Arts on prescription for community‐dwelling older people with a range of health and wellness needs

Abstract

Published evidence for the role of participatory art in supporting health and well‐being is growing. The Arts on Prescription model is one vehicle by which participatory art can be delivered. Much of the focus of Arts on Prescription has been on the provision of creative activities for people with mental health needs. This Arts on Prescription program, however, targeted community‐dwelling older people with a wide range of health and wellness needs. Older people were referred to the program by their healthcare practitioner. Professional artists led courses in visual arts, photography, dance and movement, drama, singing, or music. Classes were held weekly for 8–10 weeks, with six to eight participants per class, and culminated with a showing of work or a performance. Program evaluation involved pre‐ and postcourse questionnaires, and focus groups and individual interviews. Evaluation data on 127 participants aged 65 years and older were available for analysis. We found that Arts on Prescription had a positive impact on participants. Quantitative findings revealed a statistically significant improvement in the Warwick–Edinburgh Mental Well‐being Scale (WEMWBS) as well as a statistically significant increase in the level of self‐reported creativity and frequency of creative activities. Qualitative findings indicated that the program provided challenging artistic activities which created a sense of purpose and direction, enabled personal growth and achievement, and empowered participants, in a setting which fostered the development of meaningful relationships with others. This evaluation adds to the evidence base in support of Arts on Prescription by expanding the application of the model to older people with a diverse range of health and wellness needs.

What is known about the topic

• Evidence for the role of participatory art to support health and well‐being is growing.

• Arts on Prescription (first delivered in the UK) is one model for delivering participatory art.

• There is limited peer‐reviewed research on the benefits of Arts on Prescription for older people with diverse health and wellness needs.

What this paper adds

• Arts on Prescription has a positive impact on the mental well‐being of older people with diverse health and wellness needs.

• Purpose and direction, personal growth and achievement, empowerment, and meaningful relationships with others were reported by participants.

• The Arts on Prescription model can assist in an holistic approach to meeting the health and wellness needs of older people.

1. INTRODUCTION

There is a growing body of evidence supporting the role of the arts in the enhancement of health and well‐being (Boyce, Bungay, Munn‐Giddings, & Wilson, 2018; Cann, 2017; Clift, 2012; Clift & Camic, 2016). Arts on Prescription (AoP), first delivered in the United Kingdom in 1995 (Rigby, 2004), is one vehicle by which participatory art has been delivered to people with health and wellness needs. In such programs, health and social care practitioners refer people to a range of creative activities undertaken in a group setting within the community, facilitated by professional artists and as an adjunct to conventional therapies, with the aim of aiding recovery and promoting health and well‐being (Bungay & Clift, 2010). The “prescription” is one way in which the activity is validated. Much of the focus of AoP has been on the provision of creative activities for people with mental health needs, and the evidence suggests positive benefits which include improvements in self‐esteem, confidence, and mood as well as greater social contact (Bungay & Clift, 2010; Jensen, Stickley, Torrissen, & Stigmar, 2017). Furthermore, evidence finds that it is valued by referring health professionals (Stickley & Hui, 2012) and may be cost‐effective (McDaid & Park, 2013). More recently, significant improvements in well‐being following an arts‐on‐referral intervention have been reported for primary care patients (mean age of 53.2 years) with self‐reported multimorbidities (e.g., metabolic, neoplastic, cardiovascular) (Crone et al., 2018). Scandinavian research suggests that AoP may also assist participants’ ability to cope with long‐standing pain (cited in Jensen et al., 2017; Rydstad, Löfgren, & Drakos, 2015).

AoP reflects the international shift away from the biomedical model of health to a more holistic approach which sees health as "complete physical, mental, and social well‐being" (Rigby, 2004; World Health Organization, 2014, p.1). In keeping with this holistic perspective, AoP programs are often delivered by the community, voluntary, or social enterprise sector (Jensen et al., 2017), utilising artists (rather than therapists) to work with small, community‐based groups of participants (Bungay & Clift, 2010). Therefore, active participation in the creative activity operates not only at the individual level but also at the group level through social engagement and inclusion (Bungay & Clift, 2010). Furthermore, demedicalised settings make AoP programs potentially less stigmatising for participants (Jensen et al., 2017). Since creative activity is inherently flexible, it can be adapted to meet the skills and limitations of participants, and thus, there are likely to be few restrictions on the type of participant who may attend. However, there continues to be limited published peer‐reviewed evidence of the benefits of AoP outside its role for participants with mental distress; much of the research is qualitative with small sample sizes; and studies involving older populations are scarce.

