They [ do more than ] Interrupt us from Sadness : Exploring the impact of participatory music making on social determinants of health and wellbeing for refugees in Australia

This journal is published by the University Library System of the University of Pittsburgh as part of its D-Scribe Digital Publishing Program, and is cosponsored by the University of Pittsburgh Press. They [do more than] Interrupt us from Sadness: Exploring the impact of participatory music making on social determinants of health and wellbeing for refugees in Australia N. Sunderland, L. Istvandity, A. Lakhani, C. Lenette, B. Procopis & P. Caballero

health such as poverty. Harrison (2013) for example, conducted research in Vancouver, Canada, that explores how "musical offerings… address issues of poverty, including lack of health" (p. 58). She explored in particular how music participation could affect highly significant determinants of health and wellbeing by developing "the skills, education levels, incomes, and occupational possibilities of participants living in material poverty, which in turn can enhance their socio-economic status, a social determinant of human health and mortality" (p. 58). The recently released Australian National Arts and Health Framework also acknowledgesalbeit in a minimal waythat arts initiatives can have an "impact on the determinants of ill-health by changing individuals' attitudes to health risks and supporting community resilience" (Standing Council on Health and the Meeting of Cultural Ministers, 2013, p. 2). While the Framework identifies individual attitudes and risks, and community resilience as "determinants of ill health", Clift (2012, p. 121) acknowledges broader determinants related to arts practice such as access to cultural capital: Cultural capital includes people's social abilities and competence for action, including their perceptions, values, norms, cognitive and operational skills and takes three different forms: incorporated (e.g. values, skills, knowledge), objectivised (e.g. books and tools) and institutionalised (e.g. educational degrees, professional titles). With respect to health, these general notions of cultural capital provide a basis for identifying health-relevant cultural capital made up of all culture-based resources that are available to people for acting in favour of their health. Parkinson and White (2013) have also discussed that the strength and nature of local cultural engagement is a key determinant of health and wellbeing. This mirrors studies with Aboriginal and Torres Strait Islander peoples in Australia, which show the direct link between strong cultural practices and "enhanced outcomes" across a range of socio-economic and health and wellbeing outcomes (Dockery, 2010). Parkinson and White (2013) emphasise that the arts have an international role to play in supporting strong healthy cultures and promoting health equity and wellbeing. Drawing on key health promotion documents such as the World Health Organisation's (WHO) Declaration of Alma Ata (1978) and the 1981 Global Strategy for Health for All by the Year 2000, Parkinson and White (2013) advocate for culture and the arts as a key determinant of health and wellbeing. The WHO foundational international agreements on health equity and health promotion position health as a state of wellbeing and not merely the absence of infirmity and disease. These agreements also acknowledge the fundamental role of human social, cultural, and physical environments as determinants of health and wellbeing. The WHO early declarations around health equity and health determinants have been extended via the more recent Rio Political Declaration on Social Determinants of Health (2011, p. 1) which states that "health equity is a shared responsibility and requires the engagement of all sectors of government, of all segments of society, and of all members of the international community, in an 'all for equity' and 'health for all' global action". In concert with Parkinson and White (2013), we see that musicians and music facilitators, participants, educators and policy makers have a vital role to play in promoting "health for all".
Within the above context, our paper explores the relevance of an existing health equity and SDOH framework (Schulz & Northridge, 2004) for both mapping and planning for sustainable health and wellbeing outcomes for participatory music programs. In this paper, we draw on a recent case study of how music participation has affected social determinants of health and wellbeing for refugee and asylum seeker participants in the Brisbane-based Scattered People music program (see http://www.scatteredpeople.com). We have adopted the title "They [do more than] interrupt us from sadness" for the paper for two reasons. The first is to acknowledge the powerful words of one of the Scattered People refugee participants who used the phrase "they interrupt us from sadness" as a way to describe one of her experiences as part of the participatory music group. We inserted the parenthesis [do more than] to emphasise that music participation does not merely generate individual mental health and wellbeing outcomes for participants, as is the focus of much music and health research. Rather, as we have outlined above and will continue to argue in this paper, music participation can produce a range of outcomes along a continuum of health determinants and outcomes ranging from individual factors through to broad social and environmental outcomes.
To explore these outcomes, we first provide an outline of the exploratory research project including the SDOH framework used for the research. We then discuss how five refugee participants' self-reported health and wellbeing outcomes from the music program align and coincide with the SDOH framework, ranging from individual level outcomes through to macro societal level or "fundamental" outcomes. We offer a commentary of the outcomes that did not fit neatly onto the existing SDOH continuum, namely cultural expression, music making, and consolidation of personal and social identity. We conclude by discussing the benefits and limitations of applying an SDOH framework to music and health research and practice in this way.

