Article

Dementia
Museum activities in 2017, Vol. 16(5) 591–610
! The Author(s) 2015
dementia care: Using visual Reprints and permissions:
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analog scales to measure DOI: 10.1177/1471301215611763

journals.sagepub.com/home/dem

subjective wellbeing
Joana Johnson
Canterbury Christ Church University, UK

Alison Culverwell
Older Adult Services, Kent & Medway NHS Partnership Trust, UK

Sabina Hulbert
Canterbury Christ Church University, UK

Mitch Robertson
The Beaney House of Art and Knowledge, UK

Paul M Camic
Canterbury Christ Church University, UK

Abstract
Introduction: Previous research has shown that people with dementia and caregivers
derive wellbeing-related benefits from viewing art in a group, and that facilitated museum
object handling is effective in increasing subjective wellbeing for people with a range of
health conditions. The present study quantitatively compared the impact of two museum-based
activities and a social activity on the subjective wellbeing of people with dementia and their
caregivers.
Methods: A quasi-experimental crossover design was used. People with early to middle stage
dementia and caregivers (N ¼ 66) participated in museum object handling, a refreshment break,
and art viewing in small groups. Visual analog scales were used to rate subjective wellbeing pre and
post each activity.
Results: Mixed-design analysis of variances indicated wellbeing significantly increased during the
session, irrespective of the order in which the activities were presented. Wellbeing significantly
increased from object handling and art viewing for those with dementia and caregivers across

Corresponding author:
Paul M Camic, Salomons Centre for Applied Psychology, Canterbury Christ Church University, Tunbridge Wells,
Kent, UK.
Email: [email protected]
592 Dementia 16(5)

pooled orders, but did not in the social activity of a refreshment break. An end-of-intervention
questionnaire indicated that experiences of the session were positive.
Conclusion: Results provide a rationale for considering museum activities as part of a broader
psychosocial, relational approach to dementia care and support the use of easy to administer
visual analog scales as a quantitative outcome measure. Further partnership working is also
supported between museums and healthcare professionals in the development of nonclinical,
community-based programs for this population.

Keywords
museum object handling, art viewing, wellbeing, dementia, caregiver

Introduction
There is growing evidence for the efficacy of nonpharmacological interventions in dementia
care aimed at improving functioning, quality of life, and increasing wellbeing (Kaufmann
and Engel, 2014). Recent research has shown that older adults who are cognitively impaired
are significantly less likely to be socially and cognitively active than older adults without a
cognitive impairment (Johnson, Whitlatch, & Menne, 2014), and that engaging in
meaningful activity in the early stages of dementia can help people to focus on their
residual abilities and offset a sense of loss (Genoe & Dupuis, 2014). This also includes the
arts, which have increasingly been shown to have cognitive, emotional, and wellbeing
benefits for people with dementia (Young, Camic, & Tischler, 2015; Zeilig, Killick, &
Fox, 2014). Argyle and Bolton (2005) have argued that it is possible to be ill and still be
in a state of wellbeing, and other authors have highlighted the crucial impact the social
context can have on the wellbeing in dementia. For example, Kitwood (1997) rejected a
solely biomedical deficit-based model of dementia so that the person does not become
defined by their illness but retains a sense of ‘‘personhood.’’ Despite diminished cognitive
function, relational needs such as social contact remain intact, as well as creativity and self-
expression (Kitwood & Benson, 1992). A definitive consensus on defining wellbeing has yet
to emerge, although it is agreed to be a complex and multidimensional construct (Dodge,
Daly, Huyton, & Sanders, 2012). Some have argued in favor of emphasizing the subjective
nature of wellbeing, elevating the capacity of the person themselves to assess their own state
of health and happiness (Keyes, Shmotkin, & Ryff, 2002). Hedonic wellbeing has been
conceptualized as one’s own pleasure and happiness and may be seen as a relatively
straightforward way in which to quantify subjective wellbeing using self-report measures
(Swindells et al., 2013). The present study drew on a definition of wellbeing as the subjective
state of experiencing pleasure and happiness (Swindells et al., 2013).

The arts in dementia care

Empirical studies have begun to investigate the impact of the arts in dementia care through
group-facilitated art viewing (e.g. Camic, Tischler, & Pearman, 2014; MacPherson, Bird,
Anderson, Davis, & Blair, 2009; Rosenberg, 2009). Results have indicated positive outcomes
in terms of increased subjective psychological wellbeing, a sense of broadening of horizons,
and social inclusion (Flatt et al., 2014; Young et al., 2015). Other findings showed increase in
Johnson et al. 593

