In what context and by which mechanisms can creative arts interventions improve wellbeing in older people? A realist review protocol

Creative arts, older people, wellbeing, mental health, creative health, creative ageing ALL Metrics - Views Downloads How to cite this article Caulfield A, Ferrey A, Roberts N et al. In what context and by which mechanisms can creative arts interventions improve wellbeing in older people? A realist review protocol [version 1; peer review: 1 approved, 1 approved with reservations]. NIHR Open Res 2025, 5:19 (https://doi.org/10.3310/nihropenres.13746.1) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente Select a format first ▬ ✚ Study Protocol [version 1; peer review: 1 approved, 1 approved with reservations] Alexandra Caulfield https://orcid.org/0000-0002-2483-4427 1, Anne Ferrey https://orcid.org/0000-0002-5644-2735 1, Nia Roberts https://orcid.org/0000-0002-1142-6440 2, [...] Jeremy Leslie-Spinks https://orcid.org/0000-0003-4169-0522 1, Helle Mölsted Alvesson3, Geoff Wong https://orcid.org/0000-0002-5384-4157 1, Trish Greenhalgh https://orcid.org/0000-0003-2369-8088 1Alexandra Caulfield https://orcid.org/0000-0002-2483-4427 1, Anne Ferrey https://orcid.org/0000-0002-5644-2735 1, [...] Nia Roberts https://orcid.org/0000-0002-1142-6440 2, Jeremy Leslie-Spinks https://orcid.org/0000-0003-4169-0522 1, Helle Mölsted Alvesson3, Geoff Wong https://orcid.org/0000-0002-5384-4157 1, Trish Greenhalgh https://orcid.org/0000-0003-2369-8088 1 PUBLISHED 04 Mar 2025 Author details Author details 1 University of Oxford Nuffield Department of Primary Care Health Sciences, Oxford, England, UK 2 University of Oxford Bodleian Libraries, Oxford, England, UK 3 Karolinska Institute Department of Global Public Health, Stockholm, Stockholm County, Sweden 2 University of Oxford Bodleian Libraries, Oxford, England, UK 3 Karolinska Institute Department of Global Public Health, Stockholm, Stockholm County, Sweden Alexandra Caulfield Roles: Conceptualization, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing Roles: Conceptualization, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing Anne Ferrey Roles: Writing – Review & Editing Roles: Writing – Review & Editing Nia Roberts Roles: Methodology, Writing – Review & Editing Roles: Methodology, Writing – Review & Editing Jeremy Leslie-Spinks Roles: Writing – Review & Editing Roles: Writing – Review & Editing Helle Mölsted Alvesson Roles: Supervision, Writing – Review & Editing Roles: Supervision, Writing – Review & Editing Geoff Wong Roles: Methodology, Supervision, Writing – Review & Editing Roles: Methodology, Supervision, Writing – Review & Editing Trish Greenhalgh Roles: Supervision, Writing – Review & Editing Roles: Supervision, Writing – Review & Editing OPEN PEER REVIEW REVIEWER STATUS In recent years, there has been growing interest at national and international policy level in the potential of creative arts to support individual and community wellbeing. Creative arts encompass a wide range of activities, including performing arts, visual arts, design and craft, literature, culture and digital and electronic arts. Participation in creative arts has been linked to lower mental distress, increased social connection, improved quality of life, personal growth and empowerment. Despite this, it remains unclear exactly how participation in creative arts interventions can improve wellbeing in older individuals. This realist review aims to synthesize evidence on how elements of creative arts interventions improve wellbeing amongst older people, in particular when, how, for whom and to what extent they work. This review will follow the RAMESES (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) quality standards and Pawson’s five iterative stages to locate existing theories, search for evidence, select literature, extract data, and draw conclusions. It will be guided by stakeholder engagement with policymakers, practitioners, commissioners, and people with lived experience. A realist approach will be used to analyse data and develop causal explanations, in the form of context-mechanism-outcome-configurations (CMOCs), which explain how creative arts interventions impact wellbeing in older people. The CMOCs will be organised into one or more programme theories. Our refined programme theory will then be used to develop guidance for service providers of creative arts who want to use their services to improve wellbeing of older people. This research will comply with the UK Policy Framework for Health and Social Care Research. Dissemination will be guided by our stakeholder group, building on links with policymakers, commissioners, providers, and the public. A final stakeholder event focused on knowledge mobilisation will aid development of recommendations. PROSPERO registration CRD42024580770. Creative activities (such as singing, painting, crafts, writing etc.) can help people feel better and improve their wellbeing. Taking part in these activities may make it easier to meet others, create a sense of belonging, a feeling of achievement and improve quality of life. In recent years, the World Health Organisation and the UK government have encouraged research to explore these benefits. They want to understand how creative activities can improve health for people and their communities. At the moment, we don’t know much about exactly how these creative activities might affect wellbeing. This review aims to identify how creative activities work to improve wellbeing in older adults, and in what kind of circumstances they work best. We hope to use our results to develop practical guidance for people who teach or provide creative arts activities. This will help improve the wellbeing of older people living in the community. Creative arts, older people, wellbeing, mental health, creative health, creative ageing Corresponding Author(s) Alexandra Caulfield ([email protected]) Grant information: This project is funded by the National Institute for Health and Care Research (NIHR) under its NIHR Academic Clinical Fellowship (ACF-2022-13-016) The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2025 Caulfield A et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Caulfield A, Ferrey A, Roberts N et al. In what context and by which mechanisms can creative arts interventions improve wellbeing in older people? A realist review protocol [version 1; peer review: 1 approved, 1 approved with reservations]. NIHR Open Res 2025, 5:19 (https://doi.org/10.3310/nihropenres.13746.1) First published: 04 Mar 2025, 5:19 (https://doi.org/10.3310/nihropenres.13746.1) Latest published: 16 Jun 2025, 5:19 (https://doi.org/10.3310/nihropenres.13746.2) The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. There is a newer version of this article available. of this article available. In recent years, there has been growing interest in the potential of creative arts to support individual and community wellbeing. Creative arts encompass a wide range of activities, including performing arts, visual arts, design and craft, literature, culture and digital and electronic arts1. Involvement may be receptive (e.g. watching a film, visiting a museum) or participatory (e.g. painting, writing), depending on the degree to which the participant is involved in the creative process, though in reality engagement likely falls across a spectrum between the two. Across the UK, 9.4 million people are thought to participate regularly in ‘everyday creativity’ or non-formalised art activities2. In addition, more formal arts programmes take place in a variety of settings, some with a specific health focus (often in conjunction with social prescribing schemes), and others without, although they may still impact health and wellbeing. Access to and engagement in art is a fundamental human right, under Article 27 of the Universal Declaration of Human Rights (UNHR), and creativity can be seen as an intrinsic part of what it means to be human3. Creative arts interventions have the potential to build social capital in communities, and to harness the positive power of community agency, improving public health4–6 Creative arts interventions may offer economic benefits for society and can reduce pressure on an overburdened health system2,7. At an individual level, the benefits of participating in creative arts are well-recognised and include lower mental distress, increased social connection, improved quality of life, personal growth and empowerment2,7–12. Against this background, there is an international policy drive calling for stronger pathways between arts, health and social care. This recognises the importance of realising the full potential for arts in public health policy and their role in helping achieve the UN Sustainable Development Goals13,14. Countries are shifting towards economic policies which incorporate wellbeing, recognising the impact of this on root causes of mental ill health, and creativity has been cited as a skill of the future by the World Economic Forum15. (https://www.weforum.org/agenda/2022/08/free-thinking-boosts-creativity/) In the UK, a recent All Party Parliamentary Group on Arts and Health has emphasized the value of arts to health, and called for a cross party departmental Creative Health Strategy2. Like many populations worldwide, the UK population is ageing; currently 11 million people (19% of the population) are over 65 and this number is increasing16. However, the number of years spent living in good health is falling2. There are multiple reasons for this, but particular challenges facing older people may include declining social networks, loneliness, physical health challenges, loss of partners, caring roles, economic challenges and ageism17–20. Compared with previous generations, families are often more geographically distant than before, with implications for community networks and support21. With regard to mental health, there is an unmet need for support: depression affects around 22% of men and 28% of women over 65, yet it is estimated that 85% of older people with depression receive no help at all from the NHS (https://www.mentalhealth.org.uk/explore-mental-health/statistics/older-people-statistics). Whilst mental health and wellbeing are interrelated concepts, they may also be discrete; one can be mentally ill whilst still achieving a state of subjective wellbeing; conversely one could lack a state of wellbeing without being mentally ill. Previous studies in this field have tended to focus on how creative arts interventions impact patient groups with specific diagnoses e.g. mental illness, dementia, cancer etc22.This review will look at individuals living in the community who have not been included in arts interventions by virtue of a particular diagnosis (e.g. mental ill-health, dementia etc.), and examine impact of creative arts interventions on individual wellbeing. We recognise that wellbeing is a difficult concept to define and will mean different things to different individuals. Following the literature in this field, we define wellbeing as a state of an individual ‘living well’, which may include elements of experienced, evaluative and social wellbeing23. Wellbeing is an important aspect of health; the WHO defines health as ‘a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity’24; This is a bold definition, and such a comprehensive state of wellbeing may be difficult to achieve, yet it remains an important goal; interventions which may facilitate movement towards an improved state of wellbeing are key to individual and community health. Despite the recognised health benefits of participating in creative arts, it remains unclear exactly how creative arts interventions impact participants’ wellbeing. There is a recognised need for better theoretical understanding of how elements of creative arts programmes impact wellbeing amongst older people, and in particular when, how, for whom and to what extent they work2,18,23,25–27. With this in mind, our review seeks to answer the question ‘in what contexts and by which mechanisms can creative arts interventions impact wellbeing in older people?’. We will use a realist approach, which is well-suited to complex interventions with multiple components, such as creative arts programmes. We will look at participatory arts interventions, defining these as an intervention where an individual has an opportunity to actively take part in the creative process e.g. by painting or writing or singing. We will also seek to uncover possible negative impacts of interventions, as well as focusing on subgroups such as men. The knowledge gained should be helpful to those planning and taking part in interventions, and will add to a growing theoretical understanding of this field. This project aims to synthesize the evidence on how elements of creative arts programmes improve wellbeing amongst older people, and in particular when, how, for whom and to what extent they work. Using this knowledge, we hope to develop guidance for providers who want to use creative arts interventions to improve the wellbeing of older people living in the community. 