The role of cultural engagement for older adults: an integrative review of scientific literature

Objective: to understand the role of cultural engagement in the lives of older adults. Method: an integrative literature review of publications from 2014 and 2019 in English, Portuguese, and Spanish was conducted. The Scopus, Web of Science, MEDLINE/ PubMed, CINAHL, PsycNET®, LILACS, SciELO Citation Index and Science Direct databases were used as sources of information. The descriptors “aged” and the related term “cultural engagement” in the three idioms were used in the search, together with the Boolean operators “AND” or “ OR”. A total of 12 articles that met the inclusion criteria were found. These were categorized based on the theme. No Brazilian studies were found. Results: the panorama found revealed that older adults are more interested in receptive cultural activities, such as going to museums, exhibitions and the theater, as these enrich and add greater social value to their lives. Cultural engagement was associated with a reduction in the incidence of neuropsychiatric disorders (dementia and depression), as well as reducing the incidence of episodes of violence. Participation in cultural activities also constituted a protective factor for cognitive abilities and for the reduction of chronic pain. There is also evidence that associates cultural engagement with a better perception of quality of life and greater well-being, happiness and positive affect, as well as the reduction of negative affect. Conclusion: engaging in cultural activities is a way of understanding and respecting cultural diversity, salvaging social identities, and enjoying and providing experiences of great social value, with beneficial impacts in the lives of older adults.


INTRODUCTION
Participation in the activities that make up our daily lives comes from individual choices, imbued with values, beliefs and experiences that, in turn, are reflections -conscious or otherwise -of the influences of a social group.Participating in these different activities is a way of expressing social identity, just as social identity influences one's engagement 1 .
In the choice of activities, the cultural context can be one of the aspects used to understand how people share, create and assign meanings to each activity they perform 2 .However, the repertoire of activities selected by people can change throughout their lives, whether by necessity, preference, ability, opportunity or by changes in their own culture 3 .
Several researchers have attempted to understand the involvement and participation of a social group in cultural activities by investigating the engagement and access to different facilities such as museums, theaters or monuments, as well as maintaining the cultural traditions that are passed from generation to generation [4][5][6][7] .However, when considering the older age group, the guiding question of such research arises: What is the nature of the engagement of older adults with cultural facilities be described?Does participation in cultural activities have any effect on the lives of these older adults?In this context, the objective of the present article was to understand the role of cultural engagement in old age.

METHODS
The present study took the form of an integrative literature review, the corpus of which was formed of scientific productions that highlight the effects of cultural engagement among older adults.The time frame adopted was five years (2014 to 2019).Searches were conducted in March 2019.
The selected information sources were: Scopus, Web of Science, MEDLINE /PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycNET®, Latin American and Caribbean Health Science Literature (LILACS), Scientific Electronic Library on Line (SciELO) Citation Index and Science Direct.
When selecting the articles the following inclusion criteria were considered, irrespective of the free access to publications: articles that addressed the theme and were in Portuguese, English or Spanish.Literature reviews, conference abstracts, annals and editorials were rejected.
In order to define the search terms, the Health Sciences Descriptors were consulted.The "older adults" descriptor and its correlates were chosen, which were combined with the search term "cultural engagement" and their respective expressions in English and Spanish.The Boolean operators "AND" and "OR" were used for combinations.The strategies constructed with the search terms and results are presented in Table 1.
A total of 139 articles were found.The works identified in the bibliographic search of the databases were exported to Microsoft Excel® spreadsheets for data storage and organization, beginning the process of selecting the research corpus.The identification, screening, eligibility and justification for exclusion steps are presented in Figure 1.In this flowchart, 12 articles met the complete selection process and comprised the final sample of this research.MEDLINE/PubMed ("aged" OR "older adults" OR "elderly" OR "older person") AND "cultural engagement" PsycNET Any Field: "aged" OR Any Field: "older adults" OR Any Field: "elderly" OR Any Field: "older person" AND Any Field: "cultural engagement" SCIelo Citation Index TOPIC: ("aged" OR "older adults" OR "elderly" OR "older person") AND TÓPICO: ("cultural engagement") Science Direct "aged" OR "older adults" OR "elderly" OR "older person") AND TOPIC: ("cultural engagement") Scopus ( TITLE-ABS-KEY ( "aged" OR "older adults" OR "elderly" OR "older person" ) AND TITLE-ABS-KEY ( "cultural engagement" ) Web of Science TOPIC: ("aged" OR "older adults" OR "elderly" OR "older person") AND TOPIC: ("cultural engagement") Total Source: authors, 2019.   1) Contact with Maori culture and language was related to better perception of well-being.
2) The frequency of visiting the tribes was directly related to the engagement in cultural activities, with a better perception of quality of life, in the physical aspects.
1) Cross-sectional study does not allow claims of causality.
2) The assessment instrument used applies concepts of quality of life of Western society, which may differ from the New Zealand concept.
Lai For analysis and systematization of the obtained data, a form was created to organize the results.To select the categories of analysis, a skim reading was initially performed to familiarize the researchers with the contents of each study 8 .Data underwent content analysis 8 for the thematic categorization process and subsequent descriptive analysis.In compliance with the theoretical framework, the articles were divided based on the objectives, methodological designs, outcomes and limitations of each study.

