Using the arts for awareness, communication and knowledge translation in older adulthood: a scoping review

ABSTRACT

Background

The arts are powerful methods of enhancing social engagement and well-being in older adulthood. Literature on arts utility in translating knowledge about ageing and related processes is emerging but poorly understood. We conducted a scoping review to map research on how the arts are used for awareness, communication, and knowledge translation in older adulthood.

Methods

We consulted a research librarian, comprehensively searched four interdisciplinary databases, systematically screened 1321 articles and extracted data from 11 included articles.

Results

Articles predominantly originated from the Health Sciences, were informed by qualitative data, and were developed linearly, from problem identification to art development. Performance theatre was the most commonly employed narrative approach.

Conclusions

Approaches to arts development in this context do not maximize collaboration and participant engagement, thereby reducing potential impacts of arts for older persons. We propose a cyclical and collaborative alternative to developing arts strategies for combined communicative and engagement purposes.

KEYWORDS:

• Arts-based knowledge translation
• creative communication
• arts-engagement

Ageing spans a complex continuum of opportunity and challenge. The intricacies of managing chronic diseases are compounded by physiological and sensory changes encountered throughout the ageing process (Speros, 2009). Prevailing social undercurrents of ageism threaten dignified care provision for older adults and contribute to the internalization of ageing-identities (Koch, Power, & Kralik, 2007). Older adults are disproportionately affected by low health literacy, which is an important determinant of health outcomes, including mortality (Bostock & Steptoe, 2012). As policy and care sectors seek ways to support and mitigate these challenges, researchers, practitioners and health organizations are increasingly looking to the arts as viable and effective approaches to improving well-being in the ageing population, thereby leveraging the creative and profound growth potentials made possible in older age (Cohen, 2006).

Perspectives on the arts and older adulthood

Art is an integral facet of culture and one of the powerful methods of communicating about and understanding human experience (Wainwright & Williams, 2005). Relatively recently, health researchers attuned to these historical facts have begun, with increasing frequency, to leverage the myriad benefits of arts engagement in older adulthood (Fraser et al., 2015). Growing evidence attests to the positive impact of art on individuals, communities and societies (Blanchard, 2006; Davies, Knuiman, Wright, & Rosenberg, 2014). The benefits of arts-engagement in later life extend across social, physiological and psychological spheres and has been shown to reduce blood pressure, anxiety and depressive symptoms; enhance social connectedness and community engagement; improve self-efficacy, sense of purpose, functional health literacy, quality of life and overall wellness (Cohen et al., 2006; Feldman, Radermacher, Lorains, & Haines, 2011; Fraser et al., 2015). In many contexts, these benefits translate into a reduced need for medical intervention and a corresponding reduction in health service use. Such benefits highlight the intrinsic and instrumental value of arts engagement.

Changing perspectives on the nature of ageing have contributed to a renewed interest in the role of arts on well-being in later life. Until relatively recently, ageing has largely been viewed from a deficit perspective, wherein the opportunities encountered in older adulthood are overshadowed by the challenges that ageing presents (Carr, Wellin, & Reece, 2009). In the late twentieth Century, a shift in thinking began, and it was recognized that potential exists for creativity and growth throughout the life cycle (Cohen et al., 2006). The accompanying shift from a deficit to a potentials perspective of ageing mirrors the dramatic social and personal changes evoked by a greying society (Hannah & Perlstein, 2008).

Globally, a number of programs, movements and policies have taken shape to capitalize and catalyze the potentials of creativity in older adulthood (Blanchard, 2006). The creative ageing movement has emerged to help older adults create and develop relationships based on mutual interest and support, enhance participation in art therapies with known benefits on common health ailments such as anxiety and depression, and to increase the availability of art activities often designed to enhance social interaction (Cox et al., 2010). The main objective of creative ageing is to usher in a new paradigm where older adults are seen for their potentials, not their deficits (Hannah & Perlstein, 2008).

