Global perspectives on dementia and art: An international discussion about changing public health policy

Abstract

In an era of global environmental deterioration and income inequity, public health faces many challenges, including the growing number of individuals, especially older people, with chronic diseases. Dementia is increasingly being seen not just as a biomedical problem to solve but as a public and community challenge to address more broadly. Concepts like prevention, brain health, and quality of life/well-being are receiving more attention. The engagement of community in addressing these challenges is being seen as critical to successful social adaptation. Arts programs are reinvigorating cultural responses to the growing number of older people with cognitive challenges. The humanities offer ways of understanding the power of words and stories in public discourse and a critical lens though which to view political and economic influences. In this paper, we report on a panel held in London on the occasion of the conference at the Royal Society for Public Health in March, 2017, in which the authors presented. Key issues discussed included problem framing, the nature of evidence, the politics of power and influence, and the development of effective interventions. In this paper, we review the rejection of two policies, one on dementia and one on the arts and humanities in public health, by the American Public Health Association; the emergence of policies in the UK; and some of the state of the art practices, particularly in training, again focusing on the UK.

Keywords

dementia arts humanities evidence international policy practice

Introduction

In a conference held at the Royal Society for Public Health (RSPH) in March, 2017 concerning research on dementia and arts the three authors of this article organized a panel entitled “Global perspectives on dementia and art: An international discussion about changing public health policy.” The first presentation examined the interface of the arts and humanities and public health in the United States through the lens of policy development at the American Public Health Association (APHA). The remaining two oral presentations focused on policy and practice in the United Kingdom. This current paper represents both an attempt to summarize the three presentations as well as the discussion with the audience. No comprehensive synthesis of all the ideas presented during the panel is attempted here, as work is ongoing.

Public health policy development with a focus on the United States

Public health concerns the biological and psychological well-being of individual human beings in social and natural communities, and involves many different activities, including research, education, and service (RSPH, 2013). Public health efforts are embedded in society and hence are involved in value conflicts, social and economic power relationships, and various forms of cultural expression. Broad definitions of health include psychosocial well-being and should motivate attention to fostering community resilience.

The arts and humanities relate to and create culture, challenge thoughts and values, and foster social transformation. The arts include diverse aspects of human behavior including visual arts, music, dance and theatre (Clift & Camic, 2015). The humanities are broad-ranging disciplines, including literature, history, and philosophy, which overlap the arts (Bracken, 2004; Hanlon, Carlisle, Hannah, Reilly, & Lyon, 2011; Weed, 1995). In turn, the humanities overlap in scope with the social sciences, including sociology, anthropology, economics, and political science (Crawford, Brown, Baker, Tischler, & Abrams, 2005). At their core, the arts and humanities are involved in personal growth, community development, cultural enrichment, and critical reflection.

The evidence for the essential roles of the arts and humanities in public health is multifaceted (Clift & Camic, 2015). Both qualitative and quantitative intervention studies, as well as epidemiological studies, attest to the value of the arts and humanities in community and across the life-course. The widespread presence of art and other museums demonstrate the public’s commitment to the value of arts in community. The humanities foster the development of narrative skills, critical thinking, and encourage the exploration of diverse ideas through history and in different cultures (Crawford et al., 2005). These approaches could be made more central to a global public health enterprise struggling with the complexities of climate change and income inequity and their effects on health.

The arts and humanities have complex relationship to health. The arts and humanities focus on pattern recognition, address contextual complexity, and reflect holistic considerations. Whether in visual or music perception or in the interactions among people in stories, human beings look for patterns of relationships. They also look to understand the connections among constituent elements to appreciate the situation as a whole system of components. Such behavior also characterizes science and clinical practice. The arts and humanities bear intimate relationships to culture and social change. The arts can also be associated with spiritual and religious aspects of health, often-neglected aspects of medical approaches to health.

