Patterns of receptive and creative cultural activities
and their association with perceived health, anxiety,
depression and satisfaction with life among adults:
the HUNT study, Norway
Turid Lingaas Holmen,
Margunn Skjei Knudtsen,
Lars Olov Bygren,
Background Cultural participation has been used both in
governmental health policies and as medical therapy,
based on the assumption that cultural activities will
improve health. Previous population studies and a human
intervention study have shown that religious, social and
cultural activities predict increased survival rate. The aim
of this study was to analyse the association between
cultural activity and perceived health, anxiety, depression
and satisfaction with life in both genders.
Methods The study is based on the third
population-based Nord-Trøndelag Health Study
(2006e2008), including 50 797 adult participants from
Nord-Trøndelag County, Norway. Data on cultural
activities, both receptive and creative, perceived health,
anxiety, depression and satisfaction with life were
collected by comprehensive questionnaires.
Results The logistic regression models, adjusted for
relevant cofactors, show that participation in receptive
and creative cultural activities was signiﬁcantly
associated with good health, good satisfaction with life,
low anxiety and depression scores in both genders.
Especially in men, attending receptive, rather than
creative, cultural activities was more strongly associated
with all health-related outcomes. Statistically signiﬁcant
associations between several single receptive, creative
cultural activities and the health-related outcome
variables were revealed.
Conclusion This population-based study suggests
gender-dependent associations between cultural
participation and perceived health, anxiety, depression
and satisfaction with life. The results support hypotheses
on the effect of cultural activities in health promotion and
healthcare, but further longitudinal and experimental
studies are warranted to establish a reliable
Previous population studies
and a human inter-
have shown that religious, social
and cultural activities predict increased survival rate
and good health.
A challenge for research is the inconsistent
concept of culture. Unesco has deﬁned the concept
of culture enclosing not only art or literature, but
also lifestyle, including physical activity, ethics,
human rights and spiritual convictions.
studies emphasise the importance of cultural
capital in the distribution of health.
In his review on the biomedical effects of art
introduced the term creative
cultural activities. In creative cultural activities, the
individuals are actively engaging in a creative
process, typically singing, playing an instrument or
painting. Creative cultural activities include also
social activities such as clubs, parish work and
various physical challenging cultural activities. On
the other hand, according to the study of Turpin,
receptive cultural activities might be activities
where the individuals are receiving some kind of
impressions or experiences without self-doing.
Typically, receptive cultural activities are visiting
museums, art exhibitions, concerts or theatres.
Thus, in the present study, cultural activity is
divided into receptive and creative activity.
Only a few studies have included leisure-time
physical activity in the concept of culture. It has
rather been used as a confounder.
According to the
General Social Survey in 1993,
we choose to
deﬁne physical leisure-time activities in the present
study as cultural activities.
The concept of health is not consistent. Research
has mostly focused on the relationship between
physical activity and other cultural activities and
accordance with Unesco’sdeﬁnition of health,
might also be important to explore the associations
between cultural activities and anxiety and
depression, and between cultural activities and
satisfaction with life (SWL).
Despite the positive association between cultural
activity and health in some studies, there are still
many gaps in the knowledge of cultural activity
and its impact on health.
In this large population-based Nord-Trøndelag
Health (HUNT) Study, cultural activity and a large
number of health factors were measured.
best of our knowledge, no previous study has
examined the relationship between participation in
receptive and creative cultural activities, and
perceived health (PH), anxiety (Anx), depression
(Dep) and SWL. The aim of this study was there-
fore to analyse such associations with a focus on
possible gender differences.
