Setouchi Sustainability & Wellbeing Research Project Report
Cultural Activities and Health; Fostering Social Capital
Takashi Yorifuji, Hiroshi Habu, Chikara Miyaji, Naomi Matsumoto, Soshi Takao
Department of Epidemiology, Okayama University Graduate School of Medicine, Dentistry andPharmaceutical Sciences
Background
Since the Echigo-Tsumari Art Triennale held in 2000, art festivals have become increasingly
popular in various parts of Japan. Many of these festivals are dependent on the particularcharacteristics and context of the region, with the main purpose of revitalizing the local community.1)
The Setouchi Triennale is an arts festival that has been organized by the Benesse Group on Naoshima
since 2010.2) It has developed into an art project with the largest number of visitors in Japan.3) The
approach to revitalizing the local community through these activities was initiated in 1992, and hascome to be known as the Naoshima Method. 4) The Naoshima Method is an approach for arts-mediatedcommunity-building through the activities of Benesse Art Site at Naoshima by Benesse Holdings andFukutake Foundation, which aim to promote “well-being” through art experiences and interaction withthe landscape, community, and people. Naoshima Town is located in western Japan, in Kagawa
Prefecture.
In the field of social epidemiology, it is said that social/environmental factors such as social
networks and attributes of communities affect individuals’ health.5), 6) Social capital (SC) is attracting
attention as one of such social determinants.7), 8) Many previous studies have examined the relationshipbetween SC and various health indicators including mortality, heart disease, mental health indicators,
and smoking.9)
Art projects can be used as tools to help foster SC, and research focusing on grassroots
bottom-up initiatives in the UK and top-down initiatives by local governments in Denmark have bothcontributed to fostering SC.10)
On the basis of the findings of previous studies, it is expected that participation in art
festivals affect people’s health directly and/or indirectly by building SC. However, to date, there has
been little scientific research examining how participation in arts festivals affects residents’ health.
The purpose of the current study is to evaluate the relationship between participating in arts
festival activities and the health/SC of residents in Naoshima. We examined two hypotheses: (1)participating in the Setouchi Triennale was associated with the higher health of residents, and (2)participating in the Setouchi Triennale was associated with higher SC.

(1) Participation in the Setouchi Triennale and the Health of Residents in Naoshima
PurposeThe purpose of this study was to investigate the relationship between participation in arts
festival activities at the Setouchi Triennale and the health of the residents in Naoshima Town using the
SRH and K6 as outcome measures.
Methods
This was a cross-sectional study. The target population were residents of Naoshima Town,
Kagawa Prefecture, Japan who were 20 years old or older as of September 1, 2021 (N = 2588). We
surveyed participants from December 6, 2021, until March 31, 2022. Participants provided written
informed consent and those who did not provide consent were excluded. We distributed self-

administered questionnaires and collected them by mail.
As an exposure variable, we determined whether residents participated in activities related
to the Setouchi Triennale.
As a primary outcome variable, self-rated health (SRH) was measured using a five-point
Likert scale (1 = excellent; 2 = very good; 3 = good; 4= fair; 5 = poor).11), 12) Evidence has accumulated
showing that SRH is associated with various physical and mental health conditions, and that it predicts
mortality.13)-17) We dichotomized the responses into good health (very good/good/moderate) and poor
health (bad/very bad).11), 12)
As a secondary outcome variable, the six-item Kessler Psychological Distress Scale (K6)
was measured. The K6 is a self-administered questionnaire about a person’s emotional state, with a
total possible score of 24 points (range, 0−24 points) consisting of six items that are rated using a fivepoint Likert scale (0 = all of the time; 1 = most of the time; 2 = some of the time; 3= a little of thetime; 4 = none of the time). The questions ask about how often the person has experienced specificsymptoms (nervousness, hopelessness, restlessness/fidgeting, being so depressed that nothing could
cheer them up, feeling that everything was an effort, and worthlessness) during the past 30 days. As