Current biomedical research often proceeds with different orientations than those found in art. Divided into specialized bodies of knowledge, biomedicine focuses on individual health and often just at organ and molecular levels. It is a culture oriented towards specific diagnoses and pharmaceutical or other technological solutions. As public health demands a systems perspective to health, it can challenge narrow reductionistic biomedical approaches to disease. It often focuses on how to change the behavior of individuals and communities, and asks deep questions about the nature and purpose of good health. In these endeavours, the arts and humanities have been and can remain powerful allies and constructive critics. The arts and humanities foster understanding about culture changes, such knowledge being important to both individual and population health efforts. For example, artistic depictions of nature can influence thinking about the relationships between humans and the natural world. In a time when aging and chronic disease are emerging as powerful drivers of our health systems, nonscientific fields can ask us how we should conceptualize aging and death. In an era of fascination with neuroscience and the diseases of the brain, the arts and humanities can ask us from where our optimism for technoscientific solutions emanates and how we can distinguish true and false hope. Perhaps we are even in need of a meta-paradigm shift, i.e. not within science alone but between science and society.

Some argue that we have entered the fifth wave of public health (Hanlon et al., 2011). Health challenges of today are different reflecting overpopulation, climate change, changing demographics and patterns of disease. Focusing on obesity, inequality and loss of well-being the authors suggest the fifth wave, like the four previous ones that started with the Industrial Revolution, reflects the historical and cultural times. The problems of this fifth wave will not be addressable just by technological solutions but will likely require major cultural shifts. We need to think of health and wealth in profoundly different ways. Ecopsychosocial is a new concept developed to point out to even those who use more mainstream formulations, such as biopsychosocial models of health, that ecosystems and systems biology are critical to health, not just molecular genetic formulations of biology. In many cases, the commodification of both health care systems and the scientific enterprise has led to poor outcomes and overall value in many countries, particularly the United States. Perhaps modernism itself needs fundamental transformation as economic and political systems become increasingly unstable and unsustainable.

The humanities themselves are in dynamic evolution (Crawford et al., 2005). The digital and neurohumanities are fostering new thinking and valuing, as well as new methodologies. The term “health humanities” may itself be replacing “medical humanities” recognizing the need to be more inclusive of lay people and different professionals besides medical doctors (Crawford et al., 2005). Some also see the new health humanities as having a closer relationship to both the arts and public health.

Policy development in the US through the American Public Health Association

A policy was proposed and rejected in 2015 by the APHA on the topic “Enhancing the role of the arts and humanities in public health” and one on dementia itself. In this section, we review the history of this process within APHA and draw some lessons from the process. Ethics is strongly related to the arts and humanities. For this reason, the Ethics Section of the APHA initiated the development of the policy on enhancing the role of arts and humanities in public health. The term bioethics was coined in 1970 (Whitehouse, 2003) and has its origins in and took inspiration from the environmentally-rich land ethic concept. These original formulations of bioethics explicitly included aesthetics (Whitehouse, 2003). Preserving the beauty (as well as integrity and stability) of a biotic community was related to behaving ethically. As bioethics grew as a field, particularly in the United States, some distancing from the humanities occurred. For example, as bioethicists became located in health care organizations, rather than main universities and received funding through sources like the NIH ELSI (Ethical, Legal and Social Issues) program, the agenda of bioethics became aligned with the priorities of biomedical progress. Moreover, concerns have been raised that bioethics itself has become disjointed and even coopted by medicine (Whitehouse, 2003). Empirical methods seem to have displaced others ways of knowing, such as critical reflection and narrative methods. The whole idea of evidence should be enriched by broader ways of thinking than just scientific approaches. If we limit the truth by what can be discovered in biomedically sanctioned forms of evidence, such as randomized controlled trials, we risk not only overemphasis on expensive and marginally beneficial pharmaceutical and medical devices but also impoverished public health interventions. A specific focus on the arts and humanities may be critical to regaining the breadth, integration and scepticism necessary for a vital presence of ethics in public health. Aesthetics can join forcefully with ethics in advancing the course of human (and other living creature) health.

The policy was developed recognizing that there is considerable evidence that demonstrates both the value of a variety of arts and narrative based projects and the factors for successful program development (Camic & Chatterjee, 2013; Cohen, 2009; Day, 2009; Earhart, 2009; Fritsch et al., 2009; Stuckey & Nobel, 2010). These attempts to improve health and well-being include individual approaches with single clients, like art and music therapy; small groups, such as dance and theater; and large-scale community change through arts centres, museums, and school programs. Moreover, other studies provide guidance about how to develop and implement effective programs (Broderick, 2011; Clift, 2012; Smith, 2002; Tesch & Hansen, 2013; White, 2010). Common evidence-based approaches include the use of needs assessment, engaging with the individuals or populations to be served early on, strong community advisory processes, attention to both measureable outcomes as well as broader qualitative evidence, such as case studies and storytelling. Identifying community champions may also be important. Early focus on sustainability through developing collaborative partnerships and diversifying political and funding support is key.

