a choir than in the more passive
activities; perhaps this grouping was not homogeneous enough. Going to some sports events
could be negatively socioeconomically skewed, but we could not find a negative influence on
survival of this unspecified variable when we controlled for other factors.
Possible
Confounding
All available cultural indicators covered in the whole sample were used and
so no more were examined with respect to mortality. The hypotheses were expressed
beforehand. The modelling of confounders was made by one of us (LOB), who was not familiar
with what data were available All but alcohol consumption were covered by the data. As
smoking was among the control variables, alcohol use probably was indirectly controlled for
to a great extent. Alcohol consumption among men might lie behind the negative influence on
mortality of a social network, but the influence of social network on mortality was anyhow
negligible in both sexes. The interaction was furthermore of no importance for the coherence
of attending events and survival. Analysis of data showed that not attending cultural events
influenced mortality, possibly in a dose-response manner. This result was also seen after
controlling for age, sex, education, income, social network, long term disease, smoking, and
physical exercise-that is, most of the confounders that are controlled for in this type of
study. It is important to remember, however, that the effect of attending cultural events
was attenuated in the latter model. It is conversely interesting to see that the crude
relative risk, only controlled for age, did not change much when the whole model was applied
as regards the variables of disease, smoking, and physical exercise; the influences of the
variables education and disposable income were less robust in this respect. Perhaps cultural
stimulation underlies some of the notorious social class differences in survival.
Possible Mechanisms
The mechanisms may be immunoregulatory.(10) One route
linking the brain to the immune system is the innervation of lymphoid organs, another is the
outflow of pituitary hormones. The nerve fibres form junctions with lymphatic organs and
release neurotransmitters that lymphocytes, macrophages, and granulocytes have receptors
for. Growth hormones and prolactin enhance immunity; glucocorticoids may protect from
autoimmune disease. The interaction may provide the means by which emotional states
influence infections and autoimmune and neoplastic disease.(11)
There might be
other routes of influence. The number of glucocorticoid receptors in the hippocampus is
increased by environmental enrichment,(12) and this could be important in depressive
diseases.(13) But how the physical matter in the brain causes subjective states is
still a mystery.(14)
Theatre has historically been widely used in European
psychiatry,(15-18) and in the United States,(19) and similar effects perhaps can
be expected in the public theatre. Attending sports events is sometimes dramatic and could
have medical effects.(20)
| Key messages |
| Attendance at cultural events, reading, and listening to or making music may influence a person's wellbeing, but little is known about the influence of cultural activities on other measures of health
When other determinants of survival were controlled for, this study found that people attending cultural events often had a better chance of survival than those attending rarely
Education unexpectedly had no significant influence on survival when other variables were controlled for
Long term follow up of large samples with confounders that are well controlled for may provide empirical eveidence to support experiments on the effects of cultural stimulation on people not attending events |
Conclusions
We conclude that this is probably a
fruitful line of research. Long term follow up of large samples in which confounders are
well controlled and the types of cultural stimulation are well specified should be used to
try to falsify the hypothesis before experiments start.
Funding: No external funding.
Conflict of interest: None.
Department of Social Medicine,
University of Umea,
S-901 85 Umea,
Sweden
Lars Olov Bygren,
head of department
Boinkum Benson Konlaan,
research assistant
Swedish Central Bureau of Statistics,
115 81 Stockholm,
Sweden
Sven-Erik Johansson,
senior statistician
Correspendence and
requests for reprints to: Professor Bygren.
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