sustained attention and intellectual engagement (Camic et al., 2014) and stimulation of
episodic memories and communication (Eekelaar, Camic, & Springham, 2012). There is
also evidence to suggest that new learning occurs in people with dementia (Clare et al.,
2000; Eekelaar et al., 2012). Mell, Howard, and Miller (2003) proposed that new skills
can emerge after the onset of dementia, and that artistic development can continue even
when language abilities deteriorate. Graham, Stockinger, and Leder (2013) demonstrated
that, for people with Alzheimer’s, esthetic judgments are similar to those of healthy adults,
providing further evidence that art-based interventions may draw on residual abilities even
when cognitive impairment is present. The involvement of caregivers in art-viewing studies
was deemed to be an important aspect, as art viewing formed a vehicle of relational
communication within the dyad giving the caregiver new insights into the person with
dementia’s abilities (Greenwood, Loewenthal, & Rose, 2002; Zeilig et al., 2014) and how
dementia itself is conceptualized (Zeilig, 2014). As evidence suggests that the wellbeing of
many people in caregiving roles may be adversely affected, it is highly pertinent to offer
psychosocial support for caregivers as well as the people they care for (Department of
Health, 2008). Previous research has suggested that art gallery-based interventions can
provide social and psychological support to caregivers in ways different from traditional
support groups (Roberts, Camic, & Springham, 2011). Focusing on residual abilities and
meaningful activities may help to offset a sense of loss for both the person with dementia and
the caregiver, and can potentially help throughout the course of illness. Several authors have
argued for the emphasis of the importance of ‘‘in-the-moment’’ subjective experience of the
person with dementia, with a focus on meaningful personal experiences for participants
(De Medeiros & Basting, 2014) and person-centered outcomes (Patel, Perera, Pendleton,
Richman, & Majumdar, 2014). Reviewing evidence for visual arts interventions, Salisbury,
Algar, and Windle (2011) concluded such interventions were shown to reduce isolation,
promote communication, encourage residual creative abilities, and enable expression of a
sense of identity. A further review of art therapies in dementia care strongly argued for
consistent inclusion of participants’ subjective experience in research rather than the
imposition of normative, outcomes-based expectations that do not adequately capture the
enrichment and enjoyment derived from these activities (Beard, 2012).
A conceptual literature review of museum object handling has found this activity to be
effective in achieving significant short-term increases in subjective wellbeing (Solway, Camic,
Thomson, & Chatterjee, 2015). Object handling sessions comprise tactile, visual, and
conversational exploration of authentic museum artifacts. Neuropsychological evidence
suggests that certain types of cutaneous touch implicated in this activity may invoke a
sense of wellbeing through being linked to emotional and motivational systems in the
brain (e.g. the insula cortex: Critchley, 2008). It has also been argued that the stimulation
of multiple sensory modalities facilitates a deeper level of encoding in working memory
(Baddeley & Hitch, 1974) and thus may facilitate learning (Paddon, Thomson, Menon,
Lanceley, & Chatterjee, 2014). Evidence exists suggesting that older adults may
particularly benefit from the simultaneous presentation of congruent information via
multiple sensory modalities (Laurienti, Burdette, Maldjian, & Wallace, 2006). Other
authors have emphasized that holding museum objects can trigger memories, projections,
and associations that may invoke a meaning-making process beneficial to subjective
wellbeing (Dudley, 2010; Rowlands, 2008).
Arts interventions have frequently been criticized for lacking a comparison group (Clift
et al., 2009) meaning that limited inferences can be drawn regarding the importance or
594 Dementia 16(5)

necessity of the art component. This has led critics to suggest that benefits obtained from
these interventions can be accounted for by social interactions alone (Simmons, 2006). Art
viewing and object handling as group activities have not yet been compared to each other,
nor have they been assessed in relation to non-art-focused social activities.

The present study

The present study investigated the impact of three museum-based activities on the subjective
wellbeing of people with dementia and their caregivers. These comprised two interventions
(art viewing and object handling) and a usual social activity in the form of a refreshment
break.

Hypotheses. The following hypotheses were tested on people with dementia and caregivers as
separate groups.
H1: There will be a significant increase in subjective wellbeing during the museum session.
H2: There will be a significant increase in subjective wellbeing during the museum session
irrespective of the order in which object handling and art viewing are experienced.
H3: There will be a significant increase in subjective wellbeing post object handling compared to
the pre object handling baseline.
H4: There will be a significant increase in subjective wellbeing post art viewing compared to the
pre art-viewing baseline.
H5: There will not be a significant increase in subjective wellbeing after a social refreshment
break compared to the prebreak baseline.
H6: The increase in subjective wellbeing will be significantly greater from object handling than
from art viewing.

Design and methods

Participants
A convenience sampling method was adopted, recruiting from a postdiagnostic group for
people recently diagnosed with dementia at a National Health Service memory assessment
clinic in the southeast of England. The sample consisted of 36 people with dementia and 30
caregivers (Table 1). Participants with different types of dementia were included based on
previous research that demonstrated asesthetic preference remains stable across different
dementias (Halpern, Ly, Elkin-Frankston, & O’Connor, 2008; Halpern & O’Connor,
2013) and that art viewing (Camic, Baker, & Tischler, 2015; MacPherson et al., 2009) and

Table 1. Gender and age of participants.