MATERIAL AND METHODS
The data were drawn out from the HUNT Study,
a population-based study of the Nord-Trøndelag
County, Norway. Nord Trøndelag County
(n¼130 000) has a homogenous population and has
Nord-Trøndelag Health Study
Research Center, Levanger,
Department of Public Health
and General Practice, Faculty of
Medicine, Norwegian University
of Science and Technology,
Nord-Trøndelag Health Trust,
Department of Health
Department of Bioscience and
Nutrition, Karolinska Institutet,
Department of Community
Medicine and Rehabilitation,
Nord-Trøndelag Health Study
Research Center, Norwegian
University of Science and
Technology, Skjesol Østre,
˚senfjord 7632, Norway;
Accepted 24 March 2011
Cuypers K, Krokstad S, Lingaas Holmen T, et al.J Epidemiol Community Health (2011). doi:10.1136/jech.2010.113571 1 of 6
a geographical, demographical and occupational structure fairly
representative of the whole of Norway, though lacking a large
The average income and mean educational level are
slightly lower than the national average. The socio-economic
inequality in mortality in the region is at the national level.
The third survey of the HUNT study (HUNT 3) was
performed in 2006e2008. All citizens in the county aged 13 and
older were invited for a health examination. In the present study,
the 50 797 adult participants (females: 27 754; males: 23 043)
aged 20 years and older were included (overall 54% response rate,
64% in the age groups 40e69). Data were collected by compre-
hensive questionnaires. Questionnaire 1, personally mailed to
each individual, contained three pages, including questions on
PH, physical and mental health, life habits and others (http://
www.hunt.ntnu.no/). The participants were requested to ﬁll in
questionnaire 1 prior to attending the screening site. Question-
naire 2, including questions about cultural participation, was
given to the attendants after the clinical examinations, asking
them to ﬁll in the questionnaire at home and return it by post.
Participants who completed both Q1 and Q2, and yielded valid
data for constructing indices for receptive and creative activities),
were included in the present study.
To compute the index for receptive cultural activities, 19 736
females and 15 937 males were included. To compute the index
for the creative cultural activities, 18 906 females and 15 494
males were included.
Receptive cultural participation was assessed by asking the
respondents in separate questions ‘How often in the last
6 months have you been to a museum or art exhibition,
a concert/theatre/ﬁlm, a church/chapel, sport-events?’The
response alternatives were for all: ‘more than three times
a month, 1e3 times a month, 1e6 times in the last 6 months, or
never.’For each cultural activity, the response alternative was
quantiﬁed with 1 (never) to 4 (more than three times a month).
Creative cultural activities were assessed by asking in separate
questions: ‘How many times in the last 6 months have you
participated in the following: an association activity or club
meeting, music/singing/theatre, parish work, outdoor activities,
dance, worked out/sports?’The response alternatives were:
‘More than once a week, once a week, 1e3 times a month, 1e5
times in the last 6 months, and never.’For each cultural activity,
the response alternative was quantiﬁed with 1 (never) to 5 (more
than once a week).
One index for the different receptive (range 4e16) and one for
the different creative (range 6e30) cultural activities were
computed by summing the score for each question. The indices
reﬂect the frequency of participation in the different cultural
Two additional indices were created by summing all different
activities (receptive and creative separately), which the respon-
dents had attended. These indices reﬂect the total number of
different receptive (range 0e4) and creative (range 0e6) cultural
activities in the last 6 months. A respondent who reported
attending all four receptive cultural activities obtained a score of
4, while a respondent who reported participation in all six
creative cultural activities obtained a score of 6.
Perceived health (PH) was assessed by the question, ‘How is
your health at the moment?’with the response alternatives:
‘very good,’‘good,’‘not so good’and ‘poor.’The variable was
dichotomised into one category (coded as 1) ‘very good’and
‘good’combined, and a second category (coded as 0) combining
‘not so good’and ‘poor.’
The distribution of PH was similar in those who responded
only to Q1 and those responding to both Q1 and Q2.