1. Conduct a realist review of the existing literature to develop an in-depth understanding (captured in a realist programme theory) of the use of the creative arts to improve the wellbeing of older people living in the community: (Work Package (WP)1, months 1-9) 2. Use the knowledge within the realist programme theory to develop guidance for service providers of creative arts who want to use their services to improve the wellbeing of older people living in the community (WP2, months 10-12) This project will run from September 2024 - August 2025. Our stakeholder group (comprising older people with lived experience of creative arts interventions, policymakers, service providers and commissioners) will be formally involved at each stage of this review. We will discuss our emerging findings and sense-check our developing theory with this group. Dissemination will be guided by our stakeholder group and will target a range of audiences, building on links with policymakers, commissioners, providers, and the public, and designed reach key actors within the field of creative health e.g. the National Centre for Creative Health and the Creative Ageing Development Agency. A final stakeholder event focused on knowledge mobilisation will aid development of recommendations. This review (PROSPERO registration no: CRD42024580770) will follow Pawson’s five iterative steps for realist reviews. Realist review is well-suited to research on creative arts interventions because such interventions are complex and multi-faceted28. Context is key to determining the relative success or failure of any given intervention, and the mechanisms underlying how context relates to outcome are not always clear. A realist approach allows us to identify and understand some of these mechanisms, building on work done by others in the field25,29. The review will be guided by the RAMESES publication standards for realist synthesis30. For the purposes of this review, the outcome is wellbeing, as defined by the authors of the primary literature; this may be measured by subjective or evaluative means. Step 1: locating existing theories The first step of the review process will be to source existing theories within the field of creative health and from other disciplines which may shed light on the contexts and mechanisms at play in creative arts interventions for older people. Early discussions and literature scoping have informed an initial programme theory (Figure 1), showing the possible contexts and mechanisms of interest. Step 2: searching for evidence The second step will involve searching the literature for relevant papers to include in the review. The search strategy will combine textword and subject heading terms for our key concepts of creative arts, wellbeing, older people and UK. Searches will identify literature published in the English language across ten databases (ASSIA (Proquest), CINAHL(EBSCOHost), Embase(OvisSP), Medline(OvisSP), PsycINFO(OvidSP, Science Citation Index, Social Science Citation Index, Arts & Humanities Citation Index, Conference Proceedings Citation Index - Science and Conference Proceedings Citation index - Social Science & Humanities (Web of Science Core Collection), without restriction based on study type or publication date. The search strategy will be designed, piloted and conducted by an experienced librarian in collaboration with the rest of the project team. In addition to database searches, this will include citation tracking and searching grey literature, as it is likely that there are many creative arts programmes for older people which may not be formally evaluated within the scientific literature, but which would include valuable material for developing the programme theory. In line with the iterative nature of realist reviews, further searching will take place to provide more data for specific subsections of the programme theory as required. Screening

will be exported to Covidence where duplicates will be removed and screening will be undertaken first by title and abstract and full text by AC (Covidence. [Internet]. 2024 [20th August 2024]. Available from: https://www.covidence.org/.). At both stages, a 10% random sample will be independently reviewed by another member of the research team, AF. Disagreements not resolved through discussion between the researchers will be resolved through majority vote within the research team. We will seek additional information from study authors where necessary to resolve questions about eligibility. Inclusion and exclusion criteria - Inclusion criteria - Exclusion criteria: • Intervention ◦ creative arts programmes with receptive involvement (where the individual has a receptive role in the activity e.g. going to a museum, watching a film) ◦ programmes run in non-community settings (e.g. nursing or care settings) ◦ programmes run in countries other than England, Wales, Scotland, Northern Ireland ◦ programmes involving activities such as gardening, cooking and volunteering (following a consensus in the literature that these are not generally considered as creative arts activities, though we recognise that this may be debatable) or with an intergenerational focus • Population ◦ older people selected for inclusion in programmes by virtue of a specific diagnosis (e.g. dementia, cancer, mental ill health) or carer role ◦ or previous profession (e.g. veterans, music therapists) ◦ older people living in a non-community setting (care home, nursing home, or inpatient in hospital etc.) • Outcome Step 3: article selection Full text articles will be selected for inclusion in the review based on relevance and rigour. Relevance will be determined by what the article is able to offer towards the development of the programme theory. Rigour will be assessed in two ways - at the level of the quality of the methods used in included articles to generate relevant data and at the level of the explanatory value of the programme theory. We will undertake quality assessment of the methodological quality of included articles only when we find that a particular article has contributed a substantial amount of data to our CMOCs or programme theory, or when a CMOC draws heavily on one article. We will judge the explanatory quality of the programme theory using criteria of consilience, simplicity and analogy. Briefly, consilience refers to the ability of any explanation to account for as much of the data as possible. Simplicity is based on Occam’s Razor and thus expects the theoretical explanations to be as simple as possible with minimal to no ad hoc exceptions. Finally analogy refers to the whether what we have found fits in with existing knowledge31. A random sample of 10% of the included articles will again be independently reviewed by a second member of the research team, AF. As previously, any disagreement not resolved by discussion will be decided upon by majority vote within the research team. Step 4: extracting and organising data Data will be extracted by AC. Descriptive data from the included studies will be inputted into an Excel spreadsheet. These descriptive data will include details of the study (authors, publication date, country), participants (number, age), intervention (type of activity, setting, duration, referral pathway, funding) and outcome (measurement, findings). Data extracted for analytic purposes to develop and test (confirm, refute or refine) the CMOCs and emerging programme theory will be inputted into NVivo (Lumivero (2023) NVivo (Version 14) www.lumivero.com), after rereading the full texts of the papers. The papers will initially be thematically coded in NVivo, both inductively (to enable the development of new ideas for the programme theory), deductively (based on the concepts contained within the initial programme theory) and retroductively (to infer what may be functioning as mechanisms). Codes will be refined through discussion as above, and interpretations and judgements agreed upon with the rest of the team, and at key points with the stakeholder group. As refinements are made, included papers will be reassessed for further contribution to the developing theory. Step 5: synthesising the evidence and drawing conclusions The analysis will then proceed to develop realist causal explanations for outcomes that are relevant to the programme theory, within each theme. The analysis will use a realist logic of analysis, moving between the data and the theory to explore how creative arts impact wellbeing in older people. The analysis will use interpretations of the coded data to build causal explanations that take the form of Context (C), Mechanism (M) and Outcome (O) configurations (CMOCs). The final programme theory will contain CMOCs that explain in which contexts certain mechanisms are triggered to produce outcomes relating to wellbeing, and consider the relative importance of these contexts. Our stakeholder group will provide feedback on the final programme theory. As this realist review is a secondary evidence synthesis of existing literature, ethical approval was not sought; however, this research will be conducted in full compliance with the Declaration of Helsinki on medical research and the UK Policy Framework for Health and Social Care Research32. Figshare: PRISMA-P checklist for ‘In what context and by which mechanisms can creative arts interventions improve wellbeing in older people? A realist review protocol’. https://doi.org/10.6084/m9.figshare.27302667.v133. Data are available under the terms of the (CC0 1.0 Public domain dedication). The authors would like to acknowledge and thank the members of our stakeholder group for their ongoing involvement in the project. For the purpose of Open Access, the author has applied a CC BY public copyright licence to any Author Accepted Manuscript (AAM) version arising from this submission. Faculty Opinions recommendedReferences - 1. Fancourt D, Finn S: What is the evidence on the role of the arts in improving health and well-being? A scoping review. Copenhagen: WHO Regional Office for Europe; (Health Evidence Network (HEN) synthesis report 67), 2019. Reference Source - 2. The All-Party Parliamentary Group on Arts Health and Wellbeing and The National Centre for Creative Health: Creative Health Review - how policy can embrace creative health. London: National Centre for Creative Health, 2023. Reference Source - 3. MacGregor N: A history of the world in 100 objects. New York: Penguin Books, 2013. - 4. 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Journal contribution, 2024. http://www.doi.org/10.6084/m9.figshare.27302667 Author details Author details 1 University of Oxford Nuffield Department of Primary Care Health Sciences, Oxford, England, UK 2 University of Oxford Bodleian Libraries, Oxford, England, UK 3 Karolinska Institute Department of Global Public Health, Stockholm, Stockholm County, Sweden 2 University of Oxford Bodleian Libraries, Oxford, England, UK 3 Karolinska Institute Department of Global Public Health, Stockholm, Stockholm County, Sweden Alexandra Caulfield Roles: Conceptualization, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing Roles: Conceptualization, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing Anne Ferrey Roles: Writing – Review & Editing Roles: Writing – Review & Editing Nia Roberts Roles: Methodology, Writing – Review & Editing Roles: Methodology, Writing – Review & Editing Jeremy Leslie-Spinks Roles: Writing – Review & Editing Roles: Writing – Review & Editing Helle Mölsted Alvesson Roles: Supervision, Writing – Review & Editing Roles: Supervision, Writing – Review & Editing Geoff Wong Roles: Methodology, Supervision, Writing – Review & Editing Roles: Methodology, Supervision, Writing – Review & Editing Trish Greenhalgh Roles: Supervision, Writing – Review & Editing Roles: Supervision, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information This project is funded by the National Institute for Health and Care Research (NIHR) under its NIHR Academic Clinical Fellowship (ACF-2022-13-016) The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Article Versions (2) Copyright © 2025 Caulfield A et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. metrics VIEWS $counts.viewCount downloads Citations CITE how to cite this article Caulfield A, Ferrey A, Roberts N et al. In what context and by which mechanisms can creative arts interventions improve wellbeing in older people? A realist review protocol [version 1; peer review: 1 approved, 1 approved with reservations]. NIHR Open Res 2025, 5:19 (https://doi.org/10.3310/nihropenres.13746.1) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. track receive updates on this article Track an article to receive email alerts on any updates to this article. Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 04 Mar 2025 Views 0 How to cite this report: Karkou V. Reviewer Report For: In what context and by which mechanisms can creative arts interventions improve wellbeing in older people? A realist review protocol [version 1; peer review: 1 approved, 1 approved with reservations]. NIHR Open Res 2025, 5:19 (https://doi.org/10.3310/nihropenres.14930.r34945) The direct URL for this report is: https://openresearch.nihr.ac.uk/articles/5-19/v1#referee-response-34945 https://openresearch.nihr.ac.uk/articles/5-19/v1#referee-response-34945 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Reviewer Report 10 May 2025 Vicky Karkou, Edge Hill University, Ormskirk, UK Approved VIEWS 0 This is a very well written piece that provides a strong rationale and study design consistent with the approach adopted. Some minor comments for improvement are: There is a good overview of arts-based interventions. The text sets ... Continue reading I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close There is a good overview of arts-based interventions. The text sets ... Continue reading This is a very well written piece that provides a strong rationale and study design consistent with the approach adopted. Some minor comments for improvement are: There is a good overview of arts-based interventions. The text sets out the whole field but it is only later on (towards the end of the introduction) that it becomes clear that the review is concerned with participatory arts interventions only. It is now clear how the RAMESES quality standards will be used (and not used consistently within the text: are you referring to quality standards or publication standards?). It will be good practice to move the websites from the text and reference website as a normal reference following relevant conventions. p.4. I would not refer to men as a subgroup, but maybe simply a group. There is a good overview of arts-based interventions. The text sets out the whole field but it is only later on (towards the end of the introduction) that it becomes clear that the review is concerned with participatory arts interventions only. It is now clear how the RAMESES quality standards will be used (and not used consistently within the text: are you referring to quality standards or publication standards?). It will be good practice to move the websites from the text and reference website as a normal reference following relevant conventions. p.4. I would not refer to men as a subgroup, but maybe simply a group. - Is the rationale for, and objectives of, the study clearly described? Yes - Is the study design appropriate for the research question? Yes - Are sufficient details of the methods provided to allow replication by others? Yes - Are the datasets clearly presented in a useable and accessible format? Not applicable Competing Interests: No competing interests were disclosed. Reviewer Expertise: Arts-based interventions, systematic literature reviews, realist evaluations, mixed methods researcher. CITE HOW TO CITE THIS REPORT Karkou V. Reviewer Report For: In what context and by which mechanisms can creative arts interventions improve wellbeing in older people? A realist review protocol [version 1; peer review: 1 approved, 1 approved with reservations]. NIHR Open Res 2025, 5:19 (https://doi.org/10.3310/nihropenres.14930.r34945) The direct URL for this report is: https://openresearch.nihr.ac.uk/articles/5-19/v1#referee-response-34945 https://openresearch.nihr.ac.uk/articles/5-19/v1#referee-response-34945 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. - Author Response 11 Sep 2025Alexandra Caulfield, University of Oxford, Oxford, UK11 Sep 2025Author ResponseResponse to Reviewers The authors would like to thank all the reviewers for taking the time to review and provide insightful feedback on our protocol. Please find your comments ... Continue reading Response to Reviewers The authors would like to thank all the reviewers for taking the time to review and provide insightful feedback on our protocol. Please find your comments addressed below: Reviewer 1- Our study population is community-dwelling UK adults aged 65 years or over recruited to interventions not by virtue of a particular diagnosis. We have chosen this population as less is known about the impact of creative arts interventions than for individuals recruited on the basis of a specific diagnosis, and it is possible that different mechanisms may be at play. It is unfortunately outside the scope of this review to include these populations in addition to our study population, and within these limitations it was felt useful to focus on a population about which less is known. - However, we acknowledge the point made by Reviewer 1 that previous theoretical work done with other populations provides important background to our current review and can enhance our understanding of the identified CMOCs. The realist framework developed by Windle et al. (2018) and the work of Cousins et al. (2020) provide valuable perspectives for situating our findings within the broader research landscape, and we aim to reflect on how our findings relate to this wider body of theoretical work in an upcoming results paper. - The concept of ‘wellbeing’ is complex and challenging to define, as rightly noted by Reviewer 1. In light of this observation, we have expanded our definition to include further discussion of the experienced, evaluative, eudaimonic and social aspects of wellbeing. The concept of ‘flourishing’, an idea very relevant to creative arts participation, seems to fall within the concept of eudaimonic wellbeing, or living one’s life in line with a sense of purpose and personal growth (Fancourt et al. 2022). - We acknowledge the valid criticism of the WHO definition of health and wellbeing. This definition has been criticised for its failure to acknowledge that an individual may simultaneously experience ‘ill-being’ as a part of subjective wellbeing (Zeilig et al. 2019); we hope we have clarified that wellbeing can co-exist alongside illness states. Social isolation and loneliness feed into experiences of wellbeing. To ensure inclusivity, we have adhered to the definitions of wellbeing used by the original study authors, rather than imposing a singular framework. Quality of life and wellbeing are interrelated concepts, and it falls beyond the scope of this paper to compare and contrast the two; the term wellbeing was chosen for this review as it seems to be most frequently used in more recent papers examining these concepts, and it may be more subjective than QoL measures (Ruggeri et al. 2020, Meiselman 2016). - We would like to clarify that artists are included within our stakeholder group under the term practitioner, and are represented within our research team (JLS). This terminology, drawn from a recent arts and public health policy paper (Dow et al. 2023), was selected to provide an inclusive descriptor which may encompass various types of artists and facilitators leading interventions. - Our stakeholder group will be consulted on how best to produce practical guidance for a range of providers (facilitators, artists, and other relevant parties e.g. linkworkers who may refer or speak to older people about the benefits of attending such programmes), and what form this should take. We have updated our PPI paragraph to make this clear. - The most commonly represented demographic at participatory creative arts interventions for over 65s in the UK is women of white British background (Dowlen 2023). We have removed the reference to men as a subgroup and clarified that our review will highlight evidence gaps within the existing literature. We will comment in our findings on any identified gaps in the literature, including where this may relate to people from global majority communities. - With regard to search strategy, this was piloted to ensure it picked up relevant papers. We sought to include a comprehensive list of databases from a range of disciplines, as well as unpublished literature, and will contact authors to source papers or clarify details as required. Due to capacity, we were unable to run the search strategy past our stakeholder group prior to running the search, but stakeholders will be offered the opportunity to comment on the search strategy during ongoing engagement work. - We acknowledge Reviewer 1’s important point regarding the complexity of distinguishing between participatory and receptive arts activities. This distinction is indeed highly debatable, with considerable practical and philosophical overlap that our study cannot fully resolve. For the purposes of this review, we have chosen to focus on arts activities that emphasize participatory elements, as we believe the mechanisms involved may differ from those in more ‘receptive’ experiences (such as attending a museum or concert), where active individual engagement may be less central. However, we recognize that the distinction is far from clear-cut. Individuals may attend participatory programmes but opt not to engage directly in the artistic activity, choosing instead to simply be present or to participate socially. We will acknowledge this limitation within the discussion of our findings. Reviewer 2- The RAMESES quality standards were used to inform the development of the review protocol published here. The RAMESES publication standards will be used to guide the write-up of review findings in a forthcoming paper. Thank you for pointing out the error referencing publication standards in the main text. This has been amended. - Whilst we agree with Reviewer 2 that website references may be more readable if included in the reference list, these links are included in the main text in line with NIHR Open referencing standards: ‘Web links, URLs, and links to the authors’ own websites should be included as hyperlinks within the main body of the article, and not as references.’ References- Windle G, Gregory S, Howson-Griffiths T, Newman A, O’Brien D, Goulding A. Exploring the theoretical foundations of visual art programmes for people living with dementia. Dementia. 2017;17(6):702-727. - Cousins E, Tischler V, Garabedian C, Dening T. A Taxonomy of Arts Interventions for People With Dementia. Gerontologist. 2020 Jan 24;60(1):124-134. doi: 10.1093/geront/gnz024 - Bone JK, Fancourt D: Arts, culture & the brain: a literature review and new epidemiological analyses. London: Arts Council England,2022. - Zeilig H, Tischler V, van der Byl Williams M, West J, Strohmaier S. Co-creativity, well-being and agency: A case study analysis of a co-creative arts group for people with dementia. J Aging Stud. 2019 Jun;49:16-24. - Ruggeri, K., Garcia-Garzon, E., Maguire, Á. et al. Well-being is more than happiness and life satisfaction: a multidimensional analysis of 21 countries. Health Qual Life Outcomes 18, 192 (2020). - Meiselman, H. L. (2016). Quality of life, well-being and wellness: Measuring subjective health for foods and other products. Food Quality and Preference, 54, 101–109. - Dow R, Warran K, Letrondo P, Fancourt D. The arts in public health policy: progress and opportunities. Lancet Public Health. 