Research Background
This research was conducted as part of an interdisciplinary exploratory research project funded by Griffith University's Arts, Education, and Law Group in 2013-2014. The project brought together a team of nine researchers from across music, humanities, health and human services disciplines to explore how music participation affects social determinants of health for asylum seekers and refugees and, potentially, other culturally and linguistically diverse and marginalised groups in Australia. Our exploratory research focussed on an in-depth qualitative case study of the Brisbane-based refugee and asylum seeker music group Scattered People, who worked as a partner in the research. This paper reports on just one component of our research, namely in-depth interviews and narrative inquiry with five refugee and asylum seeker participants involved in Scattered People (see Lenette & Sunderland, 2014;Lenette, Weston, Wise, Sunderland & Bristed., 2015).

The SDOH conceptual framework
We used Schulz and Northridge's (2004) comprehensive SDOH framework as a basis for the research. The framework is reproduced in its original form below (see Table 1) and used to present our data analysis later in this paper. Schulz and Northridge (2004, p. 456) describe their work as a "conceptual framework for understanding the implications of social inequalities for environmental health [that] emphasizes the interplay of social processes with features of the physical environment". Hence the model adopts an explicit health equity focus. The model "outlines the multiple and dynamic pathways through which underlying social, political, and economic conditions influence aspects of the environment, thereby affecting individual and population health and well-being" (ibid.).
We selected Schulz and Northridge's (2004) framework primarily due to the detailed way that it maps social and environmental determinants of health at different levels of the social-ecology (see Levins & Lopez, 1999) of health and wellbeing. Our use of the framework also extends on previous collaborative place based health promotion research conducted by the project leader (see Sunderland, Bristed, Gudes, Boddy & Da Silva, 2012;Kendall, Muenchberger, Sunderland, Harris & Cowan, 2012). We favoured the Schulz and Northridge framework for this research in particular due to its overt and detailed recognition of human rights, ideologies, and racism as significant factors that shape health and wellbeing outcomes. We argue that the recognition of such factors is particularly relevant when working with intensely marginalised, politicised, and stigmatised groups such as refugees and asylum seekers in Australia and other resettlement countries.
We have not substantially amended or adapted Schulz and Northridge's (2004) original framework for the purposes of this paper and analysis. We make some recommendations in this regard, however, in the conclusion of the paper based on our current findings, and will offer further adaptations of Schulz and Northridge's SDOH framework for music, health, and wellbeing research in future papers based on the outcomes of our broader research project.