Satisfaction with life
Respondents were asked: ‘Thinking about your life at this
moment, would you say that you by and large are satisﬁed with
life, or are you mostly dissatisﬁed?’The response alternatives
were: ‘Very satisﬁed,’‘satisﬁed,’‘somewhat satisﬁed,’‘a bit of
both,’‘somewhat dissatisﬁed,’‘dissatisﬁed’and ‘very dissatis-
ﬁed.’The variable was dichotomised into the categories 1, ‘very
satisﬁed, satisﬁed and somewhat satisﬁed,’and 0, including ‘a bit
of both, somewhat dissatisﬁed, dissatisﬁed, very dissatisﬁed.’
The responses on SWL by the participants only in Q1 and
those in both Q1 and Q2 were similarly distributed.
Anxiety and depression
Anxiety and depression were measured in Q2 by the Hospital
Anxiety and Depression scale (HADS) (range 0e42). This was
divided into two subscales, HADS-A (anxiety) and HADS-D
(depression) according to previous studies.
Both scores for
depression and anxiety were recoded into low, 0 (rating 0e7),
and high, 1 (rating 8e42).
Other health variables
The respondents were asked whether they suffered from
a chronic disease which reduced their daily functioning (yes¼1,
no¼0) and whether they had any physical or emotional prob-
lems which limited their social life (Not at all/very little/some-
what/much/was not able to socialise). Physical leisure-time
activity was measured by asking. ‘How frequently do you exer-
cise?’1, 2e3 times/week or more, and 0, once/week or less.
Other variables included were daily smoking (1: no; 0: yes),
frequency of alcohol consumption (1: few times/year; 0: weekly).
Socio-economic status (SES) was measured reclassifying the ﬁrst
digit in the Norwegian occupation classiﬁcation (STYRK) into
an approximation to the Erikson Goldthorpe Portocarero social
(A: higher-grade professionals; B: lower-grade
professionals; C: non-manual employees; D: small proprietors; E:
artisans and farmers; F: lower-grade technicians, and unskilled
In separate models, a multiple univariate binary logistic regres-
sion was used to examine the relationships between each
cultural activity and the dependent variables (PH, SWL, anxiety/
depression), controlled for all relevant cofactors (age, SES,
health-related cofactors: chronic disease, limitation in social
contact; and other lifestyle cofactors: physical activity, daily
smoking, body mass index and alcohol consumption).
Multiple univariate binary logistic regression was used to
study the association between the receptive and creative cultural
indices, and PH, SWL and anxiety/depression. In the ﬁrst model,
the association was adjusted for age. In the second model, SES,
chronic disease and limitation in social contact were also added.
In the third model, all covariates, also including physical
activity, daily smoking, body mass index and alcohol, were
entered simultaneously to adjust for eventual confounding.
Gender-speciﬁc models were performed owing to signiﬁcant
interactions between gender and both indices for the receptive
and creative cultural activities in the different models. SPSS
version 16 was used.
2 of 6 Cuypers K, Krokstad S, Lingaas Holmen T, et al.J Epidemiol Community Health (2011). doi:10.1136/jech.2010.113571
In total, 17 932 women and 14 928 men had completed data on
both the receptive and creative variables. More men than women
reported good/very good PH and low anxiety, while depression
and SWL were distributed equally among genders (table 1).
Analyses showed that more people participated in creative
than in receptive cultural activities, and this was the case in
both genders, and all age- and SES groups. The participation (less
than once/month) in both receptive and creative cultural
activities was strongly age-dependent, increasing from the
youngest age group up to the age group 40e49, and then
successively decreasing by age. The participation decreased by
lower SES. A similar pattern was seen regarding participation in
the number of different cultural activities (data not shown).
Figure 1 (A and B) shows in more detail the association
between cultural participation and SES, illustrating that cultural
participation was especially high in the two highest SES groups
and in the young and middle-aged groups, while declining in the
oldest age groups and the lower SES groups.