in previous studies, respondents who scored higher than 13 were considered to have aserious mental illness when the items were coded as 0–4. On the basis of this cutoff point,
a dichotomous variable was created as an indicator of serious psychological distress (0 =score 13 to 24 and 1 = score 0 to 12).18)-21)
In addition, we collected individual and demographic information, including sex, age, height,
weight, smoking status, alcohol consumption, duration of residence in the community, number ofpeople living together in the household, and subjective socioeconomic status (SES).
We first described demographic characteristics of the study participants by stratifying themaccording to whether they participated in the Setouchi Triennale or not. As the primary analysis, therelationship between art festival activities participation and SRH was evaluated using logistic
regression models. We first estimated the crude odds ratio (OR) and 95% confidence interval (CI),then estimated the OR and 95% CI after controlling for potential confounders as Models 2 and 3. In
Model 2, we adjusted for sex, age, body mass index (BMI), SES, and number of people living together;in Model 3, we adjusted for smoking status and duration of residence. The secondary outcome K6 wasanalyzed in the same manner as the primary outcome. Stata SE version 17.0 (StataCorp, College
Station, TX, USA) was used for all statistical analysis. This study has been approved by the Okayama
University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences and the Okayama
University Hospital Ethics Committee (approval number: K1902-003).
Results
We distributed questionnaires to the residents of Naoshima Town (N = 2588) who were 20
years old or older as of September 1, 2021, and received responses from 739 people (response rate =28.6%). Of these, we excluded 31 for whom written informed consent was not obtained, and analyzed
the remaining 708.
Table 1 shows demographic characteristics of the study participants by stratifying themaccording to whether they participated in art festival activities at the Setouchi Triennale or not. There
was no clear difference between the two groups in SES, body mass index, and the number of people
living together in the same household. The average age was 4.58 years older in the non-participationgroup compared with the participation group, and the average duration of residence in the community
was 7.89 years longer. In addition, the participation group had almost the same ratio of males tofemales (49.49% males, 50.51% females), whereas the non-participation group had a slightly higher
proportion of females (45.27% males, 54.73% females). The proportion of non-smokers was 9.74%
higher in the participation group.
Table 2 shows the results of logistic regression analysis of the relationship between arts
festival participation and SRH. The participation group had a crude OR of 2.11 (95% CI: 1.26–3.89)
for higher SRH compared with the non-participation group. The table shows the results after adjustingfor potential confounders. We observed a similar pattern of results after adjustment (Model 2:
aOR=1.85, 95% CI [1.03-3.32], and Model 3: aOR=1.90, 95% CI [1.06- 3.42]).
Table 3 shows the results of logistic regression analysis of the relationship between arts
festival participation and K6 scores. The participation group had a crude OR of 2.07 (95% CI: 0.87–4.90) for lower K6 scores compared with the non-participation group. After adjusting for potential
confounders, we observed higher point estimation and a statistically significant association (Model 2:
aOR=3.13, 95% CI [1.15-8.53], and Model 3: aOR=3.00, 95% CI [1.10-8.16]).

Table 1. Demographic characteristics of study participants in Naoshima Town (n =708).
Non-participate inParticipate in arts

arts festival

festival(n=599) a(n=100) a

Male

268 (45.27)

49 (49.49)

Female324 (54.73)

50 (50.51)

Sex, n (%)(n=691)Age, years, mean (SD)(n=681)61.83 (18.07)

57.25 (19.04)

BMI, mean (SD)(n=660)23.17 (3.79)

22.53 (2.93)

Duration of residence, mean (SD)(n=685)46.53 (25.53)

38.64 (27.79)

SES, mean (SD)(n=685)5.21 (1.56)

4.90 (1.46)

Smoking, n (%)(n=696)Non

368 (61.74)

52 (52)Pre

177 (29.70)

37 (37)

Smoker51 (8.56)

11 (11)2.51 (1.29)

2.53 (1.40)

Number of people living together,mean (SD)(n=688)

SD: standard deviation. BMI: Body mass index. SES: Subjective socioeconomic status. aThere were
missing data for 9 participants.

Table 2. The results of logistic regression analysis of arts festival participation for higher SRH.
Model 1Model 2Model 3

OR (95% CI)

OR (95% CI)

OR (95% CI)

Non-participation in arts festival

1.00 (reference)

1.00 (reference)

1.00 (reference)

Participation in arts festival

2.11 (1.21 to 3.65)

1.85 (1.03 to 3.32)

1.90 (1.06 to 3.42)

Model 1 is crude model. Model 2 is adjusted for sex, age, body mass index (BMI), SES, and number of people living together.
Model 3 is adjusted for sex, age, body mass index (BMI), SES, number of people living together smoking status and period ofresidence. SRH: self-rated health. OR: odds ratio. 95 % CI: 95 % confidence interval.