Participant recruitment and selection
The primary researcher (Author 1) worked collaboratively with two Scattered People music facilitators (Authors 5 and 6) to devise a purposive selection strategy for recruiting participants. The facilitators then approached individuals who were refugees and asylum seekers to describe the research and invite them to participate. Because participant recruitment with refugees and asylum seekers is known to be difficult (see Bergh & Sloboda, 2010), we focused on recruiting current members of the Scattered People music collective who had maintained contact with the facilitators at the time of the research. We acknowledge that this may have some effect on the outcomes of the research in terms of privileging voices of participants who have actively maintained contact with the group, but the findings of this initiative are, nevertheless, rich and useful to our exploration of SDOH and wellbeing. The facilitator arranged times and venues where the researcher could meet with the participants to engage in collaborative data creation conversations. Participants were selected primarily to represent a diversity of duration of engagement with the Scattered People program, which ranged from four years to six months. Participants were also selected to represent different nationalities and ethnic backgrounds and different genders. The resulting participant group included two Iranian women, a Kurdish male and female married couple, and one Sri Lankan male. All participants were aged between 24 and 50 years of age.

Data creation and interpretation
We used a narrative inquiry approach (Clandinin & Connelly, 2000) to create representations of refugee and asylum seeker experiences and perspectives in the research. We had originally planned to use a life histories approach (see Cole & Knowles, 2001) to guide the interviews. Upon beginning recruitment for the research, however, we realised in concert with our participants and community partners that this level of qualitative data collection was inappropriate for this particular group. This was largely due to the fact that none of the five participants wanted to use an interpreter for the research interviews and no one in the research team could speak languages in common with the participants. The life histories method also proved to be inappropriate due to some of the participants feeling concerned about their own safety, the identifiable nature of documentary evidence to be collected, and reticence to be audio-recorded during their interview. This was particularly the case for participants whose refugee status was still being determined and who had family members still living in the country from which they had fled.
We hence developed and agreed on a research process where a music facilitator from the Scattered People and the primary researcher would both meet with the refugee participants in their home or an agreed venue, to have a discussion on what the participants thought were the main health and wellbeing benefits of their participation in the Scattered People music program. The researcher took hand written notes during these conversations, then used Clandinin and Conelley's (2000) narrative inquiry method to write her own "story" (or in Clandinin and Conelley's words, "research text") about the participants' stories, which she then shared with participants and the supporting Scattered People facilitator via email and in person for verification and approval. Wherever possible, the researcher used her notes to include participants' own words in the written story. In one case, the researcher conducted a joint interview with two female participants who agreed to be audio recorded. This recording was professionally transcribed and used in the data analysis process. We recognise that this constitutes a substantially different "research text" for analysis compared to the stories prepared by the researcher based on notes solely; however, we chose to include the transcribed text as a way of privileging the direct voice and expression of these two participants who agreed to be audio recorded. Moreover, the two married participants' stories were presented together in one research text.
The primary researcher then worked collaboratively with two other members of the research team to conduct an interdisciplinary collaborative thematic analysis of the resulting "stories" and transcription (see Ryan & Bernard, 2004). Analysts were deliberately selected to represent diverse music and health disciplinary backgrounds and experiences. We then mapped our thematic analysis across the SDOH conceptual framework discussed earlier in the paper. This mapping is presented below in our discussion of key findings.

Ethics
The ethics of this research were clearly complex and needed to be highly responsive to the participants. Our decision to change the research data collection methodology reflects the degree of flexibility and responsiveness required to engage refugee participants in meaningful ways. This flexible and relational research process was supported by the fact that participants already knew the primary researcher through her ongoing role as a musician and participant in Scattered People monthly gatherings. The researcher had also been involved in a public group performance with one of the research participants. Concurrently, the Scattered People facilitator was instrumental in seeking asylum seeker participation in the research and ensuring honest and open communication with the researcher.
Griffith University's human research ethics committee reviewed all aspect of the research project. Each amendment to the research methodology was provided in writing and approved by the committee. Written consent materials were provided to participants in advance of data collection, and offers were made to provide the material in the participants' first language (none of the participants took up this offer). The Scattered People facilitator also spoke to prospective participants on the phone or in person about the purpose of the research prior to their agreeing to be involved. In addition, the researcher described the purpose of the research and answered any questions participants had prior to collecting data. Participants gave written consent prior to participation using an approved consent form or via email. In one case, a participant did not wish to use his real name to sign the consent form so used a pseudonym. This was discussed and approved by the human research ethics committee at the time. The researcher also worked with the lead Scattered People music facilitator to confirm participants' consent prior to seeking publication of any findings from the research. Each participant was offered a $40 gift card at the conclusion of the research (however, this was not discussed prior to their involvement).