People with dementia Caregivers

Gender (n) Male 25 4

Female 11 26

Age (years) Mean (SD) 74 (7.06) 66 (9.95)

Range 58–85 48–83
Johnson et al. 595

object handling (Camic & Kimmel, 2015) activities had also been shown to be beneficial
across types and stages of dementia. Prevalence of dementia type in the sample was as
follows: 8% early onset Alzheimer’s (n ¼ 3), 47% Alzheimer’s (n ¼ 17), 13%
frontotemporal dementia (n ¼ 5), 11% vascular dementia (n ¼ 4), 21% mixed-type
dementia (n ¼ 8). This was broadly comparable to national prevalence figures, although
Alzheimer’s was slightly underrepresented in the sample while frontotemporal and mixed
were slightly overrepresented (Alzheimer’s Society, 2014). Early to middle stages were
defined by a Clinical Dementia Rating of .5 or 1 (Morris, 1997). Recruitment from
postdiagnostic groups indicated a recent diagnosis of dementia. Moreover, those selected
for the groups had a mild to moderate level of impairment with preserved language to the
extent that they could engage in a group relying on verbal communication skills, with an
ability to follow conversations and hold information in mind.
The average length of time since diagnosis was nine months (range: 2–24 months).
Inclusion criteria were a diagnosis of any type of dementia in the early to middle stages,
living at home, and capacity to give informed consent. Two people with dementia had a
comorbid diagnosis of Parkinson’s disease; one had a lateral visual impairment. Caregivers
had to be over the age of 18 and could be a spouse, relative, or friend. People with dementia
could attend without a caregiver if they wished. Recruitment took place over 13 months;
134 participants initially registered their interest in participating (64 dyads and six people
with dementia who did not identify a caregiver). Nine dyads were unable to attend due to
illness; 15 dyads changed their mind about participating in the study without giving a reason;
10 dyads no longer wished to participate due to other life events taking precedence. The
study was approved by the UK National Research Ethics Service (reference 13/LO/1353).

Design
This quasi-experimental study had a mixed 2  4 repeated-measures crossover design with
two separate groups: people with dementia and caregivers. The first factor (between subjects)
was the order in which participants experienced the interventions, with one level as object
handling first and art viewing last (summarized as order 1: MOH-AV) and the other level as
art viewing first and object handling last (summarized as order 2: AV-MOH). The second
factor (within-subjects factor) was the time point at which self-report measures of subjective
wellbeing were administered (Figure 1). This factor had four levels: time 1 (prefirst
intervention), time 2 (post first intervention and pre refreshment break), time 3

Figure 1. Time points at which self-report measures of subjective wellbeing were administered.
596 Dementia 16(5)

(post refreshment break and pre second intervention), and time 4 (post second intervention).
Control measures implemented included using the same facilitator for all sessions and use of
a repeated-measures crossover design, which counterbalanced the order to account for any
order effects. Additionally, the facilitator and volunteers were not aware of the directionality
of the hypotheses. An a priori power calculation using G*Power statistical software
(Erdfelder, Faul, & Buchner, 1996) indicated that to detect a medium effect size (f ¼ .25)
with 80% power and alpha .05 two-tailed, the between-subjects factor required N ¼ 82; the
within-subjects factor required N ¼ 24; the interaction required N ¼ 24.

Measures
Visual analog scales (VAS). VASs were selected to measure subjective wellbeing (EuroQol
Group, 1990). VASs are suitable for assessing change across a short period of time, have
validity within subjects, and are usually easily administered (Wewers & Lowe, 1990). People
with dementia use VAS in a way that is conceptually similar to the general population
(Arons, Krabbe, van der Wilt, Olde-Rikkert, & Adang (2012) while Thomson and
Chatterjee (2014) successfully trialed VAS measuring happiness and wellness with people
with mild, moderate, and severe dementia. Since many researchers agree that wellbeing is a
complex, multifaceted construct, the present study used five subscales in an attempt to
capture dimensions of wellbeing outcomes pertinent to this group and setting, yet also
sought not to overly burden participants with lengthy and cognitively challenging
measures. Participants self-reported on vertical scales of 0–100 how happy/sad, well/
unwell, interested/bored, confident/not confident, and optimistic/not optimistic they were
feeling at that moment in time. Their previous ratings were not made available to them at
any time as an attempt to control for demand characteristics to report an improvement.
Ander et al. (2011) suggested that engagement may be a key aspect of wellbeing relevant to a
museum context and there is theoretical and empirical support for the benefits of engaging
people with dementia in activities they find interesting (Genoe & Dupuis, 2014). Engagement
was conceptualized as a continuum between interested and bored to avoid confusion from
other common uses of the word. The dimension of confidence was included, since research
has indicated this can decrease over time in people with dementia (Miller & Butin, 2000). The
dimension of optimism sought to measure hopefulness about the future and is included in
other measures of wellbeing (e.g. Stewart-Brown & Janmohamed, 2008). The interested,
confident, and optimistic subscales were piloted with people with dementia and caregivers
by Weiner and Camic (2014).