Despite ripples of changing societal views, positive perspectives of ageing are not universal. Ageism persists as a systematic process of stereotyping and discriminating against individuals on the basis of age and is perhaps the “last socially acceptable form of discrimination” (Kagan & Melendez-Torres, 2015, p. 644; Koch et al., 2007). While individuals hold these views, they are often unintentional, reflect deeply entrenched social values, and are “reinforced and perpetuated by the wider community” (Koch et al., 2007, p. 53). Health care providers (HCPs) are not immune to ageism: totalized identities of older persons as intellectually frail and otherwise incapable persist and can have devastating effects on care provision (Kagan & Melendez-Torres, 2015). Recognizing that ageism is socially constructed and perpetuated underscores potential avenues for change, and in recent years, research communities have looked to the arts to challenge negative societal beliefs by providing space for reflection and ushering in opportunities for more nuanced discussion. In addition to these potentials and adding to arts’ contributions to well-being, the arts can help elucidate the experiences of older persons. These experiences can then be used as the basis for communication and awareness building to entice new societal understandings (e.g. arts-based knowledge translation).

Arts-based knowledge translation and creative communication in older adulthood

Arts-engagement is an umbrella term encompassing the various ways in which individuals interact with art. Arts-based knowledge translation is a narrower term that refers to the use of any artistic modality or combination of arts-based approaches used to disseminate, engage with, or communicate about research (Archibald, Caine & Scott, 2014). This concept aligns with the perspective of the Canadian Institutes of Health Research (2015) that non-academic communication such as popular media and the arts should be the focus of knowledge translation (Alberta Health Services, 2015). Also important to this vision is the concept of creative communication and engagement, where all forms of legitimate evidence, including those derived from research and experience, are valued for their role in understanding, health literacy and decision-making.

In the context of literature on arts-engagement in older adulthood, we located relevant literature reviews where authors discussed related facets of the arts and ageing. Fraser et al. (2015) conducted a scoping review on arts engagement and quality of life for older adults. In previous work, Fraser and Al Sayah (2011) examined how the arts have been used in data collection and to transfer empirical research findings. However, this exclusive focus on “empirical research findings” did not capture approaches used to engage older adults about their health or to communicate about forms of evidence not qualifying as “empirical” by the authors’ standards (e.g. experiential knowledge). Carr et al. (2009) screened a narrow selection of gerontological journals for research on arts and ageing. Noice and colleagues reviewed the benefits and challenges of participatory arts for older adults (2014). Country-specific reviews of arts programming and delivery, which include ageing-pertinent domains such as creative ageing (Cox et al., 2010), and literature reviews focusing on a single artistic form not exclusive to older adult populations have also been conducted (Hays, Bright, & Minichiello, 2002; Rossiter et al., 2008).

Existing reviews highlight a growing interest in arts applications to well-being. Yet, we did not locate any reviews focused on arts-based knowledge translation in ageing. We did however locate one scoping review by Bostrom, Slaughter, Chojecki, and Estabrooks (2012) who identified a general gap in knowledge translation for older adults. In reviewing published systematic reviews, the authors identified a shortfall of knowledge translation research conducted in community settings; the majority of knowledge translation occurred in hospital environments. This shortfall is problematic in light of policy movements towards “ageing in place” that encourage older adults to age-at-home longer. Community-oriented communication efforts aimed at improving public awareness and knowledge about ageing and associated life events are integral to promoting well-being, preventing disability and reducing age-related decline.

As such, it is apparent that while attention has been paid to the benefits of arts-engagement in older adulthood, how the arts can specifically be used to foster engagement with health research, communicate complex research evidence, and promote understanding, knowledge gain and behaviour change has received less attention. To date, no review has focused on how the arts can be used to communicate and engage stakeholders about ageing research and ageing processes more broadly. Extant reviews and the concurrent growth in arts and ageing literature reflect growing interest across disciplines. Concurrently, the lack of a review on arts in ageing communication suggests a simultaneous need for a broader view of the role of arts in translating evidence for knowledge, attitudinal and behaviour change. Yet, eliciting and changing ageist perspectives, finding ways to engage older adults in health-related knowledge exchange and decision-making, promoting health literacy and devising methods to communicate about research in comprehensible and meaningful ways are also pressing considerations (Elliott et al., 2016). Such objectives may be particularly suited to the use of creative, arts-based approaches (Archibald et al., 2014; Archibald, Caine & Scott, 2016). Understanding how and to what effect these approaches have been used can help inform future strategies to engaging and communicating with older adults about health research. The purpose of this scoping review is therefore to describe and map the literature on arts for communication, engagement and translation of health evidence in the context of older adulthood.