Although the evidence for the impact of the arts and humanities on public health is of variable quality with few large-scale randomized trials, the participation of large numbers of individuals and numerous funding bodies attest to the perceived value and utility of such approaches for health promotion and behavior change efforts.

Since demographic aging is a major driving force for public health changes, the Aging and Public Health Section cosponsored the proposed policy. However, the original submission of the proposed policy to the APHA failed in early stages. The substantive criticisms offered included that the proposal did not provide a definition of art, excluded architecture, provided inadequate evidence for the value of art and humanities in public health, focused too much on evidence of individual art therapies, and failed to suggest adequate action steps to take in the policy space.

Given the focus on dementia of the RSPH conference in which the authors presented and the huge public health implications of these conditions that impair cognition, particularly in the elderly, we now turn to some examples from this area of social concern. Studies of biomedical interventions in dementia, like drugs or immunizations, are more amenable to standard trial designs and increasingly include the use of biomarkers that are often of unproven validity and sometimes even reliability. More studies are needed in the arts and public health in general, but the absence of narrow forms of evidence for efficacy of complex interventions should not be interpreted as the absence of efficacy. Small trials may be underpowered, and measuring effects on broad outcomes like quality of life is difficult. In general, it is not clear in our current political environment whether there is interest in the APHA to advocate for the arts and humanities given other priorities of greater concern and the intellectual stretch for the current scientifically based policy construction process.

A policy submitted by the Aging and Public Health Section of APHA (and supported by the Ethics Section) concerning the role of public health in dementia was also rejected in the same round of policy review. In this complex process arguments over the nature of diagnostic entities (like Mild Cognitive Impairment), the value of early diagnosis, and the role of biomarkers were at the core. A great danger to public health in general would be if unproven and expensive biomedical approaches are given support in public health policies where other priorities should be emphasized. In the field of dementia, public health approaches like improving nutrition, encouraging physical exercise, fostering learning activities, and promoting community engagement often do not get enough emphasis. Social attention and resources are more frequently focused on medical research to find a cure (Caspi, 2017). Digital games and brain fitness exercises get excess attention because, like drugs, they are often wrapped in pseudo-scientific marketing. This rejection of the dementia policy at APHA led to a high-level review of policymaking processes.

For the remainder of this paper, we will focus primarily on the value of the arts in public health, not the humanities, since the arts and dementia were the focus of the conference held by the Royal Society on Public Health. Moreover, arts were the exclusive focus of our last two papers about policies and practices in the UK.

Policy development in the UK: Mainstreaming demand for arts based approaches

From a policy perspective in the UK, the All Party Parliamentary Group on Arts, Health and Well-being (APPG) has put the arts and health on the radar of stakeholders and policy makers. The inquiry and subsequent report recognizes the importance of political support and partnership working to effectively create the culture change required to provide the arts and health with the recognition it deserves (APPG, 2017).

Securing the political buy in and partnerships are two of the ingredients required in developing effective public health campaigns (Frieden, 2014). By communicating the benefits of arts and health based therapy not just for policy makers but the broader public, advocates could take learnings from other public health campaigns. The success of the UK Government’s “Five a day” (Capacci & Mazzochi, 2011) campaign to encourage an increase in consumption of fruit and vegetables might be a good example. While there has been slow progress in changing behavior, public awareness has increased. Another example of a campaign which took learnings from the Five a day campaign is the Five Ways to Well-being (http://neweconomics.org/search/?_sf_s = Five + Ways) which sought to distil in a user friendly and accessible way five different activities the public could undertake that had a positive effect on their well-being, including Connect, Be Active, Keep Learning, and Give and Keep Learning.

Tools such as Five a day and Five Ways to Well-being could be adopted for the arts and health in order to increase public awareness of its therapeutic value. For example, research into the dose relationship between arts engagement and well-being (Davies, Knuiman, & Rosenberg, 2016) has concluded that those who engaged in 100 or more hours of arts engagement reported better mental well-being than at other levels of engagement. This could form the basis for a public facing population based strategy to increase arts uptake as a means of enhancing individual well-being. Such a campaign could take the form of encouraging individuals to undertake two hours a week of arts engagement to support their well-being.