Socio-economic groups are deﬁned into six scales from the
Erikson Goldthorpe Portocarera social class scheme: A, higher-
grade professionals, managers in large industrial establishments;
B, lower-grade professionals, higher-grade technicians, supervi-
sors of non-manual employees; C, non-manual employees,
higher and lower grade; D, small proprietors, farmers and self-
employed workers in primary production; E, lower-grade tech-
nicians, supervisors of manual workers and skilled manual
workers; F, unskilled workers, agricultural workers.
The descriptive data (table 2) revealed that the number of
participants reporting respectively good health, good satisfaction
with life, low anxiety and low depression increased in relation to
increasing number, and frequency of, participation in different
cultural activities. SWL, low anxiety and low depression showed
Single receptive and creative cultural activities
Fully adjusted univariate binary logistic regression models,
testing the single components of receptive and creative cultural
activities, revealed that for receptive cultural activities, only one
activity (attending a sport event) was associated with good/very
good health in women. In men, however, all receptive cultural
activities were statistically signiﬁcant associated with good/very
good health (table 3).
Active participation in creative cultural activities (association
activity or club meeting, music, singing, theatre, outdoor activi-
ties, dance and working out/sports) was associated with good/
very good health in women. In men, in contrast, participation in
parish work was signiﬁcantly associated with good/very good
health, in addition to participation in association meeting,
outdoor activities, dance and working out/sports (table 3).
Satisfaction with life
The following receptive cultural activities were associated with
good SWL: been to church, and sports event in women. In men,
attendance for all receptive cultural activities was signiﬁcantly
associated with good SWL (table 3). In women, the following
creative cultural activities were statistically associated with
Table 1 Participants in the third survey of the Nord-Trøndelag Health
Study (2006e2008) with complete answers on all questions about
receptive and creative cultural activity*
Female n: 17932 Male n: 14928
20e29 1732 10 977 7
30e39 2812 16 1752 12
40e49 3825 21 3040 20
50e59 4023 22 3746 25
60e69 3219 18 3225 22
70e79 1678 9 1666 11
80+ 643 4 522 4
Not so good/poor 4643 27 3339 23
Very good/good 12636 73 11116 77
High score 2284 13 1281 9
Low score 15140 87 13255 91
High score 1688 10 1482 10
Low score 15665 90 13030 90
Satisfaction with life
Bit of both/very dissatisﬁed 2365 13 1766 12
15207 87 12848 88
The variation in the number of respondents on perceived health, anxiety, depression and
satisfaction with life is due to missing data.
*Data shown are number and percentage of female and male respondents, distributed in age
groups and responses about perceived health, anxiety, depression and satisfaction with life.
Figure 1 Relationship age groups, socio-economic groups and amounts
of different receptive cultural activities in females (A) and males (B).
Cuypers K, Krokstad S, Lingaas Holmen T, et al.J Epidemiol Community Health (2011). doi:10.1136/jech.2010.113571 3 of 6
high SWL: participation in association meeting, music, singing,
theatre, outdoor activity, dance, and working out/sports. Men
who participated actively in association meeting, outdoor
activity, dance, workout and sports reported a signiﬁcantly
The receptive cultural activities been to museum, art exhibition,
concert, theatre, ﬁlm and sports events, in women, and all
receptive cultural activities, including been to church/chapel, in
men, were associated with low anxiety scores (table 3). In
Table 2 Cultural activities by perceived health, satisfaction with life, anxiety and depression in both
n: 31734, % n: 32185, % n: 31960, % n: 31866, %
Receptive cultural activities
1 activity/6 months 69.3 84.8 86.1 87.2
2 different activities/6 months 77.0 87.0 89.4 91.6
3 different activities/6 months 81.1 90.3 91.5 93.2
4 different activities/6 months 84.0 91.4 92.6 94.0
Creative cultural activities
1 activity/6 months 66.3 84.1 85.7 86.5
2 different activities/6 months 74.6 85.8 88.2 90.1
3 different activities/6 months 79.7 89.0 90.9 92.5
4 different activities/6 months 83.5 91.0 91.9 93.7
5 different activities/6 months 83.9 91.0 92.5 94.1
Index receptive cultural activities
Never 71.8 85.7 87.4 88.6
1e6 times/6 months 82.1 90.6 92.2 93.6
1e3 times/month 81.8 92.3 90.8 92.2
Index creative cultural activities
Never 68.1 84.8 86.5 87.2
1e5 times/6 months 81.4 89.4 91.1 92.9
1e3 times/month 85.5 91.4 93.3 94.4
Data shown are percentages reporting very good/good health, very satisﬁed/satisﬁed/somewha t satisﬁed with life, low anxiety score
(<8) and low depression score (<8), using the Hospital Anxiety and Depression scale.