Evaluation questionnaire. A brief open-ended feedback questionnaire aimed to elicit responses

about participants’ experiences was given at the end of the intervention.

Procedure
A museum in the southeast of England was the site for the study. Its permanent collection
includes artifacts from ancient Egypt; the Anglo-Saxon period; as well as a wide range of
paintings, taxidermy, and other curiosities from the 17th to 20th centuries.

The museum session. The average size of each museum group was six people (three people
with dementia and their caregivers) ranging from four to eight people. The facilitator and
Johnson et al. 597

two volunteers were present at each session. Sixteen sessions were scheduled and 11 were run
in total (five were cancelled due to dropout; remaining participants were transferred to a
subsequent session). Sessions were counterbalanced: six sessions began with object handling
and five with art viewing with the social activity between them (Figure 1). Objects were
presented one at a time and people had the opportunity to hold, examine, and talk about
them as a group as they were passed round. Questions about impressions of the objects
included sensory descriptions, preferences, and reflections; associations and anecdotes were
encouraged. A wide range of objects were used (e.g. Victorian carbolic soap, ancient
Egyptian scarab stone, Iron Age axe head, geode, 19th-century African headdress rest,
fossilized shark’s tooth, 18th-century tinderbox). The social intervention consisted of
general conversation with refreshments. Art viewing comprised viewing selected paintings
in the gallery and the facilitator’s use of open questions to discuss color, texture, esthetic
preferences, and speculation on the artist’s intent. Paintings were selected which had
different content and styles, and a potential for visual discovery. At the conclusion of the
museum session, participants completed the evaluation form and were given a pack
containing a debriefing letter, a museum brochure, a postcard of one of the paintings, and
a list of questions similar to ones asked by the facilitator to use on future museum visits if
desired.

Data analysis
VAS subscale scores (happiness, wellness, interestedness, confidence, optimism) at each time
point were summed to derive a composite overall wellbeing score. Overall wellbeing scores
were used as the dependent variable for inferential statistics; SPSS version 22 was used for all
analyses. Since VASs are deemed to be interval scales (Paul-Dauphin, Guillemin, Virion, &
Briancon, 1999), data were checked for normality in order that parametric analyses could be
conducted where possible. Mixed-design analysis of variance (ANOVAs) was conducted to
test for main effects of time and order for people with dementia and caregivers as separate
groups. The size and significance of the differences between time 1 and 2 (pre and post first
intervention), time 2 and 3 (pre and post refreshment break), and time 3 and 4 (pre and post
second intervention) were then tested by performing bootstrap paired-sample t-tests.
Bonferroni corrections (Bland & Altman, 1995) were applied to reduce the risk of
inflation of Type I error: alpha levels were adjusted accordingly (a ¼ .05 / 3 ¼ .017). These
procedures were applied to all t-tests reported.

Results
Shapiro–Wilk’s tests for normality of distribution for overall wellbeing scores at time 1, 2, 3,
and 4; visual inspection of histograms; normal Q–Q plots; and box plots showed that overall
wellbeing scores were approximately normally distributed for people with dementia and
caregivers within orders 1 and 2. Skewness and kurtosis values are also in line with this
interpretation (Table 2). Mean VAS scores for overall wellbeing at times 1, 2, 3, and 4
indicated an increase over the course of the museum session (Table 3). Overall wellbeing
change scores were calculated by subtracting preintervention wellbeing scores from
postintervention wellbeing scores. All overall wellbeing change scores were positive,
indicating that participants’ subjective wellbeing tended to increase after experiencing
either intervention (Table 4).
598 Dementia 16(5)

Table 2. Shapiro–Wilk’s statistics showing normality of distribution for overall wellbeing scores.

Shapiro–Wilk Statistic
Overall Participant
Order wellbeing Statistic df p Skewness (SE) Kurtosis (SE)

Order 1 Time 1 PWD .946 19 .337 .13 (.52) 1.17 (1.01)

MOH-AV Caregiver .902 15 .101 1.01 (.58) .55 (1.12)
Time 2 PWD .878 19 .019a .95 (.52) .34 (1.01)
Caregiver .918 15 .181 .69 (.58) .26 (1.12)
Time 3 PWD .913 19 .083 42 (.52) 1.03 (1.01)
Caregiver .920 15 .195 .87 (.58) .17 (1.12)
Time 4 PWD .929 19 .169 .46 (.52) .82 (1.01)
Caregiver .798 15 .003a 1.78 (.58) 3.31 (1.12)
Order 2 Time 1 PWD .947 17 .408 .078 (.55) .54 (1.06)
AV-MOH Caregiver .959 15 .676 .36 (.58) .65 (1.12)
Time 2 PWD .918 17 .137 .14 (.55) 1.15 (1.06)
Caregiver .933 15 .299 .01 (.58) 1.42 (1.12)
Time 3 PWD .876 17 .028a 1.27 (.55) 3.11 (1.06)
Caregiver .969 15 .836 .09 (.58) 1.90 (1.12)
Time 4 PWD .887 17 .041a .33 (.55) 1.43 (1.06)
Caregiver .907 15 .124 .79 (.58) .078 (1.12)

AV: art viewing; MOH: museum object handling; PWD: people with dementia; SE: standard error.
a
denotes data that deviated significantly from a normal distribution. Bootstrapping procedures were later used to
compensate.