This paper reports the findings from an AoP program in Sydney, Australia, which targeted community‐dwelling older people with a wide range of health and wellness needs. The program was developed, implemented, and evaluated through a unique collaborative partnership comprising a large aged care provider (expertise in service delivery), and a University Faculty of Medicine (expertise in evaluation) and Faculty of Art and Design (expertise in arts education and practice). The program was funded for an 18‐month period by the Australian Government as a new and innovative service delivery project to address healthy and active ageing, an identified aged care priority area. This paper addresses some of the limitations of previous research and includes a large sample size, evaluation using a before and after design with both quantitative and qualitative methodologies, and a broad target group comprising older people with a diverse range of needs.

2. METHODS

2.1. Program design

The AoP program was publicised within the two local communities through visits by program staff to health practitioners, local councils, libraries, community groups, and local hospitals. Media coverage through local papers was also achieved. Referrals to the program were accepted from a wide range of health practitioners.

Eligible participants were aged 65 years or older, living at home within the catchment areas, able to participate in a small group program, and independent or requiring only minimal assistance with self‐care.

Courses were available in the visual arts, photography, dance and movement, drama, singing, and music. Classes were held weekly for 8–10 weeks, with six to eight participants per class. A community care worker or volunteer was available during each class to assist participants and artists and to help with the preparation of morning or afternoon tea. Each course concluded with a showing of work or a performance. Participants could take up to three consecutive courses; a fourth consecutive course was only possible under special circumstances. The ability to take consecutive courses was limited by the program duration, and participants who were referred towards the end of the program were usually limited to a single course only. At the conclusion of the AoP program, a professionally curated exhibition with performances was held in the local community and on the University campus.

2.2. Artist recruitment and training

Professional artists were recruited through advertisements. Eleven were selected at interview and subsequently attended 2 days of training which highlighted the role of art in health, the health and wellness needs of older people, and ways of working with older people. While some art forms, such as movement and dance, naturally required physical activity, all artists were instructed to encourage physical activity where possible, such as encouraging participants to get their own morning or afternoon tea from the tea room, to stand at an easel, or to walk outside to find objects. The training also allocated time for artists to work together to plan their first class activities.

2.3. Questionnaires and data collection

The referring health practitioner provided basic demographic details, and relevant health information from a tick box list, with additional written details if needed. Referrers also identified their health and wellness aims for each referral, selected from listed tick box responses (for example, increased physical activity levels, improved mental health, cognitive stimulation, etc.). The referred person provided an emergency contact, their preferred availability, any special requirements (e.g., mobility needs), and written consent for their health and personal details to be shared with the AoP team to enable appropriate course placement.

On enrolment, participants received a participant information statement explaining the planned evaluation of the AoP program; those willing to participate in the evaluation provided written informed consent.

2.3.1. Precourse questionnaire

At the commencement of each course, participants completed a precourse questionnaire which contained open‐ended questions, statements to respond to using Likert scales, and validated measures of mental well‐being and frailty.

Open‐ended questions sought the ways in which participants hoped to benefit from the AoP program. Likert scales measured participants’ perceived levels of creativity [ranging from 0 (I do not feel that I am at all creative) to 10 (I am an extremely creative person)] and their frequency of engaging in creative activities [ranging from 0 (I stay away from creative activities) to 10 (I am always doing creative activities)].

Mental well‐being was measured using the Warwick–Edinburgh Mental Health and Well‐Being Scale (WEMWBS), developed and validated by Tennant et al. (2007). This self‐administered scale contains 14 positively worded items (answered on a 1–5 Likert scale) relating to different aspects of positive mental health. Scores range from 14 to 70, with a higher level indicating a higher level of well‐being. The WEMWBS has been shown to be sensitive to change at both the individual and group level (National Health Scotland, 2015).

To determine decline in physiological reserve and function, frailty was measured based on the definition by Fried and colleagues (Fried et al., 2001). Five recognised criteria which include unintentional weight loss, exhaustion, low physical activity level, slow walking speed, and weakness were used (Fairhall et al., 2008). Participants meeting three, four, or five criteria, as defined in Table 1, were deemed as frail; participants meeting one or two criteria were considered as possibly prefrail (Fried et al., 2001). Unintentional weight loss, exhaustion, and low physical activity levels were based on self‐reported responses by participants on the precourse questionnaire. Program staff took two measures of the time to walk four metres at usual pace (allowing a lead up of two metres) and two measures of grip strength (in kilogrammes) in the right and left hands, using a dynamometer; these measures were added to the precourse questionnaire. The first precourse questionnaire completed by a participant was considered to provide the baseline data.