Table 3 Associations between each receptive, creative cultural activity and good perceived health, good satisfaction with life, low anxiety and low
Good health Good satisfaction with life
Female Male Female Male
OR (95% CI) p Value OR (95% CI) p Value OR (95% CI) p Value OR (95% CI) p Value
Receptive cultural activity
Museum/art exhibition 1.10 (1.02 to 1.18) 0.11 1.14 (1.04 to 1.25) 0.005 1.02 (0.94 to 1.10) 0.67 1.10 (1.00 to 1.22) 0.05
Concert/theatre/ﬁlm 1.04 (0.98 to 1.11) 0.26 1.14 (1.06 to 1.22) 0.001 1.02 (0.95 to 1.09) 0.62 1.16 (1.06 to 1.26) 0.001
Church/chapel 1.01 (0.95 to 1.07) 0.79 1.11 (1.03 to 1.18) 0.003 1.20 (1.12 to 1.28) 0.0005 1.28 (1.19 to 1.39) 0.0005
Sports event 1.07 (1.02 to 1.13) 0.01 1.10 (1.04 to 1.16) 0.001 1.21 (1.15 to 1.29) 0.0005 1.29 (1.21 to 1.38) 0.0005
Creative cultural activity
Association/club meeting 1.09 (1.04 to 1.14) 0.0005 1.12 (1.08 to 1.18) 0.0005 1.17 (1.11 to 1.23) 0.0005 1.11 (1.06 to 1.17) 0.0005
Music/singing/theatre 1.07 (1.03 to 1.13) 0.002 1.01 (0.97 to 1.06) 0.60 1.06 (1.01 to 1.12) 0.01 1.00 (0.95 to 1.05) 0.96
Parish work 1.06 (0.98 to 1.16) 0.15 1.20 (1.07 to 1.34) 0.002 1.09 (0.99 to 1.20) 0.09 1.06 (0.95 to 1.19) 0.32
Outdoor activity 1.08 (1.05 to 1.12) 0.0005 1.12 (1.08 to 1.17) 0.0005 1.08 (1.04 to 1.12) 0.0005 1.06 (1.01 to 1.11) 0.01
Dance 1.14 (1.08 to 1.21) 0.0005 1.09 (1.02 to 1.18) 0.02 1.14 (1.07 to 1.21) 0.0005 1.12 (1.03 to 1.22) 0.01
Workout/sports 1.06 (1.03 to 1.10) 0.0005 1.13 (1.09 to 1.17) 0.0005 1.08 (1.04 to 1.11) 0.0005 1.08 (1.03 to 1.12) 0.0005
Low anxiety score Low depression score
Receptive cultural activity
Museum/art exhibition 1.09 (1.01 to 1.19) 0.03 1.13 (1.01 to 1.27) 0.03 1.13 (1.03 to 1.24) 0.01 1.33 (1.20 to 1.50) 0.0005
Concert/theatre/ﬁlm 1.14 (1.06 to 1.22) 0.0005 1.28 (1.16 to 1.41) 0.0005 1.21 (1.12 to 1.32) 0.0005 1.39 (1.27 to 1.52) 0.0005
Church/chapel 1.04 (0.97 to 1.10) 0.31 1.14 (1.04 to 1.25) 0.003 1.11 (1.03 to 1.19) 0.007 1.03 (0.95 to 1.11) 0.52
Sports event 1.18 (1.11 to 1.25) 0.0005 1.21 (1.12 to 1.30) 0.0005 1.10 (1.03 to 1.18) 0.006 1.11 (1.04 to 1.19) 0.002
Creative cultural activity
Association/club meeting 1.18 (1.12 to 1.24) 0.0005 1.16 (1.10 to 1.23) 0.0005 1.12 (1.06 to 1.19) 0.0005 1.18 (1.12 to 1.25) 0.0005
Music/singing/theatre 1.03 (0.98 to 1.08) 0.21 1.04 (0.98 to 1.10) 0.20 1.03 (0.98 to 1.09) 0.31 1.08 (1.02 to 1.15) 0.005
Parish work 1.05 (0.96 to 1.16) 0.29 0.98 (0.86 to 1.10) 0.69 1.06 (0.95 to 1.18) 0.34 1.07 (0.95 to 1.20) 0.29
Outdoor activity 1.09 (1.05 to 1.13) 0.0005 1.08 (1.03 to 1.13) 0.003 1.09 (1.04 to 1.14) 0.0005 1.09 (1.04 to 1.14) 0.0005
Dance 1.11 (1.05 to 1.18) 0.0005 1.07 (0.97 to 1.18) 0.16 1.10 (1.03 to 1.18) 0.005 1.06 (0.97 to 1.15) 0.20