III. Mapping Health and Wellbeing Outcomes on the SDOH Continuum
Themes generated from participant interviews and stories were mapped onto the Schulz and Northridge (2004) SDOH framework and are presented in Table 2. Similar to the framework, the diagram includes four levels, Individual (Health and Wellbeing), Micro/Interpersonal (Proximate), Meso/Community (Intermediate) and Macro (Fundamental), and the corresponding factors are presented below each level in the diagram. During data analysis, it became clear that participants were able to identify the direct outcomes that they experienced as a result of participating in Scattered People music activities. Additionally, participants also outlined the potential outcomes they may experience as a result of Scattered People music performances. Consequently, the themes identified have been populated in Table 2 in two ways. Themes written in standard text throughout the diagram represent outcomes that participants directly experienced as a result of their participation. Themes documented in italics represent outcomes that participants hope their involvement in music making activities would yield, and their thoughts about the potential outcomes of their music performances.

Individual health and wellbeing
As illustrated in the diagram, at the Individual Health and Wellbeing level, all outcomes experienced by participants fell under the category Wellbeing. All five participants suggested that their participation impacted their mental health and provided them with a sense of happiness. The excerpt from the interview with Z provides an example of this: I remember one day my husband was in the hospital, so I couldn't sleep, you know -I couldn't sleep one night and then I was very tired and I was in a hurry to go home and then have a rest. So on my way, I went to pick up my daughter from the school. Then I met this group again, near to school. So I went there. We had chat together and they sang music again and then I completely forgot, every tiredness goes away from me. Yeah and then it changed to happiness. I'm still having this feeling. (Z) The account above shows how music participation can encourage feelings of happiness and wellbeing amongst participants, and directly counter adverse feelings that they may be experiencing. Similar to the above, Z also suggested that involvement in the group and participation in the music activities, "interrupt us from sadness and turned it to happiness things. Mind and soul". For this participant, feelings of happiness remained after participation in music sessions had ceased, indicating that there may be lasting impacts on some participants' lives.
Other participants also suggested the idea of music participation changing feelings and perspectives and having a lasting impact. For example, S provided a similar story to Z, and suggested that during times of distress, music provided an outlet to remedy such feelings. The following interview excerpt from S exemplifies this point: Actually, for first time when I came to Nundah, you know, in this journey we have lots of problems and we are scared, actually. When I came to Nundah for first time, I was in shock…. But I saw many people, they try to speak slowly to me and I'm -I can't explain exactly what I was feeling, but I was so excited. So, like I was, wow, friendly, very kind, people. It was my pleasure to meet them. It was really good…. They push me for, hey, [S], sing! [S] During the interview, S also echoed ideas suggested by Z that participation in such activities potentially had lasting impacts. Specifically, S suggested that exposure to music has "change[d] my feelings, [and] can change my life" (S).
Themes generated from four participants' narratives also supported similar ideas, specifically that participation in music making activities encouraged mental wellbeing, and feelings of happiness. Moreover, participants also highlighted how engaging in music making activities could work to counter negative feelings and experiences. For example, J suggested that sometimes he did not go along to the Scattered People sessions because he felt sad or did not feel like socialising on those days. However, when he did go along, it made him feel well and happy, as he felt he was connecting with other people. Another participant, "Joy" (pseudonym), also suggested that participation in Scattered People activities supported mental wellbeing through the transformation of adverse feelings into ones of happiness. For example, Joy "has had many hard times and things are hard" but he works out ways to make himself feel good. He said, "'some problems I can solve with my mind'. Some he can't. Joy plays music, gets involved with friends…For Joy, music creates 'happiness'. He said 'music is very important to me'" (Joy's Story).