Research approach and methodology

The objective of this study was to describe and map how arts strategies have been used for awareness, understanding, attitudinal or behaviour change in ageing contexts, through scoping review methodology. Scoping review is a review method generally used to identify, describe and map core aspects of research conducted on a given topic (Colquhoun et al., 2014). Like a systematic review, a scoping review follows a systematic approach to addressing a specific question but is particularly useful to uncover how a previously un-reviewed topic of study has been empirically studied. As such, scoping reviews can be useful when little is known about a topic. We followed the following five stages for scoping reviews as outlined by Arksey and O’Malley (2005):

Determining the purpose

We were interested in understanding how the arts have been used to communicate about ageing, ageing-related processes and associated care. We initially conceptualized this as arts-based knowledge translation for frailty – the age-related state of increased risk for adverse health events and stressors. However, a cursory review revealed no relevant articles for this population using the knowledge translation terminology. We therefore revised our research question to “how have the arts in any form been used to raise awareness, communicate about, or engage with evidence (e.g. knowledge, research, inquiry) on ageing or ageing-associated phenomena?”. This revised question reflects outcomes commonly of interest to knowledge translation research (e.g. LaRocca, Yost, Dobbins, Ciliska, & Butt, 2012).

We developed a logic matrix to reflect our research question, which included the population, concepts and context of interest to the review (The Joanna Briggs Institute, 2015). We consulted with a research librarian to develop and pilot comprehensive search strategies to reflect this matrix. The search strategy was iteratively revised according to the search results retrieved and databases searched.

Identifying relevant studies

We used an inclusive approach to searching the EMBASE, Academic Search Complete, Scopus and CINAHL databases, selected based on their breadth and diverse disciplinary foci. We did not use date limiters but limited our inclusion to English language journal articles published online. We used combinations of keywords such as storytelling, art, arts-based, theatre, dance, older adult, knowledge translation, elderly and frailty, and used truncation when appropriate to capture pertinent articles.

We mined the reference lists of relevant articles and those of existing systematic and scoping reviews pertinent to the general topic area for potentially applicable articles. We reviewed the titles of all articles for pertinence to the research question. When the content of the article was not apparent from the title, we screened the article abstract or the full text if necessary to determine relevance.

Study selection

We used systematic methods for article inclusion by way of explicit inclusion and exclusion criteria, which was uniformly applied across studies. To be included in the review, articles needed to use some form of art (e.g. storytelling, theatre, dance, visual art) to communicate evidence on ageing, associated conditions, or care of older adults, to any stakeholder group. Research that elucidated older persons experiences of ageing through the arts was included if the findings were then artistically shared to communicate about ageing or related processes, as was research where older persons used art as a medium to assimilate new knowledge about ageing or healthy ageing. We conceptualized research broadly as systematic inquiry, which enabled artists engaged in systematic study and reflection of ageing or related processes to be eligible for inclusion in the review.

Empirical studies of all research designs, and theoretical or debate articles pertinent to the study question were eligible for inclusion. We excluded articles where the arts-based initiative focused on end of life care or death and dying based on the unique characteristics of this transcendent life stage as the 4th age or the “period of decline and dependency prior to death” (Carr et al., 2009, p. 200). Articles focusing on Photovoice, art therapy and creative ageing, like all other articles, were only included if the directional flow of information was from researcher (or practitioner) to the stakeholder (e.g. the older adult) or bidirectional (i.e., knowledge exchange), thereby differentiating the scoping review focus from arts-based data collection, which represents only a one-way flow of information (i.e. from researcher to participant) (Archibald, Scott & Hartling, 2014).