2023 Feb;8(2):e155-e160. doi: 10.1016/S2468-2667(22)00313-9 - Dowlen, R. (2023) Vision paper: culture, health and wellbeing. January 2023. Leeds: Centre for Cultural Value. Response to ReviewersCompeting Interests: No competing interests were disclosed. Close The authors would like to thank all the reviewers for taking the time to review and provide insightful feedback on our protocol. Please find your comments addressed below: Reviewer 1- Our study population is community-dwelling UK adults aged 65 years or over recruited to interventions not by virtue of a particular diagnosis. We have chosen this population as less is known about the impact of creative arts interventions than for individuals recruited on the basis of a specific diagnosis, and it is possible that different mechanisms may be at play. It is unfortunately outside the scope of this review to include these populations in addition to our study population, and within these limitations it was felt useful to focus on a population about which less is known. - However, we acknowledge the point made by Reviewer 1 that previous theoretical work done with other populations provides important background to our current review and can enhance our understanding of the identified CMOCs. The realist framework developed by Windle et al. (2018) and the work of Cousins et al. (2020) provide valuable perspectives for situating our findings within the broader research landscape, and we aim to reflect on how our findings relate to this wider body of theoretical work in an upcoming results paper. - The concept of ‘wellbeing’ is complex and challenging to define, as rightly noted by Reviewer 1. In light of this observation, we have expanded our definition to include further discussion of the experienced, evaluative, eudaimonic and social aspects of wellbeing. The concept of ‘flourishing’, an idea very relevant to creative arts participation, seems to fall within the concept of eudaimonic wellbeing, or living one’s life in line with a sense of purpose and personal growth (Fancourt et al. 2022). - We acknowledge the valid criticism of the WHO definition of health and wellbeing. This definition has been criticised for its failure to acknowledge that an individual may simultaneously experience ‘ill-being’ as a part of subjective wellbeing (Zeilig et al. 2019); we hope we have clarified that wellbeing can co-exist alongside illness states. Social isolation and loneliness feed into experiences of wellbeing. To ensure inclusivity, we have adhered to the definitions of wellbeing used by the original study authors, rather than imposing a singular framework. Quality of life and wellbeing are interrelated concepts, and it falls beyond the scope of this paper to compare and contrast the two; the term wellbeing was chosen for this review as it seems to be most frequently used in more recent papers examining these concepts, and it may be more subjective than QoL measures (Ruggeri et al. 2020, Meiselman 2016). - We would like to clarify that artists are included within our stakeholder group under the term practitioner, and are represented within our research team (JLS). This terminology, drawn from a recent arts and public health policy paper (Dow et al. 2023), was selected to provide an inclusive descriptor which may encompass various types of artists and facilitators leading interventions. - Our stakeholder group will be consulted on how best to produce practical guidance for a range of providers (facilitators, artists, and other relevant parties e.g. linkworkers who may refer or speak to older people about the benefits of attending such programmes), and what form this should take. We have updated our PPI paragraph to make this clear. - The most commonly represented demographic at participatory creative arts interventions for over 65s in the UK is women of white British background (Dowlen 2023). We have removed the reference to men as a subgroup and clarified that our review will highlight evidence gaps within the existing literature. We will comment in our findings on any identified gaps in the literature, including where this may relate to people from global majority communities. - With regard to search strategy, this was piloted to ensure it picked up relevant papers. We sought to include a comprehensive list of databases from a range of disciplines, as well as unpublished literature, and will contact authors to source papers or clarify details as required. Due to capacity, we were unable to run the search strategy past our stakeholder group prior to running the search, but stakeholders will be offered the opportunity to comment on the search strategy during ongoing engagement work. - We acknowledge Reviewer 1’s important point regarding the complexity of distinguishing between participatory and receptive arts activities. This distinction is indeed highly debatable, with considerable practical and philosophical overlap that our study cannot fully resolve. For the purposes of this review, we have chosen to focus on arts activities that emphasize participatory elements, as we believe the mechanisms involved may differ from those in more ‘receptive’ experiences (such as attending a museum or concert), where active individual engagement may be less central. However, we recognize that the distinction is far from clear-cut. Individuals may attend participatory programmes but opt not to engage directly in the artistic activity, choosing instead to simply be present or to participate socially. We will acknowledge this limitation within the discussion of our findings. Reviewer 2- The RAMESES quality standards were used to inform the development of the review protocol published here. The RAMESES publication standards will be used to guide the write-up of review findings in a forthcoming paper. Thank you for pointing out the error referencing publication standards in the main text. This has been amended. - Whilst we agree with Reviewer 2 that website references may be more readable if included in the reference list, these links are included in the main text in line with NIHR Open referencing standards: ‘Web links, URLs, and links to the authors’ own websites should be included as hyperlinks within the main body of the article, and not as references.’ References- Windle G, Gregory S, Howson-Griffiths T, Newman A, O’Brien D, Goulding A. Exploring the theoretical foundations of visual art programmes for people living with dementia. Dementia. 2017;17(6):702-727. - Cousins E, Tischler V, Garabedian C, Dening T. A Taxonomy of Arts Interventions for People With Dementia. Gerontologist. 2020 Jan 24;60(1):124-134. doi: 10.1093/geront/gnz024 - Bone JK, Fancourt D: Arts, culture & the brain: a literature review and new epidemiological analyses. London: Arts Council England,2022. - Zeilig H, Tischler V, van der Byl Williams M, West J, Strohmaier S. Co-creativity, well-being and agency: A case study analysis of a co-creative arts group for people with dementia. J Aging Stud. 2019 Jun;49:16-24. - Ruggeri, K., Garcia-Garzon, E., Maguire, Á. et al. Well-being is more than happiness and life satisfaction: a multidimensional analysis of 21 countries. Health Qual Life Outcomes 18, 192 (2020). - Meiselman, H. L. (2016). Quality of life, well-being and wellness: Measuring subjective health for foods and other products. Food Quality and Preference, 54, 101–109. - Dow R, Warran K, Letrondo P, Fancourt D. The arts in public health policy: progress and opportunities. Lancet Public Health. 2023 Feb;8(2):e155-e160. doi: 10.1016/S2468-2667(22)00313-9 - Dowlen, R. (2023) Vision paper: culture, health and wellbeing. January 2023. Leeds: Centre for Cultural Value. COMMENTS ON THIS REPORT - Author Response 11 Sep 2025Alexandra Caulfield, University of Oxford, Oxford, UK11 Sep 2025Author ResponseResponse to Reviewers The authors would like to thank all the reviewers for taking the time to review and provide insightful feedback on our protocol. Please find your comments ... Continue reading Response to Reviewers The authors would like to thank all the reviewers for taking the time to review and provide insightful feedback on our protocol. Please find your comments addressed below: Reviewer 1- Our study population is community-dwelling UK adults aged 65 years or over recruited to interventions not by virtue of a particular diagnosis. We have chosen this population as less is known about the impact of creative arts interventions than for individuals recruited on the basis of a specific diagnosis, and it is possible that different mechanisms may be at play. It is unfortunately outside the scope of this review to include these populations in addition to our study population, and within these limitations it was felt useful to focus on a population about which less is known. - However, we acknowledge the point made by Reviewer 1 that previous theoretical work done with other populations provides important background to our current review and can enhance our understanding of the identified CMOCs. The realist framework developed by Windle et al. (2018) and the work of Cousins et al. (2020) provide valuable perspectives for situating our findings within the broader research landscape, and we aim to reflect on how our findings relate to this wider body of theoretical work in an upcoming results paper. - The concept of ‘wellbeing’ is complex and challenging to define, as rightly noted by Reviewer 1. In light of this observation, we have expanded our definition to include further discussion of the experienced, evaluative, eudaimonic and social aspects of wellbeing. The concept of ‘flourishing’, an idea very relevant to creative arts participation, seems to fall within the concept of eudaimonic wellbeing, or living one’s life in line with a sense of purpose and personal growth (Fancourt et al. 2022). - We acknowledge the valid criticism of the WHO definition of health and wellbeing. This definition has been criticised for its failure to acknowledge that an individual may simultaneously experience ‘ill-being’ as a part of subjective wellbeing (Zeilig et al. 2019); we hope we have clarified that wellbeing can co-exist alongside illness states. Social isolation and loneliness feed into experiences of wellbeing. To ensure inclusivity, we have adhered to the definitions of wellbeing used by the original study authors, rather than imposing a singular framework. Quality of life and wellbeing are interrelated concepts, and it falls beyond the scope of this paper to compare and contrast the two; the term wellbeing was chosen for this review as it seems to be most frequently used in more recent papers examining these concepts, and it may be more subjective than QoL measures (Ruggeri et al. 2020, Meiselman 2016). - We would like to clarify that artists are included within our stakeholder group under the term practitioner, and are represented within our research team (JLS). This terminology, drawn from a recent arts and public health policy paper (Dow et al. 2023), was selected to provide an inclusive descriptor which may encompass various types of artists and facilitators leading interventions. - Our stakeholder group will be consulted on how best to produce practical guidance for a range of providers (facilitators, artists, and other relevant parties e.g. linkworkers who may refer or speak to older people about the benefits of attending such programmes), and what form this should take. We have updated our PPI paragraph to make this clear. - The most commonly represented demographic at participatory creative arts interventions for over 65s in the UK is women of white British background (Dowlen 2023). We have removed the reference to men as a subgroup and clarified that our review will highlight evidence gaps within the existing literature. We will comment in our findings on any identified gaps in the literature, including where this may relate to people from global majority communities. - With regard to search strategy, this was piloted to ensure it picked up relevant papers. We sought to include a comprehensive list of databases from a range of disciplines, as well as unpublished literature, and will contact authors to source papers or clarify details as required. Due to capacity, we were unable to run the search strategy past our stakeholder group prior to running the search, but stakeholders will be offered the opportunity to comment on the search strategy during ongoing engagement work. - We acknowledge Reviewer 1’s important point regarding the complexity of distinguishing between participatory and receptive arts activities. This distinction is indeed highly debatable, with considerable practical and philosophical overlap that our study cannot fully resolve. For the purposes of this review, we have chosen to focus on arts activities that emphasize participatory elements, as we believe the mechanisms involved may differ from those in more ‘receptive’ experiences (such as attending a museum or concert), where active individual engagement may be less central. However, we recognize that the distinction is far from clear-cut. Individuals may attend participatory programmes but opt not to engage directly in the artistic activity, choosing instead to simply be present or to participate socially. We will acknowledge this limitation within the discussion of our findings. Reviewer 2- The RAMESES quality standards were used to inform the development of the review protocol published here. The RAMESES publication standards will be used to guide the write-up of review findings in a forthcoming paper. Thank you for pointing out the error referencing publication standards in the main text. This has been amended. - Whilst we agree with Reviewer 2 that website references may be more readable if included in the reference list, these links are included in the main text in line with NIHR Open referencing standards: ‘Web links, URLs, and links to the authors’ own websites should be included as hyperlinks within the main body of the article, and not as references.’ References- Windle G, Gregory S, Howson-Griffiths T, Newman A, O’Brien D, Goulding A. Exploring the theoretical foundations of visual art programmes for people living with dementia. Dementia. 2017;17(6):702-727. - Cousins E, Tischler V, Garabedian C, Dening T. A Taxonomy of Arts Interventions for People With Dementia. Gerontologist. 2020 Jan 24;60(1):124-134. doi: 10.1093/geront/gnz024 - Bone JK, Fancourt D: Arts, culture & the brain: a literature review and new epidemiological analyses. London: Arts Council England,2022. - Zeilig H, Tischler V, van der Byl Williams M, West J, Strohmaier S. Co-creativity, well-being and agency: A case study analysis of a co-creative arts group for people with dementia. J Aging Stud. 2019 Jun;49:16-24. - Ruggeri, K., Garcia-Garzon, E., Maguire, Á. et al. Well-being is more than happiness and life satisfaction: a multidimensional analysis of 21 countries. Health Qual Life Outcomes 18, 192 (2020). - Meiselman, H. L. (2016). Quality of life, well-being and wellness: Measuring subjective health for foods and other products. Food Quality and Preference, 54, 101–109. - Dow R, Warran K, Letrondo P, Fancourt D. The arts in public health policy: progress and opportunities. Lancet Public Health. 2023 Feb;8(2):e155-e160. doi: 10.1016/S2468-2667(22)00313-9 - Dowlen, R. (2023) Vision paper: culture, health and wellbeing. January 2023. Leeds: Centre for Cultural Value. Response to ReviewersCompeting Interests: No competing interests were disclosed. Close The authors would like to thank all the reviewers for taking the time to review and provide insightful feedback on our protocol. Please find your comments addressed below: Reviewer 1- Our study population is community-dwelling UK adults aged 65 years or over recruited to interventions not by virtue of a particular diagnosis. We have chosen this population as less is known about the impact of creative arts interventions than for individuals recruited on the basis of a specific diagnosis, and it is possible that different mechanisms may be at play. It is unfortunately outside the scope of this review to include these populations in addition to our study population, and within these limitations it was felt useful to focus on a population about which less is known. - However, we acknowledge the point made by Reviewer 1 that previous theoretical work done with other populations provides important background to our current review and can enhance our understanding of the identified CMOCs. The realist framework developed by Windle et al. (2018) and the work of Cousins et al. (2020) provide valuable perspectives for situating our findings within the broader research landscape, and we aim to reflect on how our findings relate to this wider body of theoretical work in an upcoming results paper. - The concept of ‘wellbeing’ is complex and challenging to define, as rightly noted by Reviewer 1. In light of this observation, we have expanded our definition to include further discussion of the experienced, evaluative, eudaimonic and social aspects of wellbeing. The concept of ‘flourishing’, an idea very relevant to creative arts participation, seems to fall within the concept of eudaimonic wellbeing, or living one’s life in line with a sense of purpose and personal growth (Fancourt et al. 2022). - We acknowledge the valid criticism of the WHO definition of health and wellbeing. This definition has been criticised for its failure to acknowledge that an individual may simultaneously experience ‘ill-being’ as a part of subjective wellbeing (Zeilig et al. 2019); we hope we have clarified that wellbeing can co-exist alongside illness states. Social isolation and loneliness feed into experiences of wellbeing. To ensure inclusivity, we have adhered to the definitions of wellbeing used by the original study authors, rather than imposing a singular framework. Quality of life and wellbeing are interrelated concepts, and it falls beyond the scope of this paper to compare and contrast the two; the term wellbeing was chosen for this review as it seems to be most frequently used in more recent papers examining these concepts, and it may be more subjective than QoL measures (Ruggeri et al. 2020, Meiselman 2016). - We would like to clarify that artists are included within our stakeholder group under the term practitioner, and are represented within our research team (JLS). This terminology, drawn from a recent arts and public health policy paper (Dow et al. 2023), was selected to provide an inclusive descriptor which may encompass various types of artists and facilitators leading interventions. - Our stakeholder group will be consulted on how best to produce practical guidance for a range of providers (facilitators, artists, and other relevant parties e.g. linkworkers who may refer or speak to older people about the benefits of attending such programmes), and what form this should take. We have updated our PPI paragraph to make this clear. - The most commonly represented demographic at participatory creative arts interventions for over 65s in the UK is women of white British background (Dowlen 2023). We have removed the reference to men as a subgroup and clarified that our review will highlight evidence gaps within the existing literature. We will comment in our findings on any identified gaps in the literature, including where this may relate to people from global majority communities. - With regard to search strategy, this was piloted to ensure it picked up relevant papers. We sought to include a comprehensive list of databases from a range of disciplines, as well as unpublished literature, and will contact authors to source papers or clarify details as required. Due to capacity, we were unable to run the search strategy past our stakeholder group prior to running the search, but stakeholders will be offered the opportunity to comment on the search strategy during ongoing engagement work. - We acknowledge Reviewer 1’s important point regarding the complexity of distinguishing between participatory and receptive arts activities. This distinction is indeed highly debatable, with considerable practical and philosophical overlap that our study cannot fully resolve. For the purposes of this review, we have chosen to focus on arts activities that emphasize participatory elements, as we believe the mechanisms involved may differ from those in more ‘receptive’ experiences (such as attending a museum or concert), where active individual engagement may be less central. However, we recognize that the distinction is far from clear-cut. Individuals may attend participatory programmes but opt not to engage directly in the artistic activity, choosing instead to simply be present or to participate socially. We will acknowledge this limitation within the discussion of our findings. Reviewer 2- The RAMESES quality standards were used to inform the development of the review protocol published here. The RAMESES publication standards will be used to guide the write-up of review findings in a forthcoming paper. Thank you for pointing out the error referencing publication standards in the main text. This has been amended. - Whilst we agree with Reviewer 2 that website references may be more readable if included in the reference list, these links are included in the main text in line with NIHR Open referencing standards: ‘Web links, URLs, and links to the authors’ own websites should be included as hyperlinks within the main body of the article, and not as references.’ References- Windle G, Gregory S, Howson-Griffiths T, Newman A, O’Brien D, Goulding A. Exploring the theoretical foundations of visual art programmes for people living with dementia. Dementia. 2017;17(6):702-727. - Cousins E, Tischler V, Garabedian C, Dening T. A Taxonomy of Arts Interventions for People With Dementia. Gerontologist. 2020 Jan 24;60(1):124-134. doi: 10.1093/geront/gnz024 - Bone JK, Fancourt D: Arts, culture & the brain: a literature review and new epidemiological analyses. London: Arts Council England,2022. - Zeilig H, Tischler V, van der Byl Williams M, West J, Strohmaier S. Co-creativity, well-being and agency: A case study analysis of a co-creative arts group for people with dementia. J Aging Stud. 2019 Jun;49:16-24. - Ruggeri, K., Garcia-Garzon, E., Maguire, Á. et al. Well-being is more than happiness and life satisfaction: a multidimensional analysis of 21 countries. Health Qual Life Outcomes 18, 192 (2020). - Meiselman, H. L. (2016). Quality of life, well-being and wellness: Measuring subjective health for foods and other products. Food Quality and Preference, 54, 101–109. - Dow R, Warran K, Letrondo P, Fancourt D. The arts in public health policy: progress and opportunities. Lancet Public Health. 2023 Feb;8(2):e155-e160. doi: 10.1016/S2468-2667(22)00313-9 - Dowlen, R. (2023) Vision paper: culture, health and wellbeing. January 2023. Leeds: Centre for Cultural Value. Views 0 How to cite this report: West J and Zeilig H. Reviewer Report For: In what context and by which mechanisms can creative arts interventions improve wellbeing in older people? A realist review protocol [version 1; peer review: 1 approved, 1 approved with reservations]. NIHR Open Res 2025, 5:19 (https://doi.org/10.3310/nihropenres.14930.r35074) The direct URL for this report is: https://openresearch.nihr.ac.uk/articles/5-19/v1#referee-response-35074 https://openresearch.nihr.ac.uk/articles/5-19/v1#referee-response-35074 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Reviewer Report 23 Apr 2025 Hannah Zeilig, London College of Fashion, University of the Arts London, London, England, UK Approved with Reservations VIEWS 0 In this article, the authors present the argument that despite the growing interest in the potential for the creative arts to support wellbeing, understanding concerning the mechanisms whereby these interventions impact wellbeing for older adults is poorly understood. They also ... Continue reading 2. Grebosz-Haring K, Clift S: The need for a critical perspective on arts and health research and evidence reviews. 2025. Publisher Full Text 3. Windle G, Gregory S, Howson-Griffiths T, Newman A, et al.: Exploring the theoretical foundations of visual art programmes for people living with dementia.Dementia (London). 2018; 17 (6): 702-727 PubMed Abstract | Publisher Full Text 4. Cousins E, Tischler V, Garabedian C, Dening T: A Taxonomy of Arts Interventions for People With Dementia.Gerontologist. 2020; 60 (1): 124-134 PubMed Abstract | Publisher Full Text 5. West J, Zeilig H, Cape T, Payne L, et al.: Making a living moment more resonant: an exploration of the role of the artist in co-creative work with people living with dementia. Wellcome Open Research. 2024; 8. Publisher Full Text 6. Zeilig H, Tischler V, van der Byl Williams M, West J, et al.: Co-creativity, well-being and agency: A case study analysis of a co-creative arts group for people with dementia.J Aging Stud. 2019; 49: 16-24 PubMed Abstract | Publisher Full Text We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however we have significant reservations, as outlined above. Close In this article, the authors present the argument that despite the growing interest in the potential for the creative arts to support wellbeing, understanding concerning the mechanisms whereby these interventions impact wellbeing for older adults is poorly understood. They also describe additional reasons for why older people should have access to art. The use of a realist review is proposed, involving context-mechanism-outcome configurations (CMOCs) to create programme theories which can be used to support those who provide services aimed at improving the wellbeing of older people. The methods of the proposed study are described in detail and seem both appropriate for addressing the research question and rigorously designed. We agree that there are recognised health benefits to participating in the creative arts, but as outlined by Clift et al (2021, 2025) there is a need for more robust, systematic work in this area. We would like to offer a few observations which may further strengthen this study.