Micro/interpersonal proximate
As the diagram shows, at the Micro/Interpersonal Proximate level, four of the five participants suggested that their involvement encouraged outcomes aligned with Social Integration and Support. More specifically, interviewees suggested that their participation supported building friendships and a sense of community, as well as fostered a sense of social integration.
Findings from the joint interview illustrate how participation supported individuals' ability to build friendships and a sense of community. For example the following excerpt from the interview with S provides evidence to this point: I lived in Brisbane and then I moved to Melbourne. I just met the people in Nundah for one time. After I moved to Melbourne, I think, okay, everything finished. No relationship, no nothing. But, when Brian sent me an email and when they called me and said, hey [S], come back to Brisbane, we want to record music. …We want to make music for war, for people, for freedom, for everything and I said, wow! They don't forget me. These guys are real friends, not fake. I just -because sometimes you can feel one person really wants to be friends with you or not. These are awesome. (S) S's story suggests that participation in Scattered People activities provided her with the opportunity to forge real friendships. As mentioned in the excerpt above, S had only participated in the group once before leaving Brisbane. The group contacting her and requesting her further involvement suggested that the connections made through her brief participation were important and valuable. Additionally, S identified these friendships as sources of positive support. For example, she explained: "They pushed me. [S], sing, [S]! Play guitar, [S]! Do this, do that! They gave me really positive energy and I was, wow" (S). Long-term participants also identified the idea of strong connections and friendships made through participation in Scattered People. For example, Z suggested the value of such friendships: When I first met them, I didn't know anyone and I didn't know how to -even how to communicate with these people. But they made a very warm friendship. I've known these people about three years and I am feeling very close friendship with these people. I love them. (Z) Additionally, the friendships made by participants have been characterised as a distinct community. Specifically, "[group members] help ushow to communicate and how to be one of the social community" (Z).
The value of friendships made through Scattered People is especially significant considering that some participants have little to no opportunity to make social connections outside of this group. For example, one participant explained that "at present he doesn't connect with other people or meet people in any way other than the Scattered People group. He said he would normally meet people through work but because he hasn't gotten his visa yet, he cannot work" (J's story). Given J's circumstances, his connection to Scattered People was critical as it provided him with an outletthe only one in factto engage with the broader community.
The narratives collected suggest that participation in music activities impacted on individual's social participation and integration, by providing an opportunity for individuals to share their perspectives with people in the community. This point is illustrated throughout Joy's story. Joy suggested that "music is a great way to get people to understand refugees and their experiences" (Joy's story). Additionally, "[t]o Joy, 'it doesn't matter if we only reach five or 10 people with our stories', it is still important to share them" (Joy's story). Findings suggest that intercultural connection through sharing is an outcome of participation in Scattered People.
Participants also identified the sharing of stories as a mechanism to encourage their understanding of the Australian way of life and support their integration. For example, participating in music making activities has been identified as a practice that "did help people a bit with learning English" (J's story). Additionally, the combination of making social connections and sharing stories has been identified by participants as "very helpful [in] this country because everything in the country was very strange and different for us -cultural difference, everything" (Z).

Meso/community intermediate
At the Intermediate level (see diagram), participants suggested that their participation had an impact on the social context in which they lived. Joy discussed how participation encouraged their access to resources that had an effect on their civic participation. For example: Joy wonders if refugees can also access other information from being involved in the Scattered People. For example, can they get help with citizenship and more information? Would the people they meet in the Scattered People provide character references for refugee visa applications? (Joy's Story) Joy's questions emphasise the importance of connections made through Scattered People for participants. In his story, citizenship was integral to ensuring a healthy life in Australia, as it provided the opportunity for civic participation and social influence. Joy therefore felt that such opportunities were a direct result of participation in Scattered People music activities.