RESULTS AND DISCUSSION
The study is made up of 12 articles that are described in Table 2.
2) Participation in academic activities declined significantly in retired professors and social participation increased, especially in cultural traditions.
1) The sample was restricted to the category of university professors.Thus, it is not known if the maintenance of cultural traditions applies to the Nigerian population.Rapacciuolo et al. 13  1) There is an association between participation in sociocultural activities and subjective well-being and resilience.2) Many were unemployed and the city was in economic crisis.As women did not participate in social and cultural activities, they had lower well-being and were less resilient, as availability and access to cultural and social activities was a key element for a healthy environment.
3) Women scored higher than men in happiness when life satisfaction was assessed.1) Although not described by the authors, one limitation is due to the study design.Longitudinal studies are best suited to investigating emotional aspects and their relationships with cultural access and participation.
2) the socioeconomic condition variable was not highlighted, since this was the reason for the restricted participation of women in cultural devices.
Annear et al. 14  2) The cognitive stimulation provided by museum visits makes cultural engagement an important strategy for maintaining cognitive reserve and reducing social isolation.
1) The study was not experimental.
Goulding 16  1) Cultural engagement seems to have benefits for memory and semantic fluency, regardless of cognitive status, demographic variables, perception of health, and participation in activities.
2) The higher the frequency of engagement, the greater the protective factor for cognition, except for going to the movies.
3) There was no correlation between going to the theater/ concerts/opera and semantic fluency.
1) Cross-sectional study does not allow claims of causality.2) Data were collected from the previous year only, with no longer deadlines, which does not allow us to draw conclusions on the perpetuation of benefits.
3) There may be a two-way relationship between culture, engagement and cognition.When characterizing the research corpus, there was an absence of studies that considered the Brazilian or the Latin American population.Most of the productions were recent (2018, n=5) and from the UK (n=6).All the studies considered were published in English.
To analyze the relationship of the keywords used in the publications reviewed, an infographic was constructed to understand the terms and their associations (figure 2).In this representation, the size of the circle is directly proportional to the frequency and importance of the analyzed items.Circles are grouped by subject and represented by different colors 17 .Thus, clusters are observed, in which the following keywords stand out: cultural engagement, older adults, aging and older age, health and prevention.The connections demonstrated that research has been carried out to establish the relationship between culture and health promotion/disease prevention.
In the analysis of the objectives and methodological designs, it was found that the publications were conducted exclusively with an older population (n=5) or groups of adults and older adults (n=7).In this case, five studies included people older than 45 years [5][6][7]12,15 and two considered younger people 4,10 . In aricles with adult and older adult participants, age did not interfere with the results achieved.
Regarding the goals of the studies, the authors were concerned with investigating which cultural facilities the older adults chose 6,10 , assessing the perceptions of individuals when participating in cultural activities 9,[11][12][13][14]16 , and evaluating the relationship between cultural engagement and body functions [5][6][7]15 or changes.
In the analysis of the objectives and outcomes, it appears that the studies by Lai 10 and Goulding 16 attempted to understand which were the most sought after cultural facilities among older adults.
For people who made frequent use of the internet or apps, museums and art galleries were the most sought after places, followed by music festivals, historical sites, parks or monuments 10 .The author suggests that technology is a supportive resource for cultural engagement, as it stimulates greater interest in visiting existing places and provides an increase in sociocultural experiences 10 .In the study by Goulding 16 , participation in art history and literature classes, choirs, reading groups and museum visits appeared in this order as the choices of older adults to add greater social value to their experiences at this stage of life.
In the other studies in which cultural facilities were the effective spaces for achieving the objectives of each study, the museum was the most common location.Some studies sought to understand the perception of cultural engagement in the lives of older adults, namely those by Dyall et al. 9 , Thomson and Chatterjee 11 , Ejechi 12 , Rapacciuolo et al. 13 , Annear et al. 14 and Goulding 16 .
In the studies by Dyall et al. 9 , Ejechi 12 and Annear et al. 14 , the perceptions of older adults about maintaining their cultural traditions were investigated.The greater frequency of contact between indigenous peoples (city-dwelling) and their tribes and native languages was associated with a better perception of quality of life and well-being 9 .
In the study by Ejechi 12 meanwhile, Nigerian professors reported that they remained engaged in their cultural traditions, such as performing funeral or marriage rites, attending naming ceremonies, and worshiping the gods, represented a successful aging.
Maintaining the Japanese culture and tradition was also the strategy adopted by three long-term institutions for older adults, with the intention of offering potential gains in quality of life and health for institutionalized older adults 14 .The use of traditional Japanese flowers, festivals and foods were the strategies used to connect older adult residents with the outside world and their inherited culture 14 .
Among the other studies that sought to understand the relationship between culture and the perceptions of the research participants, that by Rappaciuolo et al. 13 investigated the cultural participation of residents of a city in economic crisis: Naples.In the survey year (2014), the unemployment figures were increasing and the opportunities for socio-cultural experiences were in decline.It was found that men had greater opportunities for cultural and social participation and had a better perception of well-being and resilience compared to women in the survey 13 .
In turn, tactile experiences with museum collections was the strategy adopted to provide cultural experiences in older adults who -due to health or age -were restricted in their attendance of cultural establishments 11 .Tactile exploration was associated with increased positive affect, well-being and happiness, and decreased negative affect.There was no difference before and after the intervention for positive affect and well-being in the psychiatric ward participants 11 .Those with no previous experience of museum visits showed curiosity about the collection, but restricted themselves to reading the fact sheets without becoming involved in tactile exploration 11 .
By analyzing the relationship between cultural engagement and bodily diseases/functions, scientific studies have shown that participation in cultural activities is associated with lower decline in cognitive functions 6 , chronic pain 7 , incidence of dementia 15 and depression 5 , as well as a lower recurrence of episodes of violence 4 .These studies stated that the frequency of engagement was directly related to increased benefits [4][5][6][7]15 .
In the study by Fancourt and Steptoe 6 there was a direct relationship between the number of trips to museums, art galleries and/or shows and lower cognitive decline, especially in memory functions and semantic fluency.However, the practice of going to the movies showed no association between frequency and protection of cognition.Similarly, going to concert or the theater/opera had no positive relationship with semantic fluency, which may be due to the late development of interest in these cultural modalities.
Maintaining cognitive skills during museum visits was also associated with a lower incidence rate of dementia, reported in a cohort study over ten years 15 .This study also reinforces the finding that cultural engagement was associated with lesser social isolation.Similarly, the social interactions provided by engaging in going to the movies, museums, galleries or the theater and watching concerts/opera was also a variable that reduced the incidence rate of depression. 5.
The engagement in these cultural opportunities, similarly, emerged as a protective factor for reports of chronic pain 7 .The authors believe that the reduction of pain, by approximately 25%, was due to cultural activities promoting responses of positive affect and social interaction, as well as being a low resistance physical activity 7 .
In turn, the study of indigenous people in custody dealt with the issues of their culture and tribal past.In those with a strong cultural identity, there were behavioral changes within the penitentiary, represented by reduced episodes of violence 4 .
In analyzing the limitations of the reviewed studies, the methodological designs were the most frequent limiting factor.