We would like to offer a few observations which may further strengthen this study. - Whilst we agree that there is not a great deal known about how creative activities affect wellbeing, we are aware that this has been of increasing interest in the last decade. For instance, Windle, G., et al., 2018 (Ref 3) explore the theoretical foundations of visual art programmes for people with dementia using realist synthesis; Cousins, E, et al., 2020 (Ref 4) created a taxonomy of arts interventions again drawing on realist methodology; there is also multi-disciplinary research into the benefits of music for people with dementia - see for example the work of Särkämö. The assumption that research pertaining to people living with dementia might not be helpful in informing work for all older adults seems problematic. - Following on from the previous point, we would question and appreciate further clarity on why this review excludes arts interventions that focus on older people with specific diagnoses (e.g. mental health, dementia or cancer.) Although we agree that previous work has tended to focus on older people with conditions such as those outlined, we think that the excellent work in this area could still be usefully informative for understanding arts interventions and their impact on wellbeing for all older adults. We think it might be important to build on and extrapolate from work that has already identified some of the CMOCs that explain in which contexts certain mechanisms operate to effect wellbeing in arts interventions. - As wellbeing is a central focus for this paper a more nuanced and rigorous definition might be helpful. The concept of flourishing has also been identified as key for wellbeing - especially in relation to the arts. For instance, how does wellbeing differ from quality of life and to what extent should loneliness and social isolation (the absence of these) also be considered? In addition, we are unclear what evaluative and social wellbeing refers to. Finally, the WHO definition is widely accepted but fails to acknowledge the ‘ill-being’ that can be encompassed as part of wellbeing (Zeilig H, et al., 2019 (Ref 6)). - A stated aim is to develop guidance for providers; it would perhaps be useful to have a little more detail on the form that this might take and how this might be differentiated for a range of providers. - There is no mention of the different needs and contexts of people who are from global majority communities and how this will be considered, and we are unclear why men are mentioned as a ‘subgroup’ (is this due to demographic exigencies?) - In identifying the stakeholder group, we wonder why artists are not explicitly mentioned. The invaluable perspective of artists who lead groups for older people in a wide variety of contexts (often over long periods of time) should be fully integrated and yet is routinely overlooked (West, J., et al., 2024 (Ref 5)). This review could be strengthened by their inclusion. - The search strategy which will be conducted by an experienced librarian and the project team could also be sense-checked by the wider stakeholder group, especially older people with lived experience of arts groups. - With regard to the exclusion criteria, we query whether going to a museum can be considered a receptive activity in the same way as watching a film might be. This (as the authors do acknowledge) is highly debatable especially since many museums include activities that encourage creative engagement. Overall, we wonder whether a creative arts activity can be clearly distinguished as being EITHER receptive OR participatory. These distinctions are complex and could be clarified.

- Clift, S., et al, 2021 (Ref 1) - Grebosz-Haring, K. et al., 2025 (Ref 2) - Windle, G., et al., 2018 (Ref 3) - Cousins, E, et al., 2020 (Ref 4) - West, J., et al., 2024 (Ref 5) - Zeilig H, et al., 2019 (Ref 6) - Is the rationale for, and objectives of, the study clearly described? Yes - Is the study design appropriate for the research question? Yes - Are sufficient details of the methods provided to allow replication by others? Yes - Are the datasets clearly presented in a useable and accessible format? Not applicable

1. Clift S, Phillips K, Pritchard S: The need for robust critique of research on social and health impacts of the arts. Cultural Trends. 2021; 30 (5): 442-459 Publisher Full Text2. Grebosz-Haring K, Clift S: The need for a critical perspective on arts and health research and evidence reviews. 2025. Publisher Full Text 3. Windle G, Gregory S, Howson-Griffiths T, Newman A, et al.: Exploring the theoretical foundations of visual art programmes for people living with dementia.Dementia (London). 2018; 17 (6): 702-727 PubMed Abstract | Publisher Full Text 4. Cousins E, Tischler V, Garabedian C, Dening T: A Taxonomy of Arts Interventions for People With Dementia.Gerontologist. 2020; 60 (1): 124-134 PubMed Abstract | Publisher Full Text 5. West J, Zeilig H, Cape T, Payne L, et al.: Making a living moment more resonant: an exploration of the role of the artist in co-creative work with people living with dementia. Wellcome Open Research. 2024; 8. Publisher Full Text 6. Zeilig H, Tischler V, van der Byl Williams M, West J, et al.: Co-creativity, well-being and agency: A case study analysis of a co-creative arts group for people with dementia.J Aging Stud. 2019; 49: 16-24 PubMed Abstract | Publisher Full Text Competing Interests: No competing interests were disclosed. CITE HOW TO CITE THIS REPORT West J and Zeilig H. Reviewer Report For: In what context and by which mechanisms can creative arts interventions improve wellbeing in older people? A realist review protocol [version 1; peer review: 1 approved, 1 approved with reservations]. NIHR Open Res 2025, 5:19 (https://doi.org/10.3310/nihropenres.14930.r35074) The direct URL for this report is: https://openresearch.nihr.ac.uk/articles/5-19/v1#referee-response-35074 https://openresearch.nihr.ac.uk/articles/5-19/v1#referee-response-35074 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. - Author Response 27 Aug 2025Alexandra Caulfield, University of Oxford, Oxford, UK27 Aug 2025Author ResponseResponse to Reviewers The authors would like to thank all the reviewers for taking the time to review and provide insightful feedback on our protocol. Please find your comments ... Continue reading Response to Reviewers The authors would like to thank all the reviewers for taking the time to review and provide insightful feedback on our protocol. Please find your comments addressed below: Reviewer 1- Our study population is community-dwelling UK adults aged 65 years or over recruited to interventions not by virtue of a particular diagnosis. We have chosen this population as less is known about the impact of creative arts interventions than for individuals recruited on the basis of a specific diagnosis, and it is possible that different mechanisms may be at play. It is unfortunately outside the scope of this review to include these populations in addition to our study population, and within these limitations it was felt useful to focus on a population about which less is known. - However, we acknowledge the point made by Reviewer 1 that previous theoretical work done with other populations provides important background to our current review and can enhance our understanding of the identified CMOCs. The realist framework developed by Windle et al. (2018) and the work of Cousins et al. (2020) provide valuable perspectives for situating our findings within the broader research landscape, and we aim to reflect on how our findings relate to this wider body of theoretical work in an upcoming results paper. - The concept of ‘wellbeing’ is complex and challenging to define, as rightly noted by Reviewer 1. In light of this observation, we have expanded our definition to include further discussion of the experienced, evaluative, eudaimonic and social aspects of wellbeing. The concept of ‘flourishing’, an idea very relevant to creative arts participation, seems to fall within the concept of eudaimonic wellbeing, or living one’s life in line with a sense of purpose and personal growth (Fancourt et al. 2022). - We acknowledge the valid criticism of the WHO definition of health and wellbeing. This definition has been criticised for its failure to acknowledge that an individual may simultaneously experience ‘ill-being’ as a part of subjective wellbeing (Zeilig et al. 2019); we hope we have clarified that wellbeing can co-exist alongside illness states. Social isolation and loneliness feed into experiences of wellbeing. To ensure inclusivity, we have adhered to the definitions of wellbeing used by the original study authors, rather than imposing a singular framework. Quality of life and wellbeing are interrelated concepts, and it falls beyond the scope of this paper to compare and contrast the two; the term wellbeing was chosen for this review as it seems to be most frequently used in more recent papers examining these concepts, and it may be more subjective than QoL measures (Ruggeri et al. 2020, Meiselman 2016). - We would like to clarify that artists are included within our stakeholder group under the term practitioner, and are represented within our research team (JLS). This terminology, drawn from a recent arts and public health policy paper (Dow et al. 2023), was selected to provide an inclusive descriptor which may encompass various types of artists and facilitators leading interventions. - Our stakeholder group will be consulted on how best to produce practical guidance for a range of providers (facilitators, artists, and other relevant parties e.g. linkworkers who may refer or speak to older people about the benefits of attending such programmes), and what form this should take. We have updated our PPI paragraph to make this clear. - The most commonly represented demographic at participatory creative arts interventions for over 65s in the UK is women of white British background (Dowlen 2023). We have removed the reference to men as a subgroup and clarified that our review will highlight evidence gaps within the existing literature. We will comment in our findings on any identified gaps in the literature, including where this may relate to people from global majority communities. - With regard to search strategy, this was piloted to ensure it picked up relevant papers. We sought to include a comprehensive list of databases from a range of disciplines, as well as unpublished literature, and will contact authors to source papers or clarify details as required. Due to capacity, we were unable to run the search strategy past our stakeholder group prior to running the search, but stakeholders will be offered the opportunity to comment on the search strategy during ongoing engagement work. - We acknowledge Reviewer 1’s important point regarding the complexity of distinguishing between participatory and receptive arts activities. This distinction is indeed highly debatable, with considerable practical and philosophical overlap that our study cannot fully resolve. For the purposes of this review, we have chosen to focus on arts activities that emphasize participatory elements, as we believe the mechanisms involved may differ from those in more ‘receptive’ experiences (such as attending a museum or concert), where active individual engagement may be less central. However, we recognize that the distinction is far from clear-cut. Individuals may attend participatory programmes but opt not to engage directly in the artistic activity, choosing instead to simply be present or to participate socially. We will acknowledge this limitation within the discussion of our findings. Reviewer 2- The RAMESES quality standards were used to inform the development of the review protocol published here. The RAMESES publication standards will be used to guide the write-up of review findings in a forthcoming paper. Thank you for pointing out the error referencing publication standards in the main text. This has been amended. - Whilst we agree with Reviewer 2 that website references may be more readable if included in the reference list, these links are included in the main text in line with NIHR Open referencing standards: ‘Web links, URLs, and links to the authors’ own websites should be included as hyperlinks within the main body of the article, and not as references.’ References- Windle G, Gregory S, Howson-Griffiths T, Newman A, O’Brien D, Goulding A. Exploring the theoretical foundations of visual art programmes for people living with dementia. Dementia. 2017;17(6):702-727. - Cousins E, Tischler V, Garabedian C, Dening T. A Taxonomy of Arts Interventions for People With Dementia. Gerontologist. 2020 Jan 24;60(1):124-134. doi: 10.1093/geront/gnz024 - Bone JK, Fancourt D: Arts, culture & the brain: a literature review and new epidemiological analyses. London: Arts Council England,2022. - Zeilig H, Tischler V, van der Byl Williams M, West J, Strohmaier S. Co-creativity, well-being and agency: A case study analysis of a co-creative arts group for people with dementia. J Aging Stud. 2019 Jun;49:16-24. - Ruggeri, K., Garcia-Garzon, E., Maguire, Á. et al. Well-being is more than happiness and life satisfaction: a multidimensional analysis of 21 countries. Health Qual Life Outcomes 18, 192 (2020). - Meiselman, H. L. (2016). Quality of life, well-being and wellness: Measuring subjective health for foods and other products. Food Quality and Preference, 54, 101–109. - Dow R, Warran K, Letrondo P, Fancourt D. The arts in public health policy: progress and opportunities. Lancet Public Health. 2023 Feb;8(2):e155-e160. doi: 10.1016/S2468-2667(22)00313-9 - Dowlen, R. (2023) Vision paper: culture, health and wellbeing. January 2023. Leeds: Centre for Cultural Value. Response to ReviewersCompeting Interests: No competing interests were disclosed. Close The authors would like to thank all the reviewers for taking the time to review and provide insightful feedback on our protocol. Please find your comments addressed below: Reviewer 1- Our study population is community-dwelling UK adults aged 65 years or over recruited to interventions not by virtue of a particular diagnosis. We have chosen this population as less is known about the impact of creative arts interventions than for individuals recruited on the basis of a specific diagnosis, and it is possible that different mechanisms may be at play. It is unfortunately outside the scope of this review to include these populations in addition to our study population, and within these limitations it was felt useful to focus on a population about which less is known. - However, we acknowledge the point made by Reviewer 1 that previous theoretical work done with other populations provides important background to our current review and can enhance our understanding of the identified CMOCs. The realist framework developed by Windle et al. (2018) and the work of Cousins et al. (2020) provide valuable perspectives for situating our findings within the broader research landscape, and we aim to reflect on how our findings relate to this wider body of theoretical work in an upcoming results paper. - The concept of ‘wellbeing’ is complex and challenging to define, as rightly noted by Reviewer 1. In light of this observation, we have expanded our definition to include further discussion of the experienced, evaluative, eudaimonic and social aspects of wellbeing. The concept of ‘flourishing’, an idea very relevant to creative arts participation, seems to fall within the concept of eudaimonic wellbeing, or living one’s life in line with a sense of purpose and personal growth (Fancourt et al. 2022). - We acknowledge the valid criticism of the WHO definition of health and wellbeing. This definition has been criticised for its failure to acknowledge that an individual may simultaneously experience ‘ill-being’ as a part of subjective wellbeing (Zeilig et al. 2019); we hope we have clarified that wellbeing can co-exist alongside illness states. Social isolation and loneliness feed into experiences of wellbeing. To ensure inclusivity, we have adhered to the definitions of wellbeing used by the original study authors, rather than imposing a singular framework. Quality of life and wellbeing are interrelated concepts, and it falls beyond the scope of this paper to compare and contrast the two; the term wellbeing was chosen for this review as it seems to be most frequently used in more recent papers examining these concepts, and it may be more subjective than QoL measures (Ruggeri et al. 2020, Meiselman 2016). - We would like to clarify that artists are included within our stakeholder group under the term practitioner, and are represented within our research team (JLS). This terminology, drawn from a recent arts and public health policy paper (Dow et al. 2023), was selected to provide an inclusive descriptor which may encompass various types of artists and facilitators leading interventions. - Our stakeholder group will be consulted on how best to produce practical guidance for a range of providers (facilitators, artists, and other relevant parties e.g. linkworkers who may refer or speak to older people about the benefits of attending such programmes), and what form this should take. We have updated our PPI paragraph to make this clear. - The most commonly represented demographic at participatory creative arts interventions for over 65s in the UK is women of white British background (Dowlen 2023). We have removed the reference to men as a subgroup and clarified that our review will highlight evidence gaps within the existing literature. We will comment in our findings on any identified gaps in the literature, including where this may relate to people from global majority communities. - With regard to search strategy, this was piloted to ensure it picked up relevant papers. We sought to include a comprehensive list of databases from a range of disciplines, as well as unpublished literature, and will contact authors to source papers or clarify details as required. Due to capacity, we were unable to run the search strategy past our stakeholder group prior to running the search, but stakeholders will be offered the opportunity to comment on the search strategy during ongoing engagement work. - We acknowledge Reviewer 1’s important point regarding the complexity of distinguishing between participatory and receptive arts activities. This distinction is indeed highly debatable, with considerable practical and philosophical overlap that our study cannot fully resolve. For the purposes of this review, we have chosen to focus on arts activities that emphasize participatory elements, as we believe the mechanisms involved may differ from those in more ‘receptive’ experiences (such as attending a museum or concert), where active individual engagement may be less central. However, we recognize that the distinction is far from clear-cut. Individuals may attend participatory programmes but opt not to engage directly in the artistic activity, choosing instead to simply be present or to participate socially. We will acknowledge this limitation within the discussion of our findings. Reviewer 2- The RAMESES quality standards were used to inform the development of the review protocol published here. The RAMESES publication standards will be used to guide the write-up of review findings in a forthcoming paper. Thank you for pointing out the error referencing publication standards in the main text. This has been amended. - Whilst we agree with Reviewer 2 that website references may be more readable if included in the reference list, these links are included in the main text in line with NIHR Open referencing standards: ‘Web links, URLs, and links to the authors’ own websites should be included as hyperlinks within the main body of the article, and not as references.’ References- Windle G, Gregory S, Howson-Griffiths T, Newman A, O’Brien D, Goulding A. Exploring the theoretical foundations of visual art programmes for people living with dementia. Dementia. 2017;17(6):702-727. - Cousins E, Tischler V, Garabedian C, Dening T. A Taxonomy of Arts Interventions for People With Dementia. Gerontologist. 2020 Jan 24;60(1):124-134. doi: 10.1093/geront/gnz024 - Bone JK, Fancourt D: Arts, culture & the brain: a literature review and new epidemiological analyses. London: Arts Council England,2022. - Zeilig H, Tischler V, van der Byl Williams M, West J, Strohmaier S. Co-creativity, well-being and agency: A case study analysis of a co-creative arts group for people with dementia. J Aging Stud. 2019 Jun;49:16-24. - Ruggeri, K., Garcia-Garzon, E., Maguire, Á. et al. Well-being is more than happiness and life satisfaction: a multidimensional analysis of 21 countries. Health Qual Life Outcomes 18, 192 (2020). - Meiselman, H. L. (2016). Quality of life, well-being and wellness: Measuring subjective health for foods and other products. Food Quality and Preference, 54, 101–109. - Dow R, Warran K, Letrondo P, Fancourt D. The arts in public health policy: progress and opportunities. Lancet Public Health. 2023 Feb;8(2):e155-e160. doi: 10.1016/S2468-2667(22)00313-9 - Dowlen, R. (2023) Vision paper: culture, health and wellbeing. January 2023. Leeds: Centre for Cultural Value. COMMENTS ON THIS REPORT - Author Response 27 Aug 2025Alexandra Caulfield, University of Oxford, Oxford, UK27 Aug 2025Author ResponseResponse to Reviewers The authors would like to thank all the reviewers for taking the time to review and provide insightful feedback on our protocol. Please find your comments ... Continue reading Response to Reviewers The authors would like to thank all the reviewers for taking the time to review and provide insightful feedback on our protocol. Please find your comments addressed below: Reviewer 1- Our study population is community-dwelling UK adults aged 65 years or over recruited to interventions not by virtue of a particular diagnosis. We have chosen this population as less is known about the impact of creative arts interventions than for individuals recruited on the basis of a specific diagnosis, and it is possible that different mechanisms may be at play. It is unfortunately outside the scope of this review to include these populations in addition to our study population, and within these limitations it was felt useful to focus on a population about which less is known. - However, we acknowledge the point made by Reviewer 1 that previous theoretical work done with other populations provides important background to our current review and can enhance our understanding of the identified CMOCs. The realist framework developed by Windle et al. (2018) and the work of Cousins et al. (2020) provide valuable perspectives for situating our findings within the broader research landscape, and we aim to reflect on how our findings relate to this wider body of theoretical work in an upcoming results paper. - The concept of ‘wellbeing’ is complex and challenging to define, as rightly noted by Reviewer 1. In light of this observation, we have expanded our definition to include further discussion of the experienced, evaluative, eudaimonic and social aspects of wellbeing. The concept of ‘flourishing’, an idea very relevant to creative arts participation, seems to fall within the concept of eudaimonic wellbeing, or living one’s life in line with a sense of purpose and personal growth (Fancourt et al. 2022). - We acknowledge the valid criticism of the WHO definition of health and wellbeing. This definition has been criticised for its failure to acknowledge that an individual may simultaneously experience ‘ill-being’ as a part of subjective wellbeing (Zeilig et al. 2019); we hope we have clarified that wellbeing can co-exist alongside illness states. Social isolation and loneliness feed into experiences of wellbeing. To ensure inclusivity, we have adhered to the definitions of wellbeing used by the original study authors, rather than imposing a singular framework. Quality of life and wellbeing are interrelated concepts, and it falls beyond the scope of this paper to compare and contrast the two; the term wellbeing was chosen for this review as it seems to be most frequently used in more recent papers examining these concepts, and it may be more subjective than QoL measures (Ruggeri et al. 2020, Meiselman 2016). - We would like to clarify that artists are included within our stakeholder group under the term practitioner, and are represented within our research team (JLS). This terminology, drawn from a recent arts and public health policy paper (Dow et al. 2023), was selected to provide an inclusive