Table 3. The results of logistic regression analysis of arts festival participation for lower K6 scores.
Model 1Model 2Model 3

OR (95% CI)

OR (95% CI)

OR (95% CI)

Non-participation in arts festival

1.00 (reference)

1.00 (reference)

1.00 (reference)

Participation in arts festival

2.07 (0.87 to 4.90)

3.13 (1.15 to 8.53)

3.00 (1.10 to 8.16)

Model 1 is crude model. Model 2 is adjusted for sex, age, body mass index (BMI), SES, and number of people living together.
Model 3 is adjusted for sex, age, body mass index (BMI), SES, number of people living together smoking status and period ofresidence. K6: the 6-item Kessler Psychological Distress Scale. OR: odds ratio. 95 % CI: 95 % confidence interval.
Discussion
we evaluated the relationship between participation in arts festival activities at the Setouchi
Triennale and the health of the residents in Naoshima Town using the SRH and K6 as outcome
measures. The results suggested that participation in arts festival activities had a favorable impact on
residents’ health. Regarding generalizability and causality, caution is required in the interpretation of
our study results. However, because few previous quantitative studies have examined the relationshipbetween participation in arts festival activities and residents’ health, the current study is considered toprovide an important basis for further longitudinal research in the future.
(2) Does Participation in the Setouchi Triennale Foster Social Capital?
PurposeThe purpose of this study was to investigate the relationship between participation in the Setouchi
Triennale as an exposure and using SC as an outcome factor adjusted by potential confounders.
Methods
This was a cross-sectional study. The target population were residents of Naoshima Town, Kagawa
Prefecture, Japan who were 20 years old or older as of September 1, 2021 (N = 2588). We surveyed
participants from December 6, 2021, until March 31, 2022. Participants provided written informed
consent and those who did not provide consent were excluded. We distributed self-administeredquestionnaires and collected them by mail. This study has been approved by the Okayama University
Graduate School of Medicine, Dentistry and Pharmaceutical Sciences and the Okayama University
Hospital Ethics Committee (approval number: K2110-023).
SC has a cognitive aspect, which refers to subjective aspects, such as perceptions and values(e.g., trust and reciprocity), and a structural aspect; the latter refers to people’s connections and socialnetworks, which can be objectively verified through actual behavioral observations and records (e.g.,
participating in community activities).23) In the structural dimension, a distinction is made between
bonding SC, which refers to trust and cooperation among members of networks with similar social
identities (e.g., race, ethnicity), and bridging SC, which signifies connections among individuals
whose social identities are dissimilar.24) Bonding SC is exclusive, strengthening ties within
homogeneous, socially similar groups and enhancing access to internal resources; by contrast, bridging
SC is inclusive, strengthening ties among heterogeneous, socially diverse groups and enhancing accessto external resources.25)
Propensity score matching seeks to balance covariates across comparison groups (here,
participation versus nonparticipation in the Setouchi Triennale) by matching individuals regarding
their probability (propensity) to participate in the art project. To calculate the propensity scores, weapplied 11 covariates (sex, age, BMI, smoking status, alcohol consumption, length of residence,education, hospital visit, marital status, Number of cohabitants, source of income). We applied logistic
regression analysis to calculate the propensity score. We then used ordered logistic regression analysis
to examine the relationships between participating in the Setouchi Triennale and cognitive or structural
SC; we used subjects in the lowest cognitive or structural SC category as the reference group. We
established model 1 as a crude model. In model 2, we adjusted for the above-listed 11 covariates. For
model 3, we conducted a conditional ordered logistic regression analysis to compare the outcomes
between matched pairs. We calculated adjusted odds ratios (aORs) and 95% confidence intervals (CIs).
We used STATA/SE17.0 (StataCorp, College Station, TX, USA) for all statistical analyses; we set
statistical significance at p <.05.
Results
The demographic data appear in Table 4. Of the respondents, 53.5% were women and 45.0%
were men. The mean age was 61.3 years (standard deviation [SD], 18.3); the mean BMI was 23.2 (SD,5.16); 8.6% of respondents were smokers; 47.7% consumed alcohol.
Participation in the Setouchi Triennale was significantly associated with higher levels ofcognitive and structural SC. (Tables 5 and 6)

Table 4. Characteristics of the Analytic Sample
Total(n=706)
No.