Table 3. Mean (SD) overall wellbeing scores at time 1, 2, 3, and 4.

Mean overall Mean overall Mean overall Mean overall

wellbeing wellbeing wellbeing wellbeing
Time 1 (SD) Time 2 (SD) Time 3 (SD) Time 4 (SD)

PWD(n ¼ 36)
Order 1 (MOH-AV) 391.84 (74.30) 431.58 (68.82) 436.58 (55.88) 442.11 (47.68)
Order 2 (AV-MOH) 367.06 (89.11) 402.06 (77.96) 398.82 (83.73) 429.12 (63.34)
Caregiver (n ¼ 30)
Order 1 (MOH-AV) 382.00 (80.37) 427.00 (62.62) 434.47 (57.07) 455.33 (52.52)
Order 2 (AV-MOH) 363.67 (71.92) 410.00 (55.84) 413.33 (53.97) 434.00 (58.65)

AV: art viewing; MOH: museum object handling.

Note. Maximum overall wellbeing score ¼ 500.

People with dementia

A mixed-design ANOVA with time (time 1, 2, 3, and 4) as a within-subjects factor and order
as a between-subjects factor revealed a significant main effect of time for people with
dementia (F(3, 102) ¼ 13.54, p < .001, Zp2 ¼ .285). There was no significant main effect of
order (F(1, 34) ¼ 1.583, p ¼ .217, Zp2 ¼ .044). There was no significant interaction between
time and order (F(3, 102) ¼ .65, p ¼ .585, Zp2 ¼ .019). Therefore, Hypotheses 1 and 2 were
supported for people with dementia (Figure 2).
Johnson et al. 599

Table 4. Mean (SD) overall wellbeing change scores.

Museum object handling Art viewing

Mean overall wellbeing Mean overall wellbeing
change score (SD) change score (SD)

PWD (n ¼ 36)
Order 1 (MOH-AV) 39.74 (75.65) 5.53 (32.27)
Order 2 (AV-MOH) 30.29 (49.69) 35.00 (42.97)
Caregiver (n ¼ 30)
Order 1 (MOH-AV) 45.00 (64.22) 20.86 (30.35)
Order 2 (AV-MOH) 20.67 (41.53) 46.33 (58.99)

AV: art viewing; MOH: museum object handling.

Figure 2. Plot showing main effect of time on overall wellbeing for people with dementia with separate
lines for order.
600 Dementia 16(5)

Collapsing scores across order but maintaining time measurements aligned allowed
further exploration of the main effect of time. Paired sample t-tests indicated that overall
wellbeing scores were significantly higher at time 2 (M ¼ 417.64, SD ¼ 73.74) than at time 1
(M ¼ 380.14, SD ¼ 81.40), t(35) ¼ 3.65, p ¼ .001, d ¼ 0.61. There was no significant difference
between overall wellbeing scores at time 2 (M ¼ 417.64, SD ¼ 73.74) and time 3 (M ¼ 418.75,
SD ¼ 71.95), t(35) ¼ .133, p ¼ .895 nor were scores significantly higher at time 4 (M ¼ 435.97,
SD ¼ 55.19) than at time 3 (M ¼ 418.75, SD ¼ 71.95) with the Bonferroni corrections
applied: t(35) ¼ 2.42, p ¼ .021, d ¼ .40. Hypothesis 5, that there will not be a significant
increase in subjective wellbeing from a refreshment break, was supported for people with
dementia.
Since no significant main effects of order were found for people with dementia, results for
object handling and art viewing were pooled across both orders for this analysis (Cohen,
2007) to test Hypotheses 3 and 4 (Figure 3). This was achieved by averaging time 1 scores for
participants in order 1 with time 3 scores for participants in order 2, and averaging time 2
scores for participants in order 1 and time 4 scores for participants in order 2 and so on.
Subsequently, paired sample t-tests indicated that overall wellbeing scores were significantly
higher post object handling (M ¼ 430.42, SD ¼ 65.35) than pre object handling (M ¼ 395.14,
SD ¼ 77.82), t(35) ¼ 3.308, p ¼ .002, d ¼ .51. Hypothesis 3, that there will be a significant
increase in subjective wellbeing from object handling, was supported for people with

Figure 3. Plot showing main effect of time on overall wellbeing for people with dementia across pooled
orders.
Johnson et al. 601

dementia when scores were pooled across both orders. Paired sample t-tests also indicated
that overall wellbeing scores were significantly higher post art viewing (M ¼ 423.19,
SD ¼ 66.02) than pre art viewing (M ¼ 403.75, SD ¼ 80.47), t(35) ¼ 2.194, p ¼ .006, d ¼ .26.
Hypothesis 4, that there will be a significant increase in subjective wellbeing from art
viewing, was supported for people with dementia when scores were pooled across both
orders.