Workout/sports 1.07 (1.04 to 1.11) 0.0005 1.10 (1.05 to 1.15) 0.0005 1.08 (1.04 to 1.12) 0.0005 1.11 (1.06 to 1.15) 0.0005
Data shown are adjusted OR and 95% CI from a logistic regression model relating each receptive and creative cultural activity to good health (1: very good, good; 0: not so good, poor), good
satisfaction with life (1: very satisﬁed, satisﬁed, somewhat satisﬁed; 0: bit of both, somewhat dissatisﬁed, dissatisﬁed, very dissatisﬁed), low anxiety score (1: low; 0: high), and low depression
score (1: low; 0: high). The models are adjusted for age, socio-economic status, chronic disease, limitation in social contact, physical exercise, daily smoking, body mass index and alcohol consume.
4 of 6 Cuypers K, Krokstad S, Lingaas Holmen T, et al.J Epidemiol Community Health (2011). doi:10.1136/jech.2010.113571
women, participation in association meetings, outdoor activi-
ties, dance and working out/sports were signiﬁcantly associated
with low anxiety scores. Men, participating in association
meetings, outdoor activities and working out/sports reported
lower anxiety scores.
Attendance for each individual receptive cultural activity was
signiﬁcantly associated with low depression scores in women.
In men, three receptive cultural activities (been to museum/
exhibition, been to concert, theatre, ﬁlm and sports event) were
associated with low depression scores. Women who participated
in association meetings, outdoor activity, dance and working
out/sports reported lower depression scores. In men, partici-
pating in association meetings, music, singing, theatre, outdoor
activity and working out/sports was signiﬁcantly associated
with lower depression scores (table 3).
Indices of cultural activities
In both women and men, both indices of receptive cultural
activities and creative cultural activities were signiﬁcantly
associated with good health, good SWL, low anxiety and low
depression after adjusting for all confounders (table 4). At ﬁrst,
the effect estimates for the association between the indices of
cultural activities and good SWL, low anxiety and depression
increased when adjusted for age and then decreased after further
adjusting for the other co-variables.
These data showed that in both women and men, participation
in both receptive and creative cultural activities was associated
with good health, good SWL, a low anxiety score and a low
depression score, when adjusted for socio-economy and other
relevant cofactors. In both women and men, a doseeresponse
effect was indicated. The frequency of cultural participation and
the number of different activities were positively associated
with good health, SWL, a lower anxiety score and a lower
depression score. The study revealed that men who engaged
speciﬁcally in receptive, rather than creative, cultural activities
reported better health-related outcomes.