Table 1.

Frailty measures used

Unintentional weight loss defined as a loss of more than 4.5 kg unintentionally in the past 12 months. Self‐reported exhaustion—this criterion was met if, for the last 7 days, the response to both the following questions was “occasionally or a moderate amount of time (3–4 days)” or “most or all of the time (5–7 days)”: “How often did you feel that everything you did was an effort in the last week?” and “How often did you feel that you could not get going in the last week?” Low physical activity—this criterion was met if, in the past 3 months, participants did not perform weight‐bearing physical activity (e.g., housework, outside chores, gardening), spent most of their time sitting, and only went for a short walk once per month or less. Slow walking speed was defined as a walking time of 6 s or more over four metres (average of two measures). Weakness—defined as grip strength of 30 kg or less for male participants; 18 kg or less for female participants. The best attempt achieved from either the left or right hand was used as the maximum handgrip strength measure.

Adapted from Fairhall, Aggar et al. (2008).

2.3.2. Postcourse questionnaire

At the conclusion of each course, participants completed a questionnaire similar to the precourse questionnaire. Open‐ended responses asked participants to report the ways in which they had benefitted from the AoP program, and which aspects of the course they enjoyed the most and the least. Measures of creativity (level and frequency), the WEMWBS, and measures of the frailty criteria were repeated (with the exception of unintended weight loss since this question related to a 12‐month period); postprogram data for these variables were drawn from the last postcourse questionnaire completed by a participant.

2.3.3. Focus groups and interviews

Eight focus groups of participants (19 males, 29 females) and four individual interviews (two males and two females) were undertaken over the program period. Each was guided by the same predetermined list of questions. Interviews were recorded and transcribed for analysis.

2.4. Data analysis

2.4.1. Quantitative data

Quantitative data analysis was undertaken using SPSS Version 24. Baseline and postprogram comparisons were made using the paired t test for paired numerical data and the McNemar test for paired categorical data; an independent samples t test was used to compare mean differences in WEMWBS scores for participants who attended more (three or four) compared to less (one or two) courses. Assumptions of approximate normality were confirmed by graphical assessment (Q‐Q plots) prior to the use of parametric tests.

The management of missing data on the WEMWBS has not been tested and reported in the literature, but the estimation of more than three missing items is considered unlikely to be robust (National Health Scotland, 2015). Where a score on one of the 14 items was missing on the WEMWBS, the missing value was imputed by giving it the average score derived from the 13 completed items. Where two or more items were missing from the WEMWBS, the total score was considered missing and excluded from analysis, or, in the case of a precourse WEMWBS, replaced with the subsequent precourse WEMWBS, if available. Using the second or third precourse questionnaire as the baseline score might be expected to minimise any difference between pre‐ and postprogram scores; thus, we considered our approach to missing data to be conservative.

2.4.2. Qualitative data

After reading and rereading the transcripts, focus group and interview data were coded inductively by the first author (RP), using NVIVO 11 (NVivo qualitative data analysis software, 2010). Initial codes were grouped into a number of themes, and extracts within the data which most typically illustrated each theme were selected and reviewed, with themes being refined as necessary (Braun & Clarke, 2006). Textual responses to the open‐ended questions on the pre‐ and postcourse questionnaires were also read and coded thematically, and where data overlapped, responses were found to support existing themes. Thematic analysis was confirmed by a second author (DH) who reviewed the questionnaire responses and transcripts.

2.5. Ethics

The AoP evaluation was approved by the UNSW Human Research Ethics Committee.

3. FINDINGS

Between August 2015 and April 2017, 190 referrals were received; however, 31 of those referred did not commence (changed their mind, could not find a conveniently timed class, moved away). Also excluded from analysis are 19 participants referred for special pilot courses (courses for non‐English speakers or residents living with dementia in an aged care home); 12 participants aged under 65 years of age who were accepted onto the program at the special request of their healthcare practitioner; and one participant who could not provide informed consent. Thus, data on 127 participants aged 65 years and over are available for analysis.

3.1. Referral source and courses attended

The majority of participant referrals (n = 126, missing data = 1) came from medical practitioners (59.5%), followed by pharmacists (16.8%), allied health practitioners (15.1%), pastoral carers (7.1%), and nurses (1.6%).