Caregivers
A mixed-design ANOVA with time (time 1, 2, 3, and 4) as a within-subjects factor and order
as a between-subjects factor revealed a significant main effect of time for caregivers (F(1.95,
54.45) ¼ 23.46, p < .001, Zp2 ¼ .456 (Mauchly’s test indicated that the assumption of
sphericity had been violated (2(5) ¼ 23.70, p < .001, therefore degrees of freedom were
corrected using Greenhouse–Geisser estimates of sphericity (" ¼ .65))). There was no
significant main effect of order (F(1, 28) ¼ .945, p ¼ .339, Zp2 ¼ .033) and no significant
interaction between time and order (F(1.95, 54.45) ¼ .029, p ¼ .969, Zp2 ¼ .001). Therefore,
Hypotheses 1 and 2 were supported for caregivers (Figure 4).
As before, collapsing scores across order but maintaining time measurements
aligned allowed further exploration of the main effect of time. Paired sample t-tests
indicated that overall wellbeing scores were significantly higher at time 2 (M ¼ 418.50,
SD ¼ 58.93) than at time 1 (M ¼ 372.83, SD ¼ 75.51), t(29) ¼ 4.13, p < .001, d ¼ .75. There
was no significant difference between overall wellbeing scores at time 2 (M ¼ 418.50,
SD ¼ 58.93) and time 3 (M ¼ 423.90, SD ¼ 55.62), t(29) ¼ 1.065, p ¼ .296. Overall
wellbeing scores were significantly higher at time 4 (M ¼ 444.67, SD ¼ 55.77) than at time
3 (M ¼ 423.90, SD ¼ 55.62), t(29) ¼ 3.183, p ¼ .003, d ¼ .58. Hypothesis 5, that there will not
be a significant increase in subjective wellbeing from a refreshment break, was supported for
caregivers.
Since no significant main effects of order were found for caregivers, results for
object handling and art viewing were pooled across both orders for this analysis
(Cohen, 2007) to test Hypotheses 3 and 4 for caregivers as previously done for PWD
(Figure 5). Paired sample t-tests indicated that overall wellbeing scores were significantly
higher post object handling (M ¼ 430.50, SD ¼ 59.71) than pre object handling
(M ¼ 397.67, SD ¼ 69.13), t(29) ¼ 3.296, p ¼ .003, d ¼ .51. Hypothesis 3, that there will be
a significant increase in subjective wellbeing from object handling, was supported for
caregivers when scores were pooled across both orders (Figure 5). Paired sample t-tests
also indicated that overall wellbeing scores were significantly higher post art viewing
(M ¼ 432.67, SD ¼ 58.04) than pre art viewing (M ¼ 399.07, SD ¼ 73.25), t(29) ¼ 3.844,
p ¼ .001, d ¼ .51. Hypothesis 4, that there will be a significant increase in subjective
wellbeing from art viewing, was supported for caregivers when scores were pooled
across both orders.

Comparison of overall wellbeing change scores

This analysis tested Hypothesis 6 that the increase in subjective wellbeing would be
significantly greater from object handling than art viewing for both participant groups.
Descriptive statistics (Table 4) indicated that for people with dementia, when art viewing
was presented last, there was less of an increase in overall wellbeing than when object
602 Dementia 16(5)

Figure 4. Plot showing main effect of time on overall wellbeing for caregivers with separate lines for order.

handling was presented last. However, paired sample t-tests found no significant differences
between object handling and art viewing wellbeing change scores for either people with
dementia or caregivers within orders 1 and 2. Therefore, Hypothesis 6 was not supported
for people with dementia or caregivers.

Data from feedback forms

The evaluative comments overwhelmingly conveyed positive responses and enjoyment of the
activities. One question asked ‘‘How did you find the session today?,’’ with 91% of the 66
respondents using positive adjectives such as ‘‘interesting,’’ ‘‘excellent,’’ and ‘‘uplifting,’’
while 6% used neutral adjectives such as ‘‘OK.’’ Examples of other responses included
‘‘it’s a privilege to be able to hold something so old’’ and the session ‘‘brought me to
life.’’ A further question asked participants which activity they preferred with 55%
(n ¼ 36) selecting museum object handling, 36% (n ¼ 24) art discussion, and 9% (n ¼ 6)
‘‘both equally.’’
Johnson et al. 603

Figure 5. Plot showing main effect of time on overall wellbeing for caregivers across pooled orders.