Charting the data

We used explicit criteria to extract data from included articles into a Microsoft Excel workbook. Data extracted included author, disciplinary background of first listed author, first authors listed country of affiliation, year, journal, study aim, purpose of art, population focus, target audience, art form used, research basis (e.g. qualitative, quantitative, mixed), analysis methods, link provided to art work, description of arts component, correspondence with KT stage (e.g. dissemination, exchange), evaluation methods and time points, outcomes, funding sources received, extent of public engagement or involvement in development, and relevant collaborations. MA completed data extraction and conferred regularly with ALK in face-to-face meetings.

Collating, summarizing, and reporting the results

Two analysts discussed the most appropriate methods for presenting the findings, and then summarized extracted data from the excel file into tables and figures. Some narrative data had to be re-coded numerically (e.g. number of studies using visual versus performance art) in order to recognize patterns in the data and to communicate about the findings. We created a catalogue of the arts-based approaches, attending to the intent of arts-application and the evidential basis for the arts initiative (e.g. qualitative research).

While collating and summarizing the findings, we became increasingly interested in how the arts-based communication or translation approaches were developed. Specifically, whether authors used sequential or linear processes – wherein research informed the development of an arts-based communication tool – or cyclical processes (e.g. arts engagement to simultaneously understand and educate about a facet of ageing) was at the forefront of our analysis. In order to report this, we trialled various visual conceptualizations before agreeing on an emerging conceptual model of how arts-based strategies could become more iteratively and collaboratively developed.

Results

Atotal of 1321 articles were retrieved through database searching (i.e. CINAHL n = 380; SCOPUS n = 318; EMBASE n =152; Academic Search Complete n = 471). Following the procedures outlined above and illustrated in Figure 1, 11 articles met inclusion criteria and were included in the review. Two articles (Kontos & Naglie, 2006, 2007) represented one arts-based strategy and with the exception of graphically representing articles by year of publication (Figure 2), were counted as one article in the review.

Figure 1. Flow chart of article inclusion.

Figure 2. Number of articles by year of publication.

Of the 11 articles, first-listed authors were from Australia (27%; n = 3), Canada (27%; n = 3), the United Kingdom (27%; n = 3) and the United States of America (18%, n = 2). First author disciplinary background, determined by highest qualification, was largely from the health sciences (73%, n = 8). Nursing was the most common (45%, n = 5) followed by public health (18%, n = 2), medicine (9%, n = 1), sociology (9%, n = 1), applied computing (9%, n = 1) and English and history studies (9%, n = 1). Individuals in academic positions led the overwhelming majority of studies (91%, n = 10). The majority of authors reported receiving funding for their work (64%, n = 7). Of the seven studies where authors reported funding, 43% (n = 3) received funding from one source and 57% (n = 8) received at least two funding sources. Funding sources included conventional national, state, or provincial level granting agencies, professional organizations, universities and philanthropic funds. Journals publishing the articles varied, and included International Journal of Older People Nursing (n= 2), Qualitative Research (n= 2), Qualitative Health Research (n= 1), Educational Gerontology (n= 1), Perspectives in Biology and Medicine (n= 1), Nursing Older People (n= 1), Nurse Educator (n= 1), Technology and Disability (n= 1), Nursing Science Quarterly (n= 1), and Practice Development in Health Care (n= 1). The impact factors of the journals were obtainedthrough Web of Science, Thomas Reuters (2015) list of impact factors. The majority (42%) of the unique articles were published in journals with no impact factor; 16% had impact factors under 0.5%, 16% had impact factors between 0.5 and 1, 8% had impact factor over 1.00, and 16% had an impact factor over 1.5. Although no date limiters were set in the review, all relevant articles were published between 2004 and 2015 (Figure 2).

Authors of included articles focused on a wide range of topics. Of these, dementia was the most common focus (45%, n= 5), followed by centenarians (18%, n= 2). Widowhood, isolation, older adulthood and frailty, and the ageing process were also represented. A summary of the included studies is provided in Table 1.

Table 1. Summary of included studies.