Another important point noted in the APPG Inquiry is that the arts continues to be disproportionately accessed by well-educated, prosperous, older adults. Taking a life course approach and recognizing the importance of the social determinants as the APPG report does may help to address an inequalities issue when it comes to engaging with the arts. In order to maximize the access, more targeted approaches should be adopted for groups that may be marginalized. Moving beyond arts and health (Burns, 2013) into the broader sphere of popular culture may help to widen participation from those groups in society who may feel excluded from more traditional forms of the arts that in turn could increase the demand for arts-based therapies.

Increasing the delivery of arts-based approaches

In addition to increasing public demand and awareness, the scope of those involved in the delivery, commissioning and sign-posting to arts-based therapies should be broadened. In keeping with the move away from a medical model, the definition of the workforce that supports the public’s health has changed (RSPH, 2015) and now includes “anyone who has the opportunity or ability to positively impact upon the public’s health”. This broader definition constitutes 15 million people working across 57 different occupational groups that would hitherto not necessarily consider them part of the effort to improve the public’s health. Professions such as pharmacy teams, Allied Health Professionals and the Fire Service could have a role to play in signposting the public towards arts-based therapies and interventions. In terms of dementia, certain professional groups such as the fire service and occupational health teams already engage with at risk groups such as older adults. A perquisite for greater involvement from the wider workforce is appropriate training and support. In order to build the evidence base to support wider workforce involvement would require data collection in terms of what is effective, and there are already tools and resources such as Public Health England’s evaluation framework for arts and health.

Widening the pool of people involved in championing and possibly elements of delivery of arts-based approaches may also address issues around the diversity of the workforce that has been identified as needing to better reflect the diversity of the population as a whole who can access arts-based therapies (DCMS, 2016).

The mainstreaming provision of arts-based therapies outside of more traditional provision, such as Healthcare Professionals, also aligns to the Health in All Policies (HiAP) agenda.

Greater use of Asset-based approaches such as arts on prescription or other forms of “social prescribing” have also been shown to be effective (Bungay & Clift, 2010). By harnessing traditional primary care services and the wider workforce, to refer patients to a range of local, non-clinical services, often provided by the voluntary and community sector there are benefits in three key areas: improving mental health outcomes, improving community well-being, and reducing social exclusion which is relevant for older people with depression or who are socially isolated. Such “information prescriptions” could be beneficial to individuals living with dementia, in consultation with a health or social care professional.

Current state of practice focusing on staff training in the UK

The conversation between policymaking and practice should be a dynamic two-way street. This section discusses two points relating to the potential benefits to day-to-day dementia care staff (i.e. registered nurses and qualified/non-qualified care assistants) of arts engagement. The first applies to the role that staff might play in arts interventions that aim to benefit the people for whom they care; the second is the potential role of arts in equipping staff with professional and personal resources necessary to deliver reciprocally rewarding care within contemporary models of care.

As the concepts of health preservation, quality of life and well-being receive more attention in global health policies (e.g. Alzheimer’s Society, 2012; APPG, 2014; WHO, 2012), a rethink of practice models is becoming increasingly important across the entire spectrum of health professionals and workers who care for people living with dementia. Past models of care, which continue at various levels to have a tenacious foothold, focus on bioscience and pay less attention to the emotional aspects of practice (Jack & Wibberley, 2013; Saunders & Shaw, 2015). Contemporary models emphasize human behavior, feelings, emotions and past and present experiences that relate more closely to a psychodynamic approach. Creative arts in this context may have a significant role to play because of the increasingly understood link with emotional expression, personal growth and nurturing of healthy interrelationships (e.g. Gordon-Nesbitt, 2015; Gordon-Nesbitt, 2017).

Today, incumbency upon clinicians to explore non-pharmacological interventions (NPIs) in favour of, or alongside drug therapy is widely promoted. Music and psychosocial interventions are not infrequently referred to as particularly effective (e.g. Millán-Calenti et al., 2016; Richter, Meyer, Mohler, & Kopke, 2012). Little clarity, however, is forthcoming on who is responsible for identifying appropriate interventions, prescription and delivery processes, and the monitoring of effects .