Macro Fundamental
As illustrated in the diagram, at the Fundamental level, outcomes for participants mapped to both Macrosocial and Inequality aspects. Specifically, two of the five participants highlighted how the creation or performance of music had the potential to impact ideologies and social structures, and encourage equitable access to resources. Participants created music with the purpose of changing individual ideologies about refugees and asylum seekers in Australia and encourage ideas of equality and acceptance. For example, when discussing the purpose of music making with Scattered People, S suggested that: I think the refugee people have many pain, because they lost their family, their friends, their country. So I want people and other people know this, don't push their head -on their head. I said, because, I remember one time I was in the train and one of the women told me, why you came to our country? I said, you know, I have lots of answers for her, but I was just silent, silent, silent and I think, think, think. Okay, your country, I agree. But this world, I think we are one [spirit]. For those participating in Scattered People music activities, sharing messages and stories became a mechanism to encourage understanding, and further reducing stigma. In some instances, participants witnessed how this change took place. An excerpt from Joy's story exemplifies this: Most importantly, Joy thinks that music is a great way to get people to understand refugees and their experiences. He said "people enjoy listening and get a message at the same time". Joy has a really good understanding of what audiences enjoy because he is a musician. He notices what the audience enjoys and doesn't enjoy. He said he can see that music changes people's minds as they hear the Scattered People's songs. (Joy's story) Participants felt that their music gatherings and performances had the potential to improve understandings of refugee experiences, and hopefully lead to more acceptance. As Joy suggested above, Scattered People music has the potential to change individuals' ideas about refugees and asylum seekers, and in turn potentially affect the lives of both groups. S also suggested the idea of changing lives through advocacy, and highlighted that she made music to "help other people" and "when I see people [I] just want to play or sing for freedom, to make a better world" (S).
Clearly, participants recognised that their music engagement had the potential to encourage change on a Fundamental, specifically Macrosocial level. Similar to outcomes at the Intermediate level, encouraging ideological shifts and equitable access to resources were identified by participants as potential outcomes of Scattered People music performances.

Reported health and wellbeing outcomes that did not fit neatly on the existing SDOH continuum
While many themes arising from participant interviews fit neatly onto the SDOH framework, we also identified a number of factors that were reported as contributing directly and indirectly to participants' health and wellbeing that sit outside this model. Specifically, these outcomes related to aspects of (i) cultural expression; (ii) music making; and (iii) consolidation of personal and social identity. These factors are interrelated, with each impacting on the others in relation to wellbeing outcomes for participants. Thus, considering these three aspects, broadly related to artistic and cultural influences, can contribute to broadening current understandings of SDOH and wellbeing.

Cultural expression
In the Scattered People sessions, participants were encouraged to share aspects of their own culture, while also participating in musical activities from other cultures. Several of the participants emphasised the role of both first and second or even third languages, including English, in making music within the group. Being able to sing in one's first language afforded individuals the opportunity to express not only aspects of their culture but also an articulation of their thoughts and feelings. So too did this experience allow participants to hear and sing in their own languagea practice which may be difficult to maintain in a resettlement setting. One participant described an example of this: [J] also enjoyed hearing songs in Persian, maybe more than in English….
[J] said he would not sing Persian songs otherwise and he would not sing them at home. He also said that he doesn't hear Persian songs anywhere else in Brisbane." (J & T's story) Musical expression in first or familiar languages appeared to be an important contributor to the wellbeing of this culturally diverse group. As one participant Joy noted, "when people can sing in their 'mother language' it creates happiness". Joy goes on to describe the importance of acknowledging individual languages in the coming together of many different cultures at the Scattered People sessions (Joy's story). In this way, participants in the program were able to connect with and maintain a sense of individuality within the culturally based plurality present among participants.