Authors (year)	Art form	Content Focus	Target Audience	Aim	Research Basis
Barlett (2015)	Textile banners Documentary film	Persons with dementia	Public	Describe managing creative process and engaging with artists	Diary interviews with 16 persons with dementia
Feldman et al. (2011)	Research-based community theatre (RBCT)	Widowhood	Public	Target ageing stereotypes, promote engagement with key life events, promote healthy ageing	Focus group interviews with culturally diverse older women
Groninger and Childress (2007)	Theatre “Rockaby”	Isolation, solitary elderly	Public	Explore how “Rockaby” could promote understanding and empathy in HCPs	Artist-based study of the nature of aging, quality of life for frail and solitary elderly, and end-of-life preparations in contemporary society
Koch et al. (2007)	Storytelling	Centenarians	Public	Combat ageism	Qualitative interviews with 24 centenarians
Koch, Turner, Smith, and Hutnik (2010)	Storytelling	Centenarians	Public	Combat ageism	Conversational interviews with 16 centenarians
Kontos and Naglie (2006)*	Performance ethnography “Expressions of Personhood”	Persons with dementia	Health practitioners (nurses & ancillary care providers)	Describe translation of ethnographic research into performance ethnography	Ethnographic fieldwork (i.e. participant observation) on personhood in Alzheimer’s unit
Kontos and Naglie (2007)*	Performance ethnography “Expressions of Personhood”	Persons with dementia	Health practitioners (nurses & ancillary care providers)	Evaluation of research based theatre	Ethnographic fieldwork (i.e. participant observation) on personhood in Alzheimer’s unit
Kontos (2010)	Drama	Persons with dementia	Dementia practitioners (nurses, personal support workers, allied health)	Improve person centered care	Existing curriculum integrated with “Expressions of Personhood” drama based on ethnographic fieldwork
Marquis-Faulkes, McKenna, Newell, and Gregor (2005).	Video-recorded theatre	Older adults, frail older adults	Older adults and sheltered housing wardens	Fall prevention	Focus group and anecdotal evidence
Mitchell, Jonas-Simpson, and Ivonoffski (2006)	Research- based theatre (RBT) “I’m Still Here”	Persons with dementia	Persons and families living with dementia, HCPs	Describe process of developing RBT	Several qualitative studies and experiences of HCPs, actors and persons with dementia
McKay and Bright (2005)	Theatre	Persons with dementia	HCPs	Dementia training for HCPs using theatre	Experience and expertise of staff groups
Pardue (2004)	Readers-Theatre	Aging	Nursing students	Nursing education about ageing	Not described

We then examined the process by which authors developed and used arts-based strategies. This examination revealed that the current state of developing arts-based strategies is most often a linear process moving from problem identification through to dissemination or implementation (Figure 3). This approach is reminiscent of “end-of-grant” knowledge translation, defined by the Canadian Institutes of Health Research as activities used to share or apply research findings once they are obtained (2015). We use the categories delineated in Figure 3 to frame examples of the types of research, art forms, collaborations and approaches to dissemination, implementation and evaluation used by the authors.

Figure 3. Current status of developing arts-based strategies.

Problem identification

During problem identification, authors generally considered the fit between the art form and research problem, and the potential or known benefits of the art form in addressing the identified shortcoming. Koch et al. (2007) identified ageism as a public problem “kept alive through negative stereotyping” (p. 53). By creating a book of centenarians’ stories, the authors sought to challenge pervasive misbeliefs, such as “inevitable cognitive decline” (p. 54), by offering alternative narratives. Marquis-Faulkes et al. (2005) used drama to create a shared context between actors and audience, and provoke discussion about older peoples falls – a common cause of morbidity and mortality in individuals over 65 years. Pardue (2004) identified that cultivating caring and empathy in nursing students is an important contemporary challenge, and identified the aesthetic learning approach of dramatic oral reading as an appropriate means to explore community concerns around ageing and chronic illness. Authors commonly identified misperceptions, misunderstandings, empathy and understanding as important targets for arts-based approaches.