It may be argued that due to the intimacy with and familiarity of the people in their care, day-to-day dementia-care staff are a valuable resource in terms of identifying need, prescribing appropriately, and evaluating the effect of NPIs based on creative arts. In addition, they are well-place for integrating into the daily routines of all older people recommendations for creative, learning and social interactions (e.g. Alzheimer Europe, 2013; National Institute for Care Excellence 2015; Vella-Burrows, 2015). Notwithstanding the value of arts interventions facilitated at appointed times by arts practitioners and therapists, day-to-day staff can react opportunistically at any given time according to the ebb and flow of needs among the people for whom they care.

The reality of day-to-day care staff taking a key role in prescribing and delivering creative arts interventions will depend on training and on-going support to support/raise their confidence and perceived skill-ability (Sung, Lee, Chang & Smith, 2011; Vella-Burrows, 2011). Currently in Europe, creative/arts-based training for dementia-care staff takes various forms. Each proposes a culture change at some level. Training to upskill staff in creative skills to enable them to facilitate arts interventions include guidance/mentoring schemes in which staff work alongside arts practitioners to learn about different arts media and methods of delivery. Examples include the Equal Arts HenPower project (www.equalarts.org.uk/our-work/henpower); Music for Life (https://wigmore-hall.org.uk/learning/music-for-life), and short courses run by the charity, Arts 4 Dementia (www.arts4dementia.org.uk).

A small body of literature draws attention to the value of creative arts in medical and nurse student education to foster tacit learning and to build relevant personal and professional strengths (e.g. Kumagai, 2012; Zeilig, Poland, Fox, & Killck, 2017). Benadé, Du Plessis, and Koen (2017) explored resilience of nurses caring for older people in South Africa. The findings highlight the importance of personal, professional, contextual and spiritual strengths to enable the handling of adverse working conditions. The role and value of emotional intelligence has also been highlighted by a number of educators as the primary competency in eliciting deep understanding of people and their problems, and the ability to use critical thinking and to find ethical solutions (Bulmer Smith, Profetto-McGrath, & Cummings, 2009; Sheard, 2009).

Bulmer Smith et al. (2009) recommend that emotional intelligence concepts are explicitly included in nurse-training curricula but they acknowledge unanswered questions relating to how it might be conceptualized, taught and measured. Here, the arts may play a significant role as evidence provides a better understanding of the link between arts engagement, emotional expression and fostering compassion and resilience (Clift, Morrison, Vella-Burrows, & Hancox, 2011; Crossick & Kaszynska, 2016; Daykin, 2017; Gordon-Nesbitt, 2015).

The premise that arts-based training can target personal and professional development to create flourishing that encompasses residents/clients/patients and all staff and environments, underpins the work of Bredan McCormack and Angela Titchen who launched the practice-development initiative, Critical Creative, over a decade ago (e.g. McCormack & Titchen, 2006; see https://criticalcreativity.org). Critical Creative centralizes creative engagement as a catalyst for education and transformational practice development in health and social care. The principles have since been taken up by the International Practice Development Collaboration in association with the Royal College of Nursing and the Foundation of Nursing Studies (e.g. Dewer, 2012; Lindsay & Schwind, 2015; Walji-Jivraj & Schwind, 2016; Webster, 2008). An example of an arts-based practice development initiative for staff in care settings for people with dementia is Ladder to the Moon’s coaching and training programmes (www.laddertothemoon.co.uk). The initiative aims to stimulate new thinking, behaviors and relationships in care settings.

On the basis of this brief discussion, there appears a convincing argument for nurturing staff-led arts activities and arts-based training for service development. Specifically, creative arts are believed to be beneficial for people with dementia but the involvement of day-to-day care staff in their prescription, delivery and evaluation needs clarity. Changing dementia care cultures require of staff a broad spectrum of professional and personal resources. Arts used as a catalyst for transformation in dementia-care education are a relatively new concept. Embedding training programs into national strategies in the future will depend on persuasive evidence of value, including cost benefits; financial investment for arts and health/social care communities to work more closely; and the scaling up of practical information/resource portals for care staff as provided currently by Critical Creative.