descriptor which may encompass various types of artists and facilitators leading interventions. - Our stakeholder group will be consulted on how best to produce practical guidance for a range of providers (facilitators, artists, and other relevant parties e.g. linkworkers who may refer or speak to older people about the benefits of attending such programmes), and what form this should take. We have updated our PPI paragraph to make this clear. - The most commonly represented demographic at participatory creative arts interventions for over 65s in the UK is women of white British background (Dowlen 2023). We have removed the reference to men as a subgroup and clarified that our review will highlight evidence gaps within the existing literature. We will comment in our findings on any identified gaps in the literature, including where this may relate to people from global majority communities. - With regard to search strategy, this was piloted to ensure it picked up relevant papers. We sought to include a comprehensive list of databases from a range of disciplines, as well as unpublished literature, and will contact authors to source papers or clarify details as required. Due to capacity, we were unable to run the search strategy past our stakeholder group prior to running the search, but stakeholders will be offered the opportunity to comment on the search strategy during ongoing engagement work. - We acknowledge Reviewer 1’s important point regarding the complexity of distinguishing between participatory and receptive arts activities. This distinction is indeed highly debatable, with considerable practical and philosophical overlap that our study cannot fully resolve. For the purposes of this review, we have chosen to focus on arts activities that emphasize participatory elements, as we believe the mechanisms involved may differ from those in more ‘receptive’ experiences (such as attending a museum or concert), where active individual engagement may be less central. However, we recognize that the distinction is far from clear-cut. Individuals may attend participatory programmes but opt not to engage directly in the artistic activity, choosing instead to simply be present or to participate socially. We will acknowledge this limitation within the discussion of our findings. Reviewer 2- The RAMESES quality standards were used to inform the development of the review protocol published here. The RAMESES publication standards will be used to guide the write-up of review findings in a forthcoming paper. Thank you for pointing out the error referencing publication standards in the main text. This has been amended. - Whilst we agree with Reviewer 2 that website references may be more readable if included in the reference list, these links are included in the main text in line with NIHR Open referencing standards: ‘Web links, URLs, and links to the authors’ own websites should be included as hyperlinks within the main body of the article, and not as references.’ References- Windle G, Gregory S, Howson-Griffiths T, Newman A, O’Brien D, Goulding A. Exploring the theoretical foundations of visual art programmes for people living with dementia. Dementia. 2017;17(6):702-727. - Cousins E, Tischler V, Garabedian C, Dening T. A Taxonomy of Arts Interventions for People With Dementia. Gerontologist. 2020 Jan 24;60(1):124-134. doi: 10.1093/geront/gnz024 - Bone JK, Fancourt D: Arts, culture & the brain: a literature review and new epidemiological analyses. London: Arts Council England,2022. - Zeilig H, Tischler V, van der Byl Williams M, West J, Strohmaier S. Co-creativity, well-being and agency: A case study analysis of a co-creative arts group for people with dementia. J Aging Stud. 2019 Jun;49:16-24. - Ruggeri, K., Garcia-Garzon, E., Maguire, Á. et al. Well-being is more than happiness and life satisfaction: a multidimensional analysis of 21 countries. Health Qual Life Outcomes 18, 192 (2020). - Meiselman, H. L. (2016). Quality of life, well-being and wellness: Measuring subjective health for foods and other products. Food Quality and Preference, 54, 101–109. - Dow R, Warran K, Letrondo P, Fancourt D. The arts in public health policy: progress and opportunities. Lancet Public Health. 2023 Feb;8(2):e155-e160. doi: 10.1016/S2468-2667(22)00313-9 - Dowlen, R. (2023) Vision paper: culture, health and wellbeing. January 2023. Leeds: Centre for Cultural Value. Response to ReviewersCompeting Interests: No competing interests were disclosed. Close The authors would like to thank all the reviewers for taking the time to review and provide insightful feedback on our protocol. Please find your comments addressed below: Reviewer 1- Our study population is community-dwelling UK adults aged 65 years or over recruited to interventions not by virtue of a particular diagnosis. We have chosen this population as less is known about the impact of creative arts interventions than for individuals recruited on the basis of a specific diagnosis, and it is possible that different mechanisms may be at play. It is unfortunately outside the scope of this review to include these populations in addition to our study population, and within these limitations it was felt useful to focus on a population about which less is known. - However, we acknowledge the point made by Reviewer 1 that previous theoretical work done with other populations provides important background to our current review and can enhance our understanding of the identified CMOCs. The realist framework developed by Windle et al. (2018) and the work of Cousins et al. (2020) provide valuable perspectives for situating our findings within the broader research landscape, and we aim to reflect on how our findings relate to this wider body of theoretical work in an upcoming results paper. - The concept of ‘wellbeing’ is complex and challenging to define, as rightly noted by Reviewer 1. In light of this observation, we have expanded our definition to include further discussion of the experienced, evaluative, eudaimonic and social aspects of wellbeing. The concept of ‘flourishing’, an idea very relevant to creative arts participation, seems to fall within the concept of eudaimonic wellbeing, or living one’s life in line with a sense of purpose and personal growth (Fancourt et al. 2022). - We acknowledge the valid criticism of the WHO definition of health and wellbeing. This definition has been criticised for its failure to acknowledge that an individual may simultaneously experience ‘ill-being’ as a part of subjective wellbeing (Zeilig et al. 2019); we hope we have clarified that wellbeing can co-exist alongside illness states. Social isolation and loneliness feed into experiences of wellbeing. To ensure inclusivity, we have adhered to the definitions of wellbeing used by the original study authors, rather than imposing a singular framework. Quality of life and wellbeing are interrelated concepts, and it falls beyond the scope of this paper to compare and contrast the two; the term wellbeing was chosen for this review as it seems to be most frequently used in more recent papers examining these concepts, and it may be more subjective than QoL measures (Ruggeri et al. 2020, Meiselman 2016). - We would like to clarify that artists are included within our stakeholder group under the term practitioner, and are represented within our research team (JLS). This terminology, drawn from a recent arts and public health policy paper (Dow et al. 2023), was selected to provide an inclusive descriptor which may encompass various types of artists and facilitators leading interventions. - Our stakeholder group will be consulted on how best to produce practical guidance for a range of providers (facilitators, artists, and other relevant parties e.g. linkworkers who may refer or speak to older people about the benefits of attending such programmes), and what form this should take. We have updated our PPI paragraph to make this clear. - The most commonly represented demographic at participatory creative arts interventions for over 65s in the UK is women of white British background (Dowlen 2023). We have removed the reference to men as a subgroup and clarified that our review will highlight evidence gaps within the existing literature. We will comment in our findings on any identified gaps in the literature, including where this may relate to people from global majority communities. - With regard to search strategy, this was piloted to ensure it picked up relevant papers. We sought to include a comprehensive list of databases from a range of disciplines, as well as unpublished literature, and will contact authors to source papers or clarify details as required. Due to capacity, we were unable to run the search strategy past our stakeholder group prior to running the search, but stakeholders will be offered the opportunity to comment on the search strategy during ongoing engagement work. - We acknowledge Reviewer 1’s important point regarding the complexity of distinguishing between participatory and receptive arts activities. This distinction is indeed highly debatable, with considerable practical and philosophical overlap that our study cannot fully resolve. For the purposes of this review, we have chosen to focus on arts activities that emphasize participatory elements, as we believe the mechanisms involved may differ from those in more ‘receptive’ experiences (such as attending a museum or concert), where active individual engagement may be less central. However, we recognize that the distinction is far from clear-cut. Individuals may attend participatory programmes but opt not to engage directly in the artistic activity, choosing instead to simply be present or to participate socially. We will acknowledge this limitation within the discussion of our findings. Reviewer 2- The RAMESES quality standards were used to inform the development of the review protocol published here. The RAMESES publication standards will be used to guide the write-up of review findings in a forthcoming paper. Thank you for pointing out the error referencing publication standards in the main text. This has been amended. - Whilst we agree with Reviewer 2 that website references may be more readable if included in the reference list, these links are included in the main text in line with NIHR Open referencing standards: ‘Web links, URLs, and links to the authors’ own websites should be included as hyperlinks within the main body of the article, and not as references.’ References- Windle G, Gregory S, Howson-Griffiths T, Newman A, O’Brien D, Goulding A. Exploring the theoretical foundations of visual art programmes for people living with dementia. Dementia. 2017;17(6):702-727. - Cousins E, Tischler V, Garabedian C, Dening T. A Taxonomy of Arts Interventions for People With Dementia. Gerontologist. 2020 Jan 24;60(1):124-134. doi: 10.1093/geront/gnz024 - Bone JK, Fancourt D: Arts, culture & the brain: a literature review and new epidemiological analyses. London: Arts Council England,2022. - Zeilig H, Tischler V, van der Byl Williams M, West J, Strohmaier S. Co-creativity, well-being and agency: A case study analysis of a co-creative arts group for people with dementia. J Aging Stud. 2019 Jun;49:16-24. - Ruggeri, K., Garcia-Garzon, E., Maguire, Á. et al. Well-being is more than happiness and life satisfaction: a multidimensional analysis of 21 countries. Health Qual Life Outcomes 18, 192 (2020). - Meiselman, H. L. (2016). Quality of life, well-being and wellness: Measuring subjective health for foods and other products. Food Quality and Preference, 54, 101–109. - Dow R, Warran K, Letrondo P, Fancourt D. The arts in public health policy: progress and opportunities. Lancet Public Health. 2023 Feb;8(2):e155-e160. doi: 10.1016/S2468-2667(22)00313-9 - Dowlen, R. (2023) Vision paper: culture, health and wellbeing. January 2023. Leeds: Centre for Cultural Value. Alongside their report, reviewers assign a status to the article: - Approved - Approved with reservations - Not approved | Invited Reviewers | || |---|---|---| | 1 | 2 | | | Version 2 (revision) 16 Jun 25 | read | | | Version 1 04 Mar 25 | read | read | Sign up for content alerts You are now signed up to receive this alert Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. 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