As expected, cultural participation was strongly associated
with socio-economy. An important question was whether the
association between cultural participation and PH, anxiety,
depression and SWL was due to socio-economy or other
confounding factors. However, after adjusting for relevant
confounding factors, it seemed that cultural participation was
independently associated with good health, a low depression
score and SWL dependent on gender.
Our results may be in concordance with Katz-Gerro,
stated that the relationship between health and socio-economy
may not be fully explained by better access to healthcare, work
conditions, social ties and health behaviours. Wilkinson
similar tendencies in the distribution of cultural attendance in
relation to social variables and physical activity.
These data showed, in concordance with Cuypers,
that a high participation in receptive and/or creative
cultural activities may induce a higher engagement in physical
activities (data not shown). Thus, it is possible that attending
cultural events may serve as a marker for a healthy lifestyle.
On the other hand, it seems that attending receptive cultural
activities is associated less with good health than participating
in creative cultural activities in women. This may indicate that
for women, it is the difference in how they perceive their health
as to whether they attend receptive or creative cultural activi-
ties. Or this may express a gender-dependent difference in the
effect of the receptive cultural activities.
Several other studies have also demonstrated an association
between cultural activities and health. In concordance with the
present study, Bygren
a positive association between different cultural activities and
health outcome. Konlaan
found a positive effect on longevity
by attending art, museum, cinema and concert. Iwasaki
that relaxing leisure (listening music, reading, TV) was the
strongest positive predictor of coping with stress, while social
leisure (being with friends, social activities) and cultural leisure
(attending concerts, ballet, theatre and museums) predicted
better mental and PH.
In contrast with other studies where gender has often been
handled as a confounding factor,
we established an interaction
between participation in cultural activities and gender. We
found, in agreement with the study of Hyyppä,
dependent effects of participation in different cultural activities.
Furthermore, our study shows a slight but consistent stronger
relationship between the receptive cultural activities and
SWL, anxiety and depression in both women and men.
However, the association in women between creative cultural
activities seemed to be stronger with PH. By contrast, in men
the relationship between the participation in receptive cultural
activities and PH is stronger than the relationship between the
creative activities and PH. This may indicate a distinctive
difference between the effects (doseeresponse) of participation
in receptive and creative cultural activities.
suggest that psycho-neuro-immu-
nological theories may be of interest when trying to explain the
effects of participating in cultural activities. Konlaan et al
found that physical exercise improved blood lipids, and cultural
participation improved blood pressure and prolactin. A possible
pathway of the positive inﬂuences of participating in cultural
activities may be found in the stress reduction that decreases
the oxidative DNA damage and the formation of 8-hydrox-
ydeoxyguanosine, elevated levels of which are linked to the
development of disease.
The strength of this study is that the data allow the effects of
cultural participation to be studied as part of a general health
Table 4 Associations between the cultural activities index and good
health, good satisfaction with life, low anxiety and low depression in
OR (95% CI) OR (95% CI)
Index receptive cultural activities 1.03 (1.01 to 1.06) 1.09 (1.06 to 1.12)
Index creative cultural activities 1.05 (1.03 to 1.07) 1.07 (1.05 to 1.09)
Good satisfaction with life
Index receptive cultural activities 1.08 (1.05 to 1.11) 1.14 (1.10 to 1.18)
Index creative cultural activities 1.06 (1.04 to 1.07) 1.04 (1.02 to 1.06)
Index receptive cultural activities 1.09 (1.05 to 1.12) 1.13 (1.09 to 1.17)
Index creative cultural activities 1.06 (1.04 to 1.07) 1.06 (1.04 to 1.08)
Index receptive cultural activities 1.10 (1.06 to 1.13) 1.12 (1.08 to 1.16)
Index creative cultural activities 1.05 (1.04 to 1.07) 1.07 (1.06 to 1.09)
Data shown are adjusted OR with 95% CI from a stepwise multivariable logistic regression
model (adjusted for age, SES, chronic disease, limitation in social contact, and physical
exercise, daily smoking, body mass index, alcohol drinking) relating index receptive and
creative cultural activities to respectively perceived health (1: very good, good; 0: not so
good, poor), satisfaction with life (1: very satisﬁed/satisﬁed/somewhat satisﬁed; 0: bit of
both/somewhat dissatisﬁed/dissatisﬁed/very dissatisﬁed), anxiety (1: low; 0: high) and
depression (1: low; 0: high).