Most participants attended between one and three courses (see Table 2). Enrolment in a fourth course occurred because a participant had become unwell and was unable to complete a previous course (n = 7), or because a participant had expressed an interest in doing an additional course, and a place was available (n = 6).

Table 2.

Number of art courses attended

Number of courses attended	Count	Percentage
One	52	40.9
Two	33	26.0
Three	29	22.8
Four	13	10.2
Total	127	100

3.2. Demographics, health information, and health aims for the program

Most participants were female (n = 94, 74.0%); the average age on enrolment was 78.1 years (S.D. 7.99 years), with a range from 65.0 years to 96.2 years.

Table 3 shows relevant health information provided by referring healthcare practitioners. Declining physical function, social isolation, and declining sense of overall well‐being were the most commonly identified issues. Almost two‐thirds (62.4%) of participants had two or more issues identified. Additional health information about participants considered relevant by referrers included the following conditions: lung disease (e.g., COPD, asthma, bronchiectasis), cardiac disease, diabetes, venous insufficiency, osteoporosis, stroke, Parkinson's disease, joint replacements, back pain, and mobility issues. Special requirements impacting program participation identified by participants themselves focussed on mobility concerns (poor balance, fear of falling, limitations in walking distance, needing assistance to stand, and being unable to stand for long periods of time), poor vision, and hearing loss.

Table 3.

Participant health information and health and wellness aims as indicated by referring healthcare practitioner, n = 127

	Count	Percent
Relevant health information (one or more may apply from defined list)
Declining physical function	52	40.9
Socially isolated/declining social interaction	41	32.3
Declining sense of overall well‐being	38	29.9
Chronic pain and illness affecting wellness	30	23.6
Frail or prefrail	30	23.6
Anxiety	28	22.0
Depression	28	22.0
Mild cognitive impairment, early or moderate dementia	24	18.9
Carer burden	10	7.9
Recent bereavement or loss	9	7.1
Health and wellness aim (one or more may apply from defined list)
Increased social connections	79	62.2
Create new interests	73	57.5
Improved mental health	69	54.3
Cognitive stimulation	65	51.2
Increased physical activity levels	63	49.6
Help find contentment/spiritual well‐being	34	26.8
Help manage loss/bereavement	10	7.9
Enrich relationship with care‐giver	9	7.1

The most common health and wellness aims for the participants identified by their referring healthcare practitioners included increased social connections, the creation of new interests, and improved mental health. Referrers identified multiple aims for most (91.2%) participants. See Table 3.

3.3. Physical measures of frailty

At baseline, unintentional weight loss was reported by 19 (17.3%, n = 110) participants; self‐reported exhaustion by 29 (25.2%, n = 115) participants, and low physical activity by 14 (12.2%, n = 115) participants. Slow walking speed was identified in 22 (21.4%, n = 103) participants and weakness in 56 (49.6%, n = 113) participants.

Nine (7.5%) participants scored three or more on the recognised criteria indicating frailty (n = 120); 30 (25.0%) participants scored two, and 48 (40.0%) scored one on the criteria, suggesting possible prefrailty. The number of participants with frailty and prefrailty may be an underestimate, as data on all five criteria were available on only 91 (71.5%) participants.

There were no statistically significant differences between baseline and postprogram assessments in the proportion of participants scoring on the individual frailty criteria of self‐reported exhaustion (determined from two items), low physical activity levels (determined from three items), slow walking speed, or weakness.

3.4. Creativity measures

On a Likert scale ranging from 0 to 10, the average baseline level of creativity was 5.1 (SD = 2.5) and of frequency of creative activities was 4.4 (SD = 2.7) (n = 116). Postprogram the mean levels had increased to 6.9 (SD = 2.1) and 6.2 (SD = 2.4) respectively (n = 110). Paired samples t tests found a mean difference of 1.56 (95% CI: 1.14–1.98) for level of creativity (t = 7.35, df = 99, p < 0.001) and 1.60 (95% CI: 1.06–2.14) for frequency of creativity (t = 5.91, df = 99, p < 0.001).

3.5. WEMWBS

For four participants, an imputed score on a single missing item in the baseline WEMWBS was required; and because multiple WEMWBS items were missing, precourse WEMWBS scores from the second (for four participants) and third (for three participants) courses were used as baseline scores. This resulted in baseline WEMWBS scores for 123 participants. Scores ranged from 24 to 68, with the mean baseline WEMWBS score being 49.8 (SD = 9.4).