Music making
On the other hand, the idea of participating in musical activities in the absence of proficient English language skills was at first daunting for some participants. As explained by S, "I always think you should speak very well English to connect to people, but I saw many people, they try to speak slowly to me…I was so excited… It was really good. They push for me, hey, [S], sing!". An initial perceived language barrier was soon overcome for S, when it became apparent that there were many people speaking different languages and from diverse culture groups present, yet all participants had gathered for the one common purposeto share music. Another participant, Z, echoed S's sentiment and said: "Always music can explain…there are lots of languages in the world. The music and song or poetry could be one of those [languages] which could transfer people's feelings and emotion to other people. So we kind of speak to [the] world [through] the music" (Z). Z is alluding to how music has the ability to communicate emotions regardless of the language of any lyrics, as well as the ability for Scattered People participants to perceive this emotion.
For these participants, music allowed a connection that did not require a common spoken language. S explained, "music is an international language for every people, for all of us" (S & Z interview). While cultural differences were acknowledged within the group, participants also recognised the shared function of music making for all those present. In the context of the sessions, music was used for an expression of self, an expression of trauma and grief. As stated earlier in this paper, music making became an avenue to build social bonds. Indeed, this activity was emphasised by participants as being integral to their wellbeing, and was recognised as a quick and effective method for connecting with others. For example, J described that meeting people through Scattered People was very important to him, stating that he thought it would not be as easy to connect with people through other activities (J's story). S also expressed how the welcoming nature of the group and the inclusiveness of the musical activities made her feel "excited", while Z described the group as "part of our family" (S & Z interview). In these ways, music comprised a universal function to this diverse group and contributed to positive wellbeing outcomes for participants.

Consolidation of personal and social identity
Participants frequently described music as having an effect on their mental wellbeing. Specifically, they noted feelings of happiness or relief, but in speaking about their relationship with music, they also referred to concepts of identity and agency. Closely related to the ideas of expression and communication discussed above, 'self and social identity' as a concept appears to contribute greatly to health and wellbeing outcomes, yet it too is absent from the SDOH continuum. Nevertheless, individuals felt excited, happy and proud to sing songs in their own language; this indicates that these aspects are elements of self-identity. Similarly, music gave participants a certain freedom of expression that they may not have had before. For example, S described how women were not allowed to sing in her home country, but that being able to sing in her new country gave her a sense of agency, and a sense that she may be able to change the world around her through music (S & Z interview).
It also appears that participants retained part of their ethnic identity, especially through language, but also created a new, shared social identity with other people in similar circumstances. For example, Joy described his ideal scenario on putting together a musical concert with other participants: "if we have five songs for example, three should be for the refugees [i.e. in refugee languages] and two for the audience [i.e. in English]" (Joy's story). This split between "songs for refugees" and "songs for the audience" can be understood as a representation of integrated identity within this particular group. Thus, in the context of the Scattered People sessions, participants were creating a shared identity through the unified function of music for the group, as an avenue of expression, communication and reception of thoughts, feelings and stories. Music making activities can therefore positively contribute to a sense of wellbeing for participants through the promotion of music as part of personal and social identity.