Conclusion

Art as a universal aspect of culture seems essential to human flourishing, as well as increasingly important to social resilience and adaptability. Key themes in the three RSPH conference papers and discussion that followed included the role of evidence, the importance of training, and the desirability of cross-national conversations. We also agreed that more efforts should be made to develop policies and practices that encourage the role of the arts in dementia care. Such efforts should be based on a broad sense of what constitutes evidence and should be integrated in other culture and community change movements, such as Dementia Friends and Age/dementia Friendly Communities. Preparing for the growing number of persons or people of all ages with dementia might also enhance our own inclusive sense of humanity and promote better communities for all of us. Going forward we should take the long view and include more intergenerational programming in our planning. In a time of constrained resources, programs that benefit people of all ages and levels of cognitive-challenges might provide more social and economic value to society than dementia or elder specific ones.

Footnotes

Acknowledgements

We thank the organizers of the March 2017 First International Research Conference on the Arts and Dementia: Theory, Methodology and Evidence held at the Royal Society for Public Health, London, UK.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Peter J Whitehouse is a professor of Neurology and current or former professor of Psychiatry, Neuroscience, Psychology, Cognitive Science, Bioethics, Nursing, History, and Organizational Behavior, Case Western Reserve University Strategic Advisor in Innovation Baycrest Health Center and Professor of Medicine and Institute of Life Course and Aging, University of Toronto President, Intergenerational Schools International.

Trish Vella-Burrows, RN, PhD, FRSPH, is a current deputy director for the Sidney De Haan Research Centre for Arts and Health and visiting lecturer in Arts and Health, Canterbury Christ Church University and. Director for the newly developed International Network for Research and Applied Practice. She has a Special interest in practice models of care for people with long-term conditions wherein the arts can play a central role in inspiring and maintaining the wellbeing of care staff and those for whom they care.

Duncan Stephenson is a director of Communications, Royal Society for Public Health. Duncan has overall responsibility for all areas of marketing and communication, and in developing the organization’s voice on public health issues. Duncan has been behind many of RSPH’s new campaigns including: campaigning for alcohol calorie labeling; creating outdoor smoking exclusion zones; Health on the High Street – a national campaign to make High Streets more health promoting; and most recently drug policy reform, social media and mental health, and calls for the introduction of activity-equivalence calorie labeling for food and drink. Duncan has fifteen years-experience in campaigns, media relations and public affairs working mainly on health and wellbeing issues.

References

Alzheimer’s Society. (2012). Dementia 2012: A national challenge. Retrieved from www.alzheimers.org.uk

Alzheimer-Europe. (2013). 2013: National policies covering the care and support of people with dementia and their carers. Retrieved from www.alzheimer-europe.org/Policy-in-Practice2/Country-comparisons/2013-National-policies-covering-the-care-and-support-of-people-with-dementia-and-their-carers

APPG. (2014). Building on the National Dementia Strategy: Change, progress and priorities. All Party Preliminary Group on Dementia. Retrieved from file:///C:/Users/acer/Downloads/APPG_on_Dementia_-_2014_report_-_Building_on_the_NDSE.pdf

APPG. (2017). Creative health: The arts for health and wellbeing. Report for All Party Parliamentary Group on Arts, Health and Wellbeing. Retrieved from www.artshealthandwellbeing.org.uk/appg-inquiry/Publications/Creative_Health_Inquiry_Report_2017.pdf

Benadé

Du Plessis

Koen

(2017). Exploring resilience in nurses caring for older persons. Health SA Gesondheid, 22, 138–149.

Bracken

M. B.

(2004). Epidemiology as a liberal art: From graduate school to middle school, an unfulfilled agenda. Annals of Epidemiology, 24(3), 171–173.

Broderick

(2011). Arts practices in unreasonable doubt? Reflections on understandings of art practices in healthcare contexts. Arts & Health, 3, 95–109.

Bulmer Smith

Profetto-McGrath

Cummings

(2009). Emotional intelligence and nursing: An integrative literature review. International Journal of Nursing Studies, 46, 1624–1636.

Bungay

Clift

(2010). Arts on prescription: A review of practice in the UK. Perspectives in Public Health, 130(6), 277–281.

10.

Burns

(2013). Beyond arts and health: The need to include all of popular culture. Perspectives in Public Health, 133(1), 21–22.

11.

Camic

P. M.

Chatterjee

H. J.

(2013). Museums and art galleries as partners in public health interventions. Perspectives in Public Health, 133, 66–73.