%

Male

318

45.0

Female

378

53.5

Other

5

0.7

Missing

5

0.7

Mean

SD

Sex

Age

688

61.3

18.27

BMI

666

23.2

5.16

45.5

25.96

Smoking status
Non-smoker

640

90.7

Smoker61

8.6

Missing50.7

Non-drinker

363

51.4

Drinker

337

47.7

Missing6

0.9

Alcohol consumption

Length of Residence on Naoshima
Education
Primary/Junior high school/High school

438

62.0

Vocational school/University/Graduate school/Other

255

36.1

Missing

13

1.8

Yes

429

60.8

No

272

38.5

Missing5

0.7

Unmarried

102

14.5

Married592

83.9

Missing12

1.7

Regular hospital visits

Marital status

Number of cohabitants
1

136

19.3

2

285

40.4

3≦

280

39.7

Missing50.7Social security benefits

282

39.9

Own income

265

37.5

Family income/Other

111

15.7

Missing48

6.8

Low(1≦, <5）

205

29.0

Middle（5）

328

46.5

High(5<）

158

22.4

Missing15

2.1

Participation

100

14.2

Non-participation

597

84.6

Source of income

SES

Art project

SD: standard deviation. BMI: Body mass index. SES: Subjective socioeconomic status
Table 5.

The odds ratios of Cognitive Social capital by Participate in art project
Model 1（n=693）

Model 2（n=600）

Model 3（n=356）

OR［95%CI］

OR［95%CI］

OR［95%CI］

Cognitive Social capital

2.807[1.884,4.182]

3.035[1.935,4.761]

2.913[1.846,4.596]

Trust

3.226

[1.821,5.717]

3.467[1.816,6.618]

2.547[1.341,4.838]

Reciprocity

2.069[1.373,3.119]

2.377[1.493,3.784]

2.373[1.488,3.783]

Model 1: crude. Model 2: adjusted by sex, age, BMI, smoking status, alcohol consumption, length of residence, education,
hospital visits, marital status, number of cohabitants, source of income. Model 3 adjusted by propensity score. OR: odds
ratio. 95 % CI: 95 % confidence interval.

Table 6.

The odds ratios of Structural Social capital by Participate in art project
Model 1（n= 685）

Model 2（n=592）

Model 3（n=344）

OR［95%CI］

OR［95%CI］

OR［95%CI］

Structural Social capital

4.608[3.053,6.954]

5.575[3.496,8.893]

4.535[2.839,7.244]

Bonding Social capital

2.130[1.339,3.388]

2.626[1.533,4.501]

3.013[1.758,5.164]

Bridging Social capital

3.776[2.521,5.654]

4.204[2.645,6.683]

3.430[2.172,5.415]

Model 1: crude. Model 2: adjusted by sex, age, BMI, smoking status, alcohol consumption, length of residence, education,
hospital visits, marital status, number of cohabitants, source of income. Model 3 adjusted by propensity score. OR: odds
ratio. 95 % CI: 95 % confidence interval.
Discussion
This study examined the hypothesis that participating in the Setouchi Triennale wasassociated with higher levels of cognitive and structural SC. These results support our a priori
hypothesis. Art project participation demonstrated the potential to foster cognitive or structural SC in
the community.
This investigation has several limitations. First, it was a cross-sectional study; thus, caution
must be exercised regarding the causal relationship between Setouchi Triennale participation andsocial capital. Second, the response rate for the survey was not high: our results should be interpreted
guardedly in terms of generalizability. Third, there is the issue of common method bias. We measured
both project participation as an exposure and social capital as an outcome subjectively by using thequestionnaire: it is possible that the association was overestimated. In future research, longitudinalsurveys are warranted to clarify the relationship between art project participation and building social
capital.
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