Cuypers K, Krokstad S, Lingaas Holmen T, et al.J Epidemiol Community Health (2011). doi:10.1136/jech.2010.113571 5 of 6
study with a large number of participants and with generally
high attendance rates in the middle age groups. Additionally, we
have operationalised a large number of different cultural activi-
ties, which has increased the participation rate in all layers of the
population. This method gives the best possible and broadest
overview over the cultural activity patterns of a population.
Furthermore, the study documents how the frequency in
participation and each individual cultural activity are associated
with not only PH but also other determinants of well-being,
adjusted for several possible confounding cofactors.
The associations between cultural participation and public-
health outcomes are probably more complicated than any study
design and range of variables might grasp. The measurement of
the social phenomenon is complicated. Another weakness is the
problem with evaluating the weighting of each item in
combined variables such as’concert/cinema and in the index for
creative cultural activities: physical activities and organisations,
theatre. We do not know exactly which cultural activity of the
subgroups the answer refers to.
Being cross-sectional, this study cannot determine causee
effect relationships. Another question to be put forward is the
clinical relevance of the results of this study. Although, the ORs
are very small and the CIs narrow, small changes at the popu-
lation level, however, can lead to large effects on disease risk.
There might also have been a vague selection bias. In this study,
participants had to be able to attend the screening site and be able
to ﬁll in questionnaires, so the very sick, for example, bed-ridden
patients, could not attend. Also, the very sick cannot participate
easily in cultural life. On the other hand, we can imagine that
the slightly sick might have abundant time to participate in
cultural activities and participated in the survey. Additionally,
individuals with very good health cannot improve their health
much, but may strengthen it, thus preventing ill health. This
may be difﬁcult to measure in the context of this kind of study.
This population-based study suggests gender-dependent associ-
ations between cultural participation and PH, anxiety, depres-
sion and SWL. The results indicate that the use of cultural
activities in health promotion and healthcare may be justiﬁed.
On the other hand, the limitations of this study implicate that
further longitudinal and experimental studies are warranted to
establish the causeeeffect relationship.
Acknowledgements The Nord-Trøndelag Health (HUNT) Study is a collaboration
between HUNT Research Center (Faculty of Medicine, Norwegian University of
Science and Technology (NTNU)), Nord-Trøndelag County Council and The
Norwegian Institute of Public Health.
Funding Public County Council Nord Trondelag, Norway.
Competing interests None.
Ethics approval Ethics approval was provided by the Norwegian Data Inspectorate,
The Directorate of Health and the Regional Committee for Medical Research Ethics.
Contributors All coauthors contributed equally in the development and writing of the
Provenance and peer review Not commissioned; externally peer reviewed.
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What is already known on this subject
<Previous population studies and a human-intervention study
have shown that religious, social and cultural activities predict
increased survival rate.
What this study adds
<This study revealed a gender-dependent association between
participation in cultural activities and good health, low
anxiety- and depression scores, and satisfaction with life in
<Receptive cultural activities seem to have a stronger
association with perceived health, anxiety, depression and
satisfaction with life than the creative cultural activities.
6 of 6 Cuypers K, Krokstad S, Lingaas Holmen T, et al.J Epidemiol Community Health (2011). doi:10.1136/jech.2010.113571