An imputed score on a single item in the postprogram WEMWBS was required for six participants, giving postprogram WEMWBS scores for 107 participants. Scores ranged from 33 to 70, with the mean postprogram WEMWBS score being 56.6 (SD = 7.7).

There was a statistically significant increase in WEMWBS scores between baseline and postprogram. The mean increase was 6.86 (95% CI: 5.33–8.38) points on a paired samples t test (t = 8.91, df = 104, p < 0.001). Over two‐thirds (69.5%) of participants had an increase of three or more points between the baseline and postprogram.

There was a statistically significant increase in scores for participants who attended one or two courses only (mean increase of 7.25, 95% CI: 5.39–9.11, t = 7.78, df = 63, p < 0.001), with 71.7% having an increase of three points or more. For those who attended three or four courses, the mean increase was 6.24 (95% CI: 3.53–9.00), also a statistically significant increase (t = 4.65, df = 40, p < 0.001), with 65.9% of participants having an increase of three points or more. The mean increase in WEMWBS scores did not differ by number of courses attended (i.e., one or two courses only vs. three or four courses; t = 0.636, df = 103, p = 0.526).

3.6. Qualitative data analysis

3.6.1. Ways in which participants hope to benefit from AoP (precourse)

Textual responses provided on precourse questionnaires (Q‐Id no.) about the ways in which the participants hoped to benefit from the program suggested several different themes. The first theme centres on participants hoping to “learn something new”(Q‐w1), to develop a “new skill” (Q‐e7), and to do “something different” (Q‐z3). Some participants were more specific such as wanting “to be able to play guitar” (Q‐e9), or “to use water colour paint” (Q‐a6); others hoped “to stir my creativity” (Q‐z5), to be “challenge[d] to try out new things” (Q‐a2), or to have “help in finding out what little talent we have” (Q‐u4).

Connecting with others and wanting to socialise was the second theme. This was often expressed as a desire to “meet” (Q‐t4) or “talk” (Q‐t6) to people or “making friends” (Q‐v4); others expressed a wish to become “a member of a group” (Q‐k9) and to “enjoy being in group activities” (Q‐m0).

The third theme identified was a hope to benefit by addressing some of the limitations, losses, or conditions associated with ageing. Some related to physical functioning, for example, to “help with chronic pain” (Q‐w9), to “get more movement in my hands” (Q‐a0), “to keep me walking despite peripheral neuropathy” (Q‐u8), or to gain “physical stamina and fitness” (Q‐j0). Others related to mental well‐being, for example, participants were seeking “motivation” (Q‐k4), “confidence” (Q‐k7), “relaxation” (Q‐k8), to “forget about worries” (Q‐t1) and to have “a reason to get dressed and go out”(Q‐z4). Maintaining brain health was also identified with participants wanting “to stay positive and slow memory loss” (Q‐o8) and “to keep my brain active” (Q‐z8).

3.6.2. Benefits identified by participants of AoP (postcourse)

Thematic analysis of focus group (FG) and interview (I) data and textual questionnaire (Q) responses on the benefits of AoP can be described under four main themes.

a. A sense of purpose and direction

This first theme relates to participants finding a new interest to pursue, feeling motivated, and being optimistic about the next stage in their lives.

Some participants described a sense of loss associated with ageing,

as you get older it's very easy to sit there and feel sorry for yourself and say there's nothing out there for me, what can I do? (FG‐1)

In contrast, they described AoP as offering “something constructive” (FG‐7), providing “an interest” (FG‐4), and of “going somewhere with a particular purpose in mind” (FG‐4).

For others, the program provided a new focus for the loss of direction which they experienced specifically related to retirement,

I think once we get a bit older and we retire, sometimes we wake up and say well what am I going to do today apart from the washing and the ironing or whatever; what am I going to do today? …But now we know okay Wednesday I'm going to [name] class….I think it gives you something to look forward to…you just get a bit of motivation in life. (FG‐4)

Participants also spoke of their artistic endeavours as “being a starting point” (FG5) and “the start of really something opening up for [me]” (FG‐7).

A number of participants pursued their new interest at home in conversations with family, by buying their own paints and brushes, or “finding songs that I want to put into my own repertoire” (FG‐4).

b. Personal growth and achievement

This theme related to self‐discovery gained by taking on a new challenge and finding success. This was reflected in statements about “a real sense of satisfaction” (FG‐1) and of “surprise” (FG‐8) in regard to their achievements. Participants invariably approached the program with the impression that they were “no good at art” (FG‐7), did not have “a musical bone in our body” (FG‐7), or were not “capable of doing that” (FG‐4).