Foundational research

Authors mainly drew upon academic-led qualitative research as the main source of evidence underpinning the arts-based approach (n =6). No arts-based strategies were based upon quantitative or mixed methods research. Kontos and Naglie (2006) and Mitchell et al. (2006) used qualitative research to inform the arts-based approach; the latter integrated experiential evidence as well to inform the development of the research based-theatre. McKay and Bright (2005) relied on experiential evidence to develop their theatre work around dementia, while Groninger and Childress (2007) discussed how the artist Beckett engaged in inquiry to develop the short theatre production “Rockaby”.

Identify art form and collaborators

All arts approaches incorporated a narrative component, most commonly through a variation of performance theatre (82%). The two studies by Koch et al. (2007, 2010) used written narratives of centenarians and Pardue (2004) trialled readers theatre in the classroom environment. We encountered one example of visual art in the study by Barlett (2015) whose artists and participants created textile banners for dementia activism.

The majority of academic researchers recognized the need for artistic collaborators. At times, this was described as a partnership, as was the case with Barlett’s (2015) research partnership involving a curator, social scientist and research participants. Collaborative partnerships were most evident in articles involving theatre, wherein artistic directors, actors and playwrights were often engaged in developing and delivering the performance. Art forms were selected with reference to the aim of the study, which most often centred upon health care provider (or student) training or education to improve care (n = 4), communication (n = 4), attitudinal change (n = 3) and engagement with life events (n = 1). At times authors proclaimed multiple aims (e.g. communication and attitudinal change).

Development and collaborative management

An integral aspect of developing arts-based strategies involved balancing research and artistic integrity. Authors demonstrated an understanding of this balance either implicitly or explicitly by engaging with professional artists throughout development. Barlett (2015) explicitly spoke to the balance between research and artistic integrity when using textile and visual art to challenge public views of dementia. The authors describe in detail the challenges in privileging particular visual renderings based on their aesthetic (rather than their substantive) appeal. Kontos and Naglie (2006) acknowledged the necessity of a partnership with a creative drama centre in translating ethnography to performance and spoke to pertinent and emerging aesthetic considerations such as “dramatic economy” (p. 313).

Implementation, dissemination and evaluation

Generally, arts-based strategies were approached as a product with evaluation occurring after product development, rather than as a co-creative endeavour, with cyclical and interwoven components of learning, development and evaluation. Researchers who engaged with higher levels of participant engagement throughout challenged this linearity (e.g. Barlett, 2015). Researchers encountered challenges in evaluating and assessing the impact of arts-based strategies. At times, cost was identified as a significant barrier to implementation and breadth of impact, particularly when artistic professionals were paid as consultants (e.g. McKay & Bright, 2005).

Regarding approaches to evaluation, qualitative methods were most common, although mixed methods approaches were also used. When used, mixed methods approaches were conventional in nature (e.g. sequential explanatory designs, Archibald, Radil, Zhang & Hanson, 2015), typifying interview and survey data integration with un-validated instruments (e.g. Mitchell et al., 2006). If occurring at all, evaluation typically happened immediately post-performance for theatre productions, with occasional follow-up evaluations at three (Kontos & Naglie, 2007) or four months (McKay & Bright, 2005). Written arts-based communication strategies designed to impact public perceptions were not evaluated (Koch et al., 2007, 2010).

Discussion

Arts-based methods of engaging and communicating about health research through a process that is now more typically termed knowledge translation are well aligned with the developmental status of older adulthood. The established body of evidence on creative ageing and psychology consistently reveal arts benefits to well-being, aligning with the potential for creative expression that accompanies ageing. Beginning with the midlife re-evaluation (the experience of turning inwards in self-reflection) commonly experienced in the 4th and 5th decade of life, artistic endeavours can be seen to catalyze self-reflection. A liberation phase, encountered during or after the 5th decade, can be regarded as a time to engage in something new and creative, and the “summing up” of the late ’60s onwards is often oriented to finding larger meaning in the stories of one's life (Cohen, 2006). Capitalizing on the benefits of arts-engagement to catalase conversations and communications around health and health evidence seems a fruitful possibility given these alignments. However, this two-way process of communication and understanding through the arts is under-represented in literature captured in this, and preceding, reviews.