DISCUSSION
The present integrative review of literature reveals, in the small number of scientific productions found, that the theme remains little explored.Although the area has been growing over the years, most studies came from the same region (UK) and the same group of researchers.Restricting research to one territory may not reflect the real role of cultural engagement in old age, as different populations, ethnic variations, opportunities, and availability of resources in each region and their cultures are not considered 3 .
Although cultural participation is beneficial to the lives of older adults, collecting cross-sectional data (most methodological designs) does not allow causality to be established, as this method is limited to reporting a panorama ("snapshot") of the object under study, identifying the factors related to the research problem.As they lack a sequential (temporal) follow-up on the studied phenomenon, they are subject to bias by extrinsic factors 18 .However, these cross-sectional research designs contribute to the elaboration of experimental studies that can control the variables capable of interfering in the outcomes and thus monitor the results longitudinally, or propose a follow-up analysis, to identify whether the benefits presented are perpetuated.
The reviewed studies indicate that, despite the diversity of cultural facilities frequented and traditions identified in this review, the museum was the most sought after space by older adults, or the place most used for the data collection in investigations.This is because museums are institutions that are traditionally used to document, preserve and exhibit cultural, material or immaterial heritage 19 .However, the articles indicate other useful facilities for future research on cultural dissemination and experiences, such as libraries, theaters, cinemas and monuments.
Overall, the researchers were interested in investigating the relationship between participation in cultural activities and improvements in health and well-being [20][21][22][23] .In line with the reviewed articles, maintaining inherited cultural traditions between generations provided experiences of positive affect, better social coexistence and the strengthening of interpersonal ties 12 .
Similarly, participation in different cultural opportunities increased self-esteem and positive emotions, as well as reducing social isolation, anxiety and agitation 21 and enabled the building of resilience 24 .Because of these benefits, researchers highlighted the importance of developing cultural heritage studies for the creation of health programs, as well as the elaboration of public policies. 21,23.
On the other hand, considering institutionalized older adults, studies highlight that within this care modality there are reports of greater social isolation, loss of identity and reduction of affective bonds 25,26 .Thus, the studies presented here, conducted in longterm care facilities, seem to be concerned with the health and quality of life of their residents while maintaining cultural traditions.
In addition, research corroborates the findings of this integrative review by reaffirming the benefits of cultural participation for body functioning.There are positive relationships between cultural engagement and protection against cognitive decline In a complementary manner, debates regarding socioeconomic conditions 38 and/or educational experience 16 and their relationships with cultural access and engagement should also be better discussed in future scientific productions.Offering opportunities for cultural participation to older people -with different incomes and educational levels -respectfully, without physical, communication, information and attitude barriers, is a way of making a commitment to the democratization of culture 39 .In addition, studies on strategies to disseminate cultural rights contribute to a better awareness of the social rights of older adults.