Participants spoke about being “inspired” (Q‐n9), of realising they had “some sort of gift there” (FG‐7), of being “more creative than I thought” (Q‐n4), or of uncovering a “latent talent” (FG‐3). Participants shared how they had needed help to begin this journey of personal growth and achievement, with one participant describing this as “something else to actually pull that trigger. And for me this is what it [AoP] has been” (FG‐7).

The artistic activities challenged participants, and it was this sense of rising to meet the challenge that enhanced their sense of achievement,

Basically my brain is getting dead and there is not much I can do about it because I can't remember anything. So I am limited in what I can do. But ... I've made four things now, and two of them came in very well. (FG‐2)

I think it gave me a sort of sense of achievement because like [name] I mean I haven't painted ... but when you're actually trying something and some aspect of it works ... there's a real sense of satisfaction there. (FG‐1)

Praise which celebrated achievement provided participants with validation that they had succeeded.

I've enjoyed every part of it and I suppose you know like all of us, we enjoy a bit of praise when we do something that you know, you think oh I didn't think I'd ever be able to do that… but I did it. (FG‐4)

c. Empowerment

Increased self‐confidence and self‐determination were evident among participants. They spoke about the program building “self‐esteem” (Q‐j2), and developing their confidence to tackle what they did not have the confidence to take on previously.

I've always wanted to do artwork, but I never had the confidence. (FG‐7)

I thought, you are useless, you are really bad, and I had no confidence but now I feel,’oh,’ so it's been like an awakening. (FG‐7)

Several spoke of being inspired by others in their class, and thus empowered,

I thought to myself, if they can do it, I can do it. (I‐2)

Given their recent successes, some participants voiced plans to challenge themselves with new and different artistic endeavours.

I am now going to the next course and I am going to learn to play ukulele because I spoke up and said I would really like to learn the ukulele, done, right so that's what's happening next time, I hope. (FG‐5)

A number of participants implied a new sense of assurance, empowered to meet broader challenges in their lives, and even to seek challenges.

[I] have gained confidence and belief in myself and new challenges. (Q‐b8)

I have learnt to see beyond my expectations of myself. (Q‐a2)

This course is….a stepping stone for all of us to go on to something bigger and greater in our own lives. (FG‐7)

d. Relationships with others

The fourth theme relates to meaningful companionship—interactions where people shared their experiences, listened to each other, encouraged one another, and displayed empathy. The program provided “company because I'm very lonely at home” (Q‐b6) as well as interactions which were described as “enriching” (Q‐t9), “invigorating” (FG‐7), and “terribly important” (FG‐3).

Participants described their group interactions as comprising “in‐depth talks” as well as “laughs” and “chatter, chatter work, work, chatter, chatter” (FG‐7).

Participants indicated that art created a shared interest which facilitated connection between people and the development of friendships, and one group (unprompted) reported meeting outside the program for coffee.

I think when people who are of a similar age or a similar outlook on things, it creates that little safety zone and we're okay to share some deep personal things along with the enjoyment of doing something as a collective. (FG‐7)

Sentiments that the group was about more than just the art were expressed by a number of participants:

Whether we did a good job or not a good job, that was not important ... it was just having an opportunity to spend time with one another, enjoying one another. (FG‐5)

3.6.3. The role of the artists

Focus group interviews suggested that the artists played an important role in creating and supporting participant autonomy, through working in partnership with participants, and supporting the artistic process with constructive encouragement and “formal” recognition.

Participants described artists as coming alongside them to provide guidance rather than strict instruction or direction.

They let us find our own way. They kind of guide us but they tell us you know, you try and see what you can do. (FG‐1)

She was a marvellous tutor and she didn't sort of take on just the brilliant people you know, she actually helped people to really do it without taking over, brilliant. (FG‐5)

She seems to work in a way wherever people feel a bit restricted. She seems to open things up and make it work. (FG‐3)

Artists drew out participant ideas and supported their development into creative works which participants owned, as opposed to artists stipulating an idea or leading the work.

We actually hadn't been taught anything but it's worked out well – [the artist] sits there and says ”Okay, recommend some songs, tell me songs that you like” … and [he's] taken them away and the next week he's come back with the words and all that, the chords, and we've had to almost do it ourselves, he's thrown it back on us, and it's great. (FG‐4)

Participants described artists as “very supportive” (FG‐4) and “very encouraging and complimentary” (FG‐2) which provided participants with the confidence to proceed with their artistic challenges.