Extant reviews on the arts and older adulthood show a larger sample of included studies (e.g. Fraser et al., 2015) than were included here. This can be partially explained by the historical emphasis on arts-engagement in the aging and arts-based literature and the nascent status of arts-based knowledge translation (Archibald et al., 2014). Yet, there is great utility in using art in a communicative and awareness raising capacity, which represents a flow of information from a researcher (or artist) to a participant, for a specified purpose (e.g. combat ageism, communicate about a health condition) (Archibald, Hartling, Caine, Ali & Scott, 2018). When combined with using arts for understanding – which represents a flow of information from participants to researchers (or artists) – the potential for bi-directional understanding and communication becomes apparent. For instance, the literature abounds with examples of using arts-for-engagement and arts-for-data collection in particular contexts (e.g. paediatrics) (Archibald et al., 2014). Using the arts during data collection specifically has potential to generate new and different understandings not accessible through non-arts based research approaches (e.g. survey, focus group interviews), yet such approaches are underutilized in the ageing context. Utilizing and adapting such strategies to simultaneously understand and promote communication of health research data could help achieve bi-directional information flow and a more collaborative co-creative approach to arts-based strategy development, thereby moving beyond the largely one-directional flow of information (from participant to researcher) characteristic of many arts-in health research approaches (Archibald et al., 2014).

Since knowledge translation is concerned with the communication of evidence (research and otherwise) to improve outcomes (e.g. knowledge, attitude, awareness, behaviour change), research where the arts are used solely as data collection were not included in the review. Yet, literature on the developmental appropriateness of arts engagement in older adulthood points to arts potential to effectively engage older adult participants with research (Cohen, 2006). Eliciting participant responses to existing artwork or masterworks, or using arts-based approaches to data collection can be used to access perspectives of ageing, frailty, illness and quality of life, as examples. For instance, Hodges, Keeley, and Grier (2001) used masterworks of art to analyse nurses, student nurses and older adult's perceptions of chronic illness, arts can catalyze access to entrenched perceptions. However, what is generally overlooked in the current literature is that understandings can then be recycled to participants – either alone or in conjunction with related literature – to facilitate knowledge translation objectives.

Authors frequently focused on arts for healthy ageing, but less so on arts about healthy ageing, which is more aligned with using creative methods for public awareness and communication. A combination of arts for and about healthy ageing was not encountered. However, these examples suggest that while the boundaries between “for” and “about” are currently approached as firm or impermeable, this need not be the case. There are opportunities to blur boundaries between data collection “for” information and data collection “as intervention”, creating an inclusive image of participatory arts engagement for well-being but also about well-being. To this effect, we encountered a number of artistic approaches that challenged our thinking around the boundaries of our review, encouraged us to more broadly consider the potential of artistic modalities in communicating and engaging with older adults and their carers, and whose methods could be adapted for more communicative purposes.

For instance, narrative and theatre are common modalities for communicating about health and illness. The popularity of theatre as a communication modality may reside in its capacity to clearly communicate key messages, given that it relies upon acting, interacting and reacting to life events often through a combination of verbal, auditory and physical (embodied) modalities (Rossiter et al., 2008). “Theatre is, famously, an imitation of action” (Levy, 2005, p. 20) – one that reflects life experiences through an “accessible” art form, popularized by television. The ease of interpreting narrative is catalyzed through a theatrical presentation, which promotes learning and meaning-making (Feldman et al., 2011). Arts-based methods of communicating and engaging older adults about health evidence vary in terms of the degree of precision in key messages being delivered and the extent of participation with the arts-based component (Archibald et al., 2014). Theatre offers opportunities to work within and between the axes of participation and key message delivery in malleable ways not possible through more static artistic forms.

Similarly, using storysharing (e.g. Pohlman, 2003), participants exchange stories and histories in groups larger than conventional focus groups. Pohlman (2003) reported on the stories of one such group of older adults (>65 years) who learned about each other and ageing-related experiences. Comparably, inquiry theatre, which interweaves dialogue and inquiry withtheatrical performance, could be more broadly applied to “communicate for understanding” while “engaging through performance” – allowing new data to be generated by interacting with previously collected data (Vanover, 2016). From a knowledge translation perspective, there are opportunities to incorporate specific research evidence and objectives, perhaps transforming storysharing circles to storysharing workshops, where experiences, attitudes and behaviours around a particular aim are elicited, and solutions are introduced and discussed accordingly. This could offer viable educational alternatives for health sciences students to engage with and understand the diverse experiences of the older individuals at various stages of the health illness trajectory (e.g. dementia care) in a collaborative manner.