IV. Learning and Limitations: Suggestions for Future Research
Revisiting the SDOH frameworks for music research, policy, and practice The above discussion highlights that the themes emerging from participant interviews surrounding cultural expression, music making and consolidation of personal and social identity, do not integrate into the SDOH framework in its current form. However, as the discussion also suggests, they all played a key role in the achievement of health and wellbeing outcomes of participants. This finding indicates a gap in the recognition of the position of artistic and cultural influences in terms of both health and wellbeing interventions. This gap is especially glaring within the context of culturally and linguistically diverse target groups, in which, as shown, cultural identity is one of the few aspects that individuals carry with them into new societies. More attention should thus be paid to these aspects as important determinants of wellbeing.
The prominence of these three themes in the literature indicates their importance and provides an impetus for more critical discussions from a SDOH perspective. For instance, the complexity in 'measuring' happiness and wellbeing across cultures remains an important theme, as does the critical role of interdisciplinary research to address this issue (Mathews, 2012). Moreover, the notion that music comprises traits that are understood within all cultures was initially proposed within early studies of ethnomusicology in the 19th century. Throughout the 20th century, the debate as to whether music could really be considered universal to all cultures continued, spurred on by theories of human evolution, linguistic development and greater philosophy on music (for example : Harwood, 1976;Hood, 1977;Merriam, 1964). These trends highlight the social nature of human existence, and the function of music therein. Furthermore, research in the area of music sociology has made clear connections between music activities, such as sharing, listening and music making, with the formation and consolidation of personal and social identity, such that music can become representational of the self (see for instance Bennett, 2000;Cohen, 1991;DeNora, 2000;Frith, 1981Frith, , 1996Hesmondhalgh, 2008). While concepts of music-related identity and wellbeing in culturally and linguistically diverse groups are currently under researched, the limited evidence suggests that self-and social identity in ethnic communities can be positively related to psychological wellbeing (for example Liebkind & Jasinskaja-Lahti, 2000;Liebkind, 1992;Nesdale et al., 1997;Phinney & Kohatsu, 1997;Phinney, Horenczyk, Liebkind & Vedder, 2001a). Other studies indicate that a shared social identity within minority groups can also have positive wellbeing effects (Haslam, Jetten, Postmes, & Haslam, 2009;Richer & Haslam, 2006). The findings outlined in this paper also align with these ideas.
Thus, designing a new SDOH framework, based on the Schulz and Northridge (2004) model, but encompassing other, more relevant aspects to culturally diverse groups in the context of arts-based research may provide a more accurate picture of health and wellbeing outcomes in interdisciplinary contexts. This adapted framework could then be tested through another set of interviews with the same participants, using a slightly different line of questioning that would focus on those themes identified here as external to current SDOH framework. The outcome would be that collaborative, interdisciplinary and participatory-based research as described in this paper could then yield clearer indications of the importance of arts in achieving positive wellbeing outcomes for refugees and asylum seekers and other marginalised groups.

Adapting the methodology for collaborating with refugees
It is clear that the small number of participants in this research project is a limitation, although rich data emerged from this collaboration regardless. However, this approach also reflects the challenging nature of research with refugees and asylum seekers; while it is obvious that a greater number of participants is needed, the current participants' reticence to engage in the life stories aspect of the research for instancedespite its clear relevance to research with refugees and asylum seekers (see for instance Ghorashi, 2007) suggests that other data collection options that feel 'safe' should be considered in this field. For instance, an approach where participants are asked to write down responses would give participants more time to formulate their responses considering language barriers, and may yield different sets of narratives. Literacy issues may constitute a barrier, unless translation was part of the process. Furthermore, future research could compare outcomes for marginalised groups who have not had access to music activities versus those engaged in the Scattered People group.

V. Conclusion
Georgeff, Lewis and Rosenberg argue that "[f]or people who engage in arts-related activity, there is often a resulting sense of wellbeing that is difficult to explain or quantify" (2009, p. 33). Thus, documenting and evaluating such outcomes remain challenging in this field. Examining the impact of participatory music on the health and wellbeing of refugees represents one pathway towards articulating the complex links between arts activities and the health and wellbeing of marginalised groups. This knowledge can contribute to developing solid frameworks for documenting and evaluating the health and wellbeing outcomes of arts-based activities, currently lacking in the field. Our aim in this paper was to argue that music participation involving culturally diverse groups can produce a range of outcomes along a continuum of health determinants ranging from individual factors through to broad social and environmental outcomes. We have also established that some of the wellbeing outcomes of the Scattered People music activities extend beyond a pre-established albeit useful framework. This provides an impetus for further interdisciplinary research in this field and a broader understanding of health and wellbeing in relation to culturally diverse and marginalised groups.