Discussion
As far as is known, this was the first study to have quantitatively compared two different
museum-based interventions. Subjective wellbeing significantly increased for both people
with dementia and caregivers during the museum session, irrespective of the order in
which object handling or art viewing was presented. Wellbeing scores significantly
increased from object handling and art viewing but not from a social activity (see Table 5).
Findings are in line with previous research with nondementia populations, which
demonstrated that brief object-handling interventions brought about significant increases
in subjective wellbeing (e.g. Paddon et al., 2014). Broadly, findings are also in line with
studies showing that museum art-viewing sessions elicit enjoyment and improvements in
mood among people with dementia and caregivers (e.g. Rosenberg, 2009). Previous
research has also indicated that the intervention site was deemed to be an important
aspect to participants (Camic et al., 2014; Roberts et al., 2011). Yet, as popular as art-
based interventions have become for this population, thus far there remained limited
evidence to refute that psychological benefits obtained could not be attributed to group or
social factors. In the present study, the refreshment break formed a social occasion and did
not bring about increases in participants’ wellbeing. An alternative explanation may be that
the break was of insufficient duration; making it of equal length to the other interventions
would have enabled a more robust comparison; however, the present findings do not support
604 Dementia 16(5)

Table 5. Summary of findings.

Hypothesis PWD (n ¼ 36) Caregiver (n ¼ 30)

1. There will be a significant increase in subjective wellbeing during Supported Supported

the museum session
2. There will be a significant increase in subjective wellbeing during Supported Supported
the museum session irrespective of the order in which object
handling and art viewing are experienced
3. There will be a significant increase in subjective wellbeing post Supported Supported
object handling compared to the pre object-handling baseline
4. There will be a significant increase in subjective wellbeing post Supported Supported
art viewing compared to the pre art-viewing baseline
5. There will not be a significant increase in subjective wellbeing Supported Supported
after a refreshment break compared to a prebreak baseline
6. The increase in subjective wellbeing will be significantly greater Not supported Not supported
from object handling than from art viewing

the suggestion that any group social activity increases wellbeing. This study demonstrated
the feasibility of using VAS multiple times during museum sessions with people with early to
middle stage dementia. Previous research in object handling used VAS to measure wellness
and happiness; therefore, the addition of subscales measuring interest, confidence, and
optimism added a further dimension.

Theoretical explanations
Working memory may remain relatively intact in people in early stage Alzheimer’s (Morris,
1994). Art-viewing and object-handling activities were structured to appeal to this residual
ability as they used primary sensory functions and required focus only on what was
happening in the present moment. The facilitator’s questions elicited ‘‘in the moment’’
observations with the aim that people with dementia were not placed at a disadvantage,
as factual knowledge was not emphasized. However, it was noticed that participants,
including people with dementia, frequently asked questions that indicated they wished to
acquire facts about the objects and paintings. This may imply that acquisition of semantic
knowledge is more important to this population than previously thought and is analogous
with findings suggesting that the arts can be used to support new learning in people with
dementia (Eekelaar et al., 2012).
Isserow (2008) posited that wellbeing benefits in art-based interventions may at least
partly be attributed to the triangular element of the experience, whereby attention jointly
directed at an art object by the person with dementia–caregiver dyad forms a shared
experience, promoting enjoyment from the shared interactions that follow. Object
handling adds a tactile element to viewing and discussion and in turn may elaborate and
intensify these aspects of the shared social experience (Thomson, Ander, Menon, Lanceley,
& Chatterjee, 2012) in the group or dyad. For both caregivers and people with dementia,
both art viewing and object handling appeared to enhance wellbeing, lending support to
existing guidelines for psychosocial interventions in dementia care that recommend a more
elaborate kinesthetic and multisensory experience (Spector, Woods, & Orrell, 2008).
Johnson et al. 605

Museum object handling differs from therapies using reminiscence objects, as the artifacts
are usually novel and rare. Some authors have suggested that the process of encountering
novel stimuli can increase cognitive processing in people with dementia, especially in a
context with cocurrent social interaction, positing that this may lead to new neuronal
connections being formed (Spector et al., 2008). Ander et al. (2012) found that
participants frequently expressed a sense of privilege in being able to touch museum
artifacts and wonder at the historical significance of the objects during handling sessions,
and suggested these may be key determinants implicated in increasing subjective wellbeing.
A sense of privilege may have been particularly potent for this group, given that stigma and
social exclusion are often associated with dementia (Graham et al., 2003).

Limitations
Participants were recruited from postdiagnostic support groups making it not possible to
generalize to all people with dementia and caregivers, as people do not attend these groups
for a range of reasons. It is also not known whether participants who volunteered did so due
to an existing interest in art. Most people with dementia in the study were male and most
caregivers were female; this gender imbalance formed a potential confounding variable that
needs to be considered in planning future research. The design of the present study required
a measure of subjective wellbeing suitable for repeated administration. Due to their brevity,
the dimensions captured by the VAS were limited in scope and comprehensiveness. The
meaningfulness of the results were also dependent on the extent to which participants
were able to understand the concepts represented by the VAS (Wewers & Lowe, 1990),
although only a few people with dementia appeared to have limited difficulty with this
which appeared to resolve after further explanation. In addition, it is acknowledged that
the nonsignificance of the main effect of order in ANOVAs may have been due to an
insufficient number of participants to achieve power (82 participants were required for the
between-subjects factor), therefore findings should be considered in light of this.