Well she encourages no matter what you do. The encouragement that you're doing well. Oh yes...she'll come beside you and say, well how about, have you thought of this? And it was just the gentle way she interacted with me. (FG‐2)

Artists provided validation and celebration of participants’ artistic achievements through exhibition or performance at the conclusion of a course.

when we got to the end, we were given the chance to perform, okay, to show‐off what we had actually been doing. (FG‐5)

4. DISCUSSION

This paper presents the findings from a large AoP program targeting older people with diverse health and wellness needs. Referrals to the program were sought from a range of community‐based health professionals. As AoP is not an established program in Australia (to our knowledge, this is the first program under this banner), considerable effort by the project manager and team was required in the initial stages, to raise awareness within the community and to educate local health practitioners on its potential uses and benefits. While the role of arts and health through creative, participatory, or receptive interventions has recently been acknowledged by the Australian Government through its National Arts and Health Framework indicating a supportive policy climate (Australian Government, 2014), it was our experience that health practitioner knowledge of participatory art as a non‐medical intervention alongside existing treatments for patients is limited.

Making art has always been an intrinsic part of what it means to be human (Langer, 1966; MacGregor, 2011), but a constant creative practice is not a given; its development can be either stifled or cultivated by a whole range of cultural and societal factors (Hickman, 2010; Pinker, 2003). Baseline questionnaire responses indicated that, in general, our older participants did not see themselves as “creative”; this finding was supported in focus groups and individual interviews. Increases in the level of self‐reported creativity and self‐reported frequency of creative activities suggest that AoP was both nurturing participants’ sense of creativity and authorising its practice. Furthermore, facilitation by professional artists enabled the production of creative works which were worthy of celebration and acknowledgement through exhibition or performance, affirming “creativity” to the participants themselves, their families, and their community. Some work, professionally framed, remains on display in facilities frequented by participants.

Baseline data indicates that the program was delivered to participants within the target group. Issues relating to mental well‐being were common indications for referral. Limitations in reported physical capacity (such as declining physical function, chronic pain, frailty or prefrailty, and limited mobility) suggest that opportunities for active engagement within the broader community may have been restricted for many participants; this would appear to be supported with the identification by referrers of “increased social connections” as the most frequently reported health and wellness aim for participants.

We found evidence in support of the positive impact of participatory art on the mental well‐being of participants, as measured by the WEMWBS. Over two‐thirds of participants in the AoP program showed an increase of three or more points on the WEMWBS. The mean improvement of almost seven (6.86) points from baseline to postprogram was statistically significant, with other research suggesting it may also represent clinical improvement. Data gathered from a University Staff Counselling Service found a statistically significant correlation between level of improvement on the WEMWBS and level of clinical improvement observed by counsellors (Ragonesi, Parsons, & Stewart‐Brown, 2013). Other work reported suggests that a change of three or more points is likely to be recognisable as an important change to an individual (National Health Scotland, 2015).

Our thematic analysis of qualitative data from focus groups, individual interviews, and textual questionnaire responses on the benefits of participatory art, resonates with theoretical dimensions of eudaimonic well‐being from other research. Eudaimonia refers to living life to its fullest potential, gained through engagement in meaningful endeavours (Ryan & Deci, 2001; Steger, Kashdan, & Oishi, 2008). Ryff (1989) described six theory‐guided constructs that are associated with psychological well‐being. These include self‐acceptance (defined, for example, by a positive attitude towards self), positive relations with others (defined, for example, by warm, satisfying, trusting relationships with others), autonomy (defined, for example, by self‐determination and independence), environmental mastery (defined, for example, by a sense of mastery and competence in managing the environment), purpose in life (defined, for example, by having goals in life, a sense of directedness, belief that life has purpose), and personal growth (defined, for example, by a feeling of continued development, of realising one's potential, and changes that reflect more self‐knowledge and effectiveness). Activities which are meaningful, worthwhile, and enable one's potential to be fulfilled foster the achievement of these constructs and the development of enduring well‐being (Steger et al., 2008). This is in contrast to activities which focus only on achieving simple pleasure or happiness (hedonia), which are more fleeting (Steger et al., 2008).