12.

Capacci

Mazzochi

(2011). Five a day; a price to pay: An evaluation of the UK program impact accounting for market forces. NCBI, 30(1), 87–98.

13.

Caspi

(2017). Trust at stake: Is the “dual mission” of the U.S. Alzheimer’s Association out of balance? Dementia, Retrieved from https://journals-sagepub-com.web.bisu.edu.cn/doi/abs/10.1177/1471301217719789.

14.

Clift

(2012). Creative arts as a public health resource: Moving from practice-based research to evidence-based practice. Perspectives in Public Health, 132, 120–127.

15.

Clift

Camic

(Eds.) (2015). Oxford textbook of creative arts, health, and well-being: International perspectives on practice, policy and research. Oxford: Oxford University Press.

16.

Clift

Morrison

Vella-Burrows

Hancox

(2011). Singing for mental health and well-being: Community initiatives in England. In Brader

(Ed.), Songs of resilience. Cambridge: Cambridge Scholars Press.

17.

Cohen

G. D.

(2009). New theories and research findings on the positive influence of music and the art on health with ageing. Arts & Health, 1, 48–62.

18.

Crawford

Brown

Baker

Tischler

Abrams

(2005). Health humanities. London: Palgrave-Macmillan.

19.

Crossick

Kaszynska

(2016). Understanding the value of arts & culture. The AHRC Cultural Value Project. London: AHRC. Retrieved from www.ahrc.ac.uk/documents/publications/cultural-value-project-final-report

20.

Davies

Knuiman

Rosenberg

(2016). The art of being mentally healthy: A study to quantify the relationship between recreational arts engagement and mental well-being in the general population. BMC Public Health, 16, 15. https://doi.org/10.1186/s12889-015-2672-7

21.

Day

(2009). Promoting health literacy through storytelling. OJIN: The Online Journal of Issues in Nursing, 14(3), art. 6.

22.

Daykin, N. (2017). Arts, health and well-being: A social iquiry. In T. Stickley and S. Clift (Eds.), Arts, health & well-being: A theoretical inquiry. Newcastle upon Tyne, UK : Cambridge Scholars Publishing

23.

DCMS. (2016). The culture white paper. Department for Culture, Media and Sport. Retrieved from www.gov.uk/government/publications/culture-white-paper

24.

Dewer

(2012). Using creative methods in practice development to understand and develop compassionate care. International Practice Development Journal, 2(1), Article 2. Retrieved from www.fons.org/library/journal/volume2-issue1/article2

25.

Earhart

G. M.

(2009). Dance as therapy for individuals with Parkinson disease. European Journal of Physical and Rehabilitation Medicine, 45, 231–238.

26.

Frieden

T. J.

(2014). Six component necessary for effective public health programme implementation. American Journal of Public Health, 104(1), 17–22.

27.

Fritsch

Kwak

Gran

Lang

Montgomery

R. R.

Basting

A. D.

(2009). Impact of TimeSlips, a creative expression intervention program, on nursing home residents with dementia and their caregivers. The Gerontologist, 49, 117–127.

28.

Gordon-Nesbitt

(2015). Exploring the longitudinal relationship between arts engagement and health. Arts for Health Manchester Metropolitan University, Manchester UK. ISBN: 978-1-900756-77-8.

29.

Gordon Nesbitt, R. (2017). Creative Health: The Arts for Health and Wellbeing. Report for All Party Parliamentary Group on Arts, Health and Wellbeing. Online at: www.artshealthandwellbeing.org.uk/appginquiry/Publications/Creative_Health_Inquiry_Report_2017.pdf

30.

Hanlon

Carlisle

Hannah

Reilly

Lyon

(2011). Making the case for a fifth wave in public health. Public Health, 125, 30–36.

31.

Jack

Wibberley

(2013). The meaning of emotion work to student nurses: A Heideggerian analysis. International Journal of Nursing Studies, 51(6), 900–907.

32.

Kumagai

(2012). Perspective: Acts of interpretation: A philosophical approach to using creative arts. Medical Education, 87(8), 1138–1144.

33.

Lindsay

Schwind

(2015). Arts-informed narrative inquiry as a practice development methodology in mental health. International Practice Development Journal, 5(1), Article 5. Retrieved from www.fons.org/library/journal/volume5-issue1/article5

34.