In response to the linear approach to art development reflected in Figure 3, we offer an alternative schematic (Figure 4) building upon these five categories: problem identification, foundational research, identifying art form and collaborators, development and collaborative management, and implementation, dissemination and evaluation. An iterative process that cycles between the five categories in a non-linear manner reflects the bidirectional information sharing characteristic of an integrated knowledge translation approach, premised on partnerships between knowledge users throughout the entire research process (Canadian Institutes of Health Research, 2015). Like integrated knowledge translation, knowledge generated through such a collaborative process is likely to be of greater pertinence and utility to stakeholder groups, thereby increasing the likelihood of its use (Canadian Institutes of Health Research, 2015).

Figure 4. Iterative co-creative process of arts-based knowledge translation development.

Implications for research and clinical practice

The benefits of arts in older adulthood need not be limited to arts engagement approaches. There is potential to leverage the powerful communicative benefits of the arts to further enhance well-being, thereby duly maximizing those outcomes associated with arts engagement and knowledge translation. There is a need to extend the current dialogue around arts in older adulthood to acknowledge arts informative and communicative potentials and to better integrate arts within extant conceptualizations of knowledge translation. What were once new perspectives on creative ageing are becoming embedded in social and research spheres, yet persistent challenges facing the ageing population entice further emphasis and expansion of arts in health efforts globally.

Working with older adults to develop arts strategies aimed at communicating evidence, raising awareness of healthy ageing and associated processes for attitude and behaviour change can more thoroughly reflect a collaborative approach. Current linear methods of development reflect an “end-of-grant” perspective of knowledge translation wherein research findings are communicated after they are produced, rather than involving participants actively throughout the entire research and arts-production process in an integrated manner. New viewpoints and perspectives made possible through active participation in arts-production may provide meaningful primary research data and simultaneous artistic outputs; for instance, kinetic participation in dance and auditory stimulation through musical engagement can evoke understandings inexpressible to participants using narrative forms alone (Archibald et al., 2014; Archibald et al., 2016). Perspectives of persons often excluded from research participation, such as persons with dementia or moderate to severe frailty, could be catalyzed using participatory research approaches.

Clinicians and caregivers working with older adults are tasked with providing education about ageing, associated morbidities and ageing-related processes in comprehensible and meaningful ways. Creative methods of communicating health research evidence using arts-based knowledge translation offer altnerative ways of delivering these health messages. Authors of articles included in this scoping review have created resources that can be reused across contexts (e.g. filmed vignettes, narratives of centenarians). Clinicians and other stakeholders (e.g. aged care providers) can also consider how existing and new efforts at arts-engagement could be combined with the communication of health research evidence to concurrently maximize impacts to well-being and knowledge translation.

Conclusion

The current review provides a snapshot of the status of developing arts-based strategies for communicating and engaging about research and affiliated evidence in older adulthood. This review provides a state of the science of arts for knowledge translation (broadly defined) for older adults, maps existing processes used to develop arts-based approaches to knowledge translation, and provides an alternative, integrated concept of how to approach co-creating arts strategies for well-being and communicative or awareness building purposes. As the role of arts engagement in older adulthood is increasingly recognized along with the concomitant move towards knowledge translation, evidence-based health care and collaborative research more generally, there is remarkable potential to combine arts engagement with knowledge translation through the arts to maximize involvement and benefit for older adults.

Acknowledgments

MA acknowledges the generous fellowship support received from the Canadian Institutes of Health Research in support of her postdoctoral research, and the National Health and Medical Research Council Centre of Research Excellence in Trans-disciplinary Frailty Research to Achieve Healthy Ageing.

Disclosure statement

No potential conflict of interest was reported by the authors.