Some of Ryff's dimensions of psychological well‐being, specifically, purpose in life and personal growth, show declines in older age, from middle age (Ryff, 1989). Ryff and Singer (2008) propose that sharp downward trends in purpose in life and personal growth particularly may reflect the current challenges faced by society in offering older people roles which are meaningful and in providing opportunities for sustained growth. Given that three of the four themes identified in this current research (which we labelled personal growth and achievement, a sense of purpose and direction, and empowerment) overlap aspects of these constructs shown by Ryff (1989) to decline in older age, suggests that programs such as AoP are helpful in addressing this societal void experienced by older people.

For some participants, the AoP program also addressed loneliness, by encouraging the development of relationships with others. Australian research indicates that around one‐third of older people report feeling lonely at least sometimes which is comparable to samples in other countries (Steed, Boldy, Grenade, & Iredell, 2007). Steed et al. (2007) found that having friends and a confidant were important in protecting against loneliness. The common point of interest created by the art‐making process was reported by participants to facilitate relationship building which enabled participants to share personal matters within their group. This finding is supported by other research which suggests that friendships emerge more readily from shared activities than in settings which are more overtly focused on friendship formation (Cattan, 2005).

We suggest that the manner in which the professional artists worked with participants also facilitated the gains in mental well‐being attained. Participants reported that they were challenged by their artistic endeavours and met these challenges in partnership with the artists who provided constructive encouragement. Importantly, artists avoided activities which were prescriptive and directive, focussing on empowering participants and maximising opportunities for personal growth and achievement.

The WEMWBS provides a single quantitative measure combining both hedonic and eudaimonic perspectives on mental well‐being (National Health Scotland, 2015). The qualitative findings from focus groups and individual interviews were valuable as a means of triangulating the program outcomes as determined by the WEMWBS; and in providing a deeper understanding of how and why AoP may enhance positive mental health in older people.

The proportion of participants with frailty at baseline was somewhat similar to reported estimates of frailty for community‐dwelling older Americans (65 years and older), which range from 7% to 12% (Xue, 2011). Frailty puts older adults at greater risk of poor health outcomes, and prefrailty puts older adults at risk of progression to frailty (Xue, 2011). Therefore, calls have been made to prioritise research into interventions to prevent or reduce frailty (Xue, 2011). We were unable to demonstrate statistically significant reductions in the number of participants scoring on individual frailty criteria. Given that specific and intensive interventions are generally required to address frailty (Fairhall et al., 2008), these findings are not unexpected. We had insufficient data to examine the impact of individual art forms, such as movement and dance, on frailty, and all courses were offered only on a weekly basis. However, other research on arts and health has found effects on physical health more generally. For example, Clift et al. (2013) found that singing reduced chronic respiratory symptoms and Heiberger et al. (2011) found that dancing improved functional mobility.

4.1. Limitations

The AoP program was only offered to older people from two geographic areas in metropolitan Sydney. These areas represent people from diverse cultural backgrounds and areas of higher and lower socioeconomic status. However, caution should be applied in generalising our findings to a broader population. As focus group transcripts were deidentified, it is possible that focus group findings may include some participants aged less than 65 years of age. Given the small number of younger participants in the AoP program, this is unlikely to have had a marked impact on our qualitative results. Since our AoP program was a funded service, rather than a research project, we deliberately limited the number of measures at baseline and outcome so as not to burden participants. Anecdotal accounts of improvements in physical health were shared with artists, but these were not objectively measured. We suggest future researchers consider the inclusion of measures to capture changes in chronic respiratory symptoms and functional ability.

5. CONCLUSION

This evaluation adds to the limited evidence base in support of AoP for older people and presents, to our knowledge, the first evaluation of AoP in Australia. Our results suggest a positive impact on mental well‐being for participants with a diverse range of health and wellness needs. This may be due to the program's ability to foster eudaimonic well‐being through the provision of challenging artistic activities which create a sense of purpose and direction, enable personal growth and achievement, and empower participants, in a setting which fosters the development of meaningful relationships with others. The Australian Government is currently pursuing a wellness and reablement agenda in the delivery of funded support services in the community to eligible older people (Department of Health, 2018). The group‐based nature of AoP presents an efficient model of service delivery in comparison to services delivered on an individual basis, and the outcomes from AoP align closely with the intended outcomes of the Commonwealth Home Support Programme (Department of Health, 2018). These elements may support the wider adoption of AoP programs for older people, in Australia.

CONFLICT OF INTEREST

No conflicts of interest have been declared

Poulos RG, Marwood S, Harkin D, et al. Arts on prescription for community‐dwelling older people with a range of health and wellness needs. Health Soc Care Community. 2019;27:483–492. 10.1111/hsc.12669