McCormack

Titchen

(2006). Critical creativity: Melding, exploding, blending. Educational Action Research, 14(2), 239–266.

35.

Millán-Calenti

Lorenzo-López

Alonso-Búa

de Labra

González-Abraldes

Maseda

(2016). Optimal nonpharmacological management of agitation in Alzheimer’s disease: Challenges and solutions. Clinical Interventions in Aging, 11, 175–184.

36.

National Institute for Care Excellence. (2015). Older people: Independence and mental well-being. NICE Guideline NG32. Retrieved from www.nice.org.uk/guidance/ng32

37.

Richter

Meyer

Mohler

Kopke

(2012). Psychosocial interventions for reducing antipsychotic medication in care home residents. Cochrane Database Systematic Review, 12, CD008634.

38.

RSPH. (2013). Arts, health and well-being: Beyond the millennium: How far have we come and where do we want to go? Retrieved from file://stafs-nhr-01.ccad.canterbury.ac.uk/pkv2/Downloads/Arts%20and%20health%20report-smaller.pdf

39.

RSPH. (2015). Rethinking the Wider Public Health Workforce August 2015 Centre for Workforce Intelligence. Retrieved from www.rsph.org.uk/our-work/policy/wider-public-health-workforce.html

40.

Saunders

Shaw

(2015). Creating caring cultures: Getting started. Foundation of Nursing Studies, London UK. Retrieved from www.fons.org/resources/documents/FoNS-Creating-Caring-Cultures–Getting-Started-Script-April-2015.pdf

41.

Sheard

(2009). Nurturing: Emotions at work in staff. London: Alzheimer’s Society.

42.

Smith

(2002). Spend (slightly) less on health and more on the arts—Health would probably be improved. British Medical Journal, 325, 1432–1433.

43.

Stuckey

H. L.

Nobel

(2010). The connection between art, healing, and public health: A review of current literature. American Journal of Public Health, 100, 254–263.

44.

Sung

H.-C.

Lee

W.-L.

Chang

S.-M.

Smith

(2011). Exploring nursing staff's attitudes and use of music for older people with dementia in long-term care facilities. Journal of Clinical Nursing, 20(11), 1776–1783..

45.

Tesch

Hansen

E. C.

(2013). Evaluating effectiveness of arts and health programmes in primary healthcare. Arts & Health, 5, 19–38.

46.

Vella-Burrows

(2011). Care staff perspectives of the role of music in the care of people living with dementia (PhD thesis, Department of Music and Performing Arts, Canterbury Christ Church University).

47.

Vella-Burrows

(2015). The arts and older people; a global perspective. In Clift

Camic

(Eds.), Creative arts, health and well-being. International perspectives on practice, policy and research. Oxford: Oxford University Press (Chapter 29).

48.

Walji-Jivraj

Schwind

(2016). Nurses’ experience of creating an artistic instrument as a form of professional development: An arts-informed narrative inquiry. International Practice Development Journal, 7(1), Article 3. Retrieved from www.fons.org/Resources/Documents/Journal/Vol7No1/IPDJ_0701_3.pdf

49.

Webster

(2008). Enabling privacy and dignity in care: Using creative arts to develop practice with older people. Report. International Practice Development Journal, 5(1), Article 5. Retrieved from https://www.fons.org/resources/documents/Project%20Reports/DissSeriesVol5No3.pdf

50.

Weed

D. L.

(1995). Epidemiology, the humanities, and public health. American Journal of Public Health, 85(7), 914–918.

51.

White

(2010). Developing guidelines for good practice in participatory arts-in-health-care contexts. Journal of Applied Arts and Health, 1, 139–155.

52.

Whitehouse

(2003). The rebirth of bioethics: Extending the original formulations of Van Rensselaer Potter. The American Journal of Bioethics, 3(4), W26–W31.

53.

WHO. (2012). Dementia: A public health priority. World Health Organization and Alzheimer’s Disease International, Geneva Switzerland. Retrieved from www.who.int

54.

Zeilig

Poland

Fox

Killck

(2017). The arts in dementia care education: A developmental study. Journal of Public Mental Health, 14(1), 18–23. https://doi.org/10.1108/JPMH-06-2014-0028