CONCLUSION
Engaging in cultural activities is a way of understanding and respecting cultural diversity, rescuing social identities, enjoying and providing experiences of high social value, with beneficial impacts on the lives of older people.
In the present integrative review, it was found that older adults were more interested in receptive cultural activities (museums, galleries, and theater).Cultural engagement was associated with the protection of cognitive skills or the reduced incidence of neuropsychiatric diseases, chronic pain and inappropriate behavior.Similarly, culture was associated with a better perception of quality of life, well-being, happiness and positive affect.
When considering the issues of aging in the public policy agenda, it has been found that this theme is still related to dependence, inactivity, frailty and disease, aspects that are also the most recurrent in studies and research in the area.Thus, the present study -in line with conferences around the world, which have reinforced the need to expand research in gerontology -sought to contribute through a different approach, targeting the diverse needs of older people.Review studies such as this one constitute an initial phase of identifying demands and gaps in a given theme, and from them new research possibilities emerge.
Edited by: Tamires Carneiro Oliveira Mendes by maintaining mental functions for a longer period 27 .However, in older adults with dementia, museum experiences had no benefit on cognitive functions, although their effects were positive for mood regulation and the promotion of social interactions 28 .
In addition, a reduction in the rate of depression was also found in older adults who performed the tactile exploration of museum collections 29 , as well as in adults and older adults who participated in concerts, theaters and cinemas 30 and in research that investigated older adults who took part in a community choir 31 .
The literature also points to the benefits of culture in behavior and the perception of pain.The strong cultural identity with other indigenous prisoners associated violence with the poor perception of social and emotional well-being which, in turn, had associations with cultural, spiritual, physical and/ or social aspects 32,33 .Similarly, researchers reaffirm the inverse relationship between sociocultural engagement and pain, in which positive affect was considered a "painkiller" in the lives of people with chronic pain 34,35 .
In the present integrative review, certain themes related to the universal right to participate in cultural experiences were not discussed, but may serve as recommendations for future research.No articles were found that sought to identify the environmental and social barriers imposed on these older adults while participating in cultural activities.In addition, older adults with physical, mental and/ or sensory disabilities did not participate in the studies.Inclusion policies for people with disabilitiesand specifically policies for inclusion in culture -are regulated by law as part of the full exercise of citizenship 36,37 .However, studies suggest that people with disabilities still experience difficulties in accessing and participating in cultural services and facilities, due to the lack of accessibility, whether architectural and/or attitudinal 38 .The debate on cultural accessibility for the population with specific needs is necessary to broaden access and participation in cultural activities for all.

Table 1 .
Search strategies and results of articles identified.Rio de Janeiro, 2019.

Table 2 .
Characterization of articles in relation to authors and year of publication, region in which studies took place, research objectives, methodological designs, outcomes and limitations of the studies.Rio de Janeiro, 2019.