Practice implications
The results lend support to healthcare professionals encouraging people with dementia and
caregivers to make use of museum activities such as object handling and viewing art after
being recently diagnosed. Museum activities should also be considered through the
progression of dementia, including use in day care and residential care settings through
museum outreach programs or the development of ‘‘mini-museums’’ within care homes
(Camic & Kimmel, 2015). Using material objects and art works also offers cocurating
opportunities for people with dementia and caregivers working together with museum/art
gallery staff to develop in-house museum tours and traveling exhibitions to care homes. The
intervention provided an implicit message that meaningful activities can continue after
diagnosis in line with a rehabilitation-based approach to dementia care (Clare et al.,
2000). Several caregivers commented on the appeal of a group suitable for their needs
that was situated in a nonmedical institution, supporting previous ideas of the value of
offering therapeutic interventions not associated with illness in nonstigmatizing
community settings (Ander et al., 2012). Healthcare and museum professionals could
consider formalizing links in order to offer health-related psychosocial interventions
within such stimulating and engaging settings (Camic & Chatterjee, 2013).
606 Dementia 16(5)

Future research
To further explore the benefits of this type of intervention, multiple museum sessions over a
longer period of time are recommended. Adding measures to assess cognitive domains
alongside wellbeing, as has been done in singing research (Särkämö et al., 2014), would
broaden our understanding of the impact. Using museum sessions as a community-based,
non-clinical intervention to support dyad relationships (Camic et al., 2014) is also worth
investigating in order to further determine their psychosocial value for dementia care.
A three-armed randomized controlled trial to compare object handling, art viewing, and a
treatment-as-usual group would provide more robust evidence for the efficacy of these
activities. Further research would also benefit from observational methods such as using
video recording to code aspects of physical engagement with objects alongside VAS
measures. Zeilig et al. (2014) has recommended that research is further broadened to
include people with moderate–severe dementia and results of the present study warrant
further investigation into art viewing and object handling as potentially helpful
interventions for this population.

Conclusions
This study compared two art-based activities, object handling and art viewing, and a social
activity in the form of a refreshment break, that took place within a museum setting. It is the
first study of its kind to quantitatively demonstrate that art viewing and museum object
handling both showed statistically significant increases in subjective wellbeing as compared
to a nonart social event for people with dementia and their caregivers, further delineating the
value of the museum activities as a psychosocial intervention. Collaboration between
healthcare providers and museum or arts professionals provides an example of harnessing
existing community resources to promote psychosocial wellbeing outside of traditional
medical settings. Best practice guidelines for psychosocial interventions in dementia care
now recommend engagement in arts-related activities and sensory stimulation (Guss et al.,
2014), although the evidence for museum-based interventions remains a small but
growing area of research. Since social and cognitive stimulation are commonly cited as
needs for people with dementia (Cohen-Mansfield, 2005), it seems a highly appropriate
time to extend the research base to evidence what the arts can contribute to meeting these
needs. In this study, we have demonstrated that art activities in a museum can be accessed
and enjoyed by people with dementia and their caregivers, and that such activities provide
a beneficial impact on subjective wellbeing in a way that refreshments and conversation
do not.

Acknowledgements
The authors would like to thank the people who participated in this project for generously volunteering
their time and providing feedback about their experiences of the interventions. We would also like to
thank the award winning Beaney House of Art and Knowledge in Canterbury, Kent, UK for being
such welcoming hosts of the project and offering their expertise, time, and long-term commitment to
community-oriented research. Special thanks to Kent and Medway National Health Service
Partnership Trust for their knowledge about dementia care and help with recruitment.
Johnson et al. 607

Declaration of Conflicting Interests

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

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

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Dr. Joana Johnson is a clinical psychologist practicing in NHS older adult services in
London. She trained at Salomons Centre for Applied Psychology, Canterbury Christ
Church University, Tunbridge Wells, Kent, UK.

Ms. Alison Culverwell is a consultant clinical psychologist and Head of Older Adult Services
in the east Kent region at Kent & Medway NHS Partnership Trust, Canterbury, Kent, UK.

Dr. Sabina Hulbert is a social psychologist and senior lecturer in the School of Psychology,
Politics and Sociology, Canterbury Christ Church University, Canterbury campus, where
she is also university lead for quantitative methods.

Ms. Mitch Robertson is head of programming and collections, Canterbury Museums and
Galleries, Canterbury, Kent, United Kingdom.

Prof. Paul M. Camic is a clinical health psychologist and professor of psychology and public
health. His research includes looking at the impact of museums and art galleries on social
inclusion and on subjective wellbeing in people with dementia. He is also Research Director
of the Salomons Centre for Applied Psychology, Canterbury Christ Church University,
Tunbridge Wells, Kent, UK TN3 0TF.