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Over the past 2 years of the coronavirus disease 2019 (COVID-19) pandemic (1), physical distancing was deployed as a preventive public health measure to reduce the transmission of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This physical distancing had at least two unintended consequences for older adults. First, these measures often deprived older people of face-to-face access to social activities and social networks, which often led to an increase in their social isolation (2). Second, in many countries, such as Canada, there was an increased demand for access to the health care system and community resources, which could not always be met (3, 4). This combination of an increase in social isolation and increased pressure on the healthcare system and community organizations often led to a degradation in physical and mental health, making older adults frail and increasing their risk of adverse outcomes (5). For instance, research suggests that older adults who experience social isolation are at a greater risk for incident morbidities, which can contribute to greater physical frailty and even premature death (5, 6). Conversely, physical frailty itself may also increase social isolation (5). Moreover, it has been demonstrated that older adults' wellbeing and quality of life are impacted negatively by both social isolation and physical frailty (5–8). This highlights the need for innovative interventions that promote the social inclusion of older adults, especially in the wake of 2 years of the COVID-19 pandemic.

Systematic reviews of quantitative studies have attempted to evaluate the effectiveness of interventions designed to increase the social inclusion, and sense of connectedness, of older adults experiencing social isolation (8–15). Due to the heterogeneity of interventions and their results, to date, there has been no conclusive evidence on the effectiveness of specific strategies to increase social inclusion in this population.

Further research is required to determine what “works” to improve social inclusion. These systematic reviews do, however, point to three key characteristics of effective interventions. First, group activities have a greater effect than those performed alone (8–12). Second, engaging participants in goal-oriented endeavors, rather than in passive activities with no explicit purpose, appears to be more effective in increasing feelings of social inclusion (12–15). Third, activities that include a creative component (such as arts-based activities) evoke positive emotions that are beneficial (15). Moreover, cultural interventions predicated on any type of arts-based activity have been shown to have beneficial effects that may improve people's quality of life (16, 17).

A socially-inclusive society enables all to remain engaged in collective daily life for as long as possible as they age (18). The concept of social inclusion implies on-going, meaningful participation in society. Providing occasions and places where individuals may participate in shared activities are key attributes of an inclusive society. Because they offer a variety of opportunities to participate meaningfully in arts-based group activities - from guided tours to lectures and workshops - museums may fulfill such a role, fostering a sense of social inclusion. Indeed, the potential of museums to improve the social inclusion of older adults experiencing social isolation has been demonstrated in a British study on “museums as spaces for wellbeing.”¹ Since 2015, a participatory, arts-based workshop series has been offered by the Montreal Museum of Fine Arts (MMFA, Montreal, Quebec, Canada) (19). In an examination of this program, it was demonstrated that an intervention involving art creation in a group setting at the MMFA improved the wellbeing, quality of life and health condition of community-dwelling older adults in Montreal (19). Building on this initial study, in 2019, we then co-developed an arts-based activity with the MMFA, consisting of weekly guided tours carried out over a 3-month cycle. Because of physical distancing requirements during the COVID-19 pandemic, these guided tours were adapted into virtual guided tours. The impacts and effects of such virtual tours on older adults experiencing social isolation had never been examined. We hypothesized that weekly virtual MMFA tours could reduce social isolation and improve the wellbeing, quality of life and health condition, including the physical frailty, of older adults living in Montreal. This study thus aims to examine whether a 3-month cycle of weekly virtual tours of the MMFA may have improved feelings of social inclusion, wellbeing and quality of life, and reduced physical frailty in older adults living within the community of Montreal.

As shown in Table 1, there was no significant difference between groups for participants' baseline characteristics, except for sex and ethnicity. There were fewer females and Caucasians in the intervention group compared to the control group (P ≤ 0.013). There were significant greater mean scores for DSSI, EQ-5D and CESAM (P ≤ 0.001) at M3 compared to M0 in the intervention group (Table 2). There was only a trend (P = 0.059) for greater WEMWBS mean scores in the intervention group. No significant change in all scales' scores between M0 and M3 was found in the control group. Inter-group comparisons showed that DSSI, WEMWBS, EQ-5D and CESAM mean scores were significantly higher in the intervention group compared to the control group at M3 (P < 0.033), while significant difference was found at M0. Table 3 shows that participation in weekly virtual MMFA tours was significantly associated with improvements in all scales (P ≤ 0.012).

The findings of this RCT show that the 3-month cycle of weekly virtual MMFA tours had multidimensional benefits in participating older adults. Social isolation decreased and both physical and mental health improved significantly.

The decrease in social isolation reported in our study is consistent with the results of previous studies, which have shown that arts-based activities can reduce social isolation, and that these interventions are most effective when they are practiced in a group setting and actively engage participants (10–13). In addition, a meta-analysis previously demonstrated that interventions that focus on changing a person's perceptions and that stimulate positive emotions are more beneficial than those that focus on building social ties (15). Furthermore, interventions involving cultural activities, such as the visual arts, regardless of artistic genre or type of activity, have demonstrable benefits including the generation of positive emotions, which have been shown to improve wellbeing, self-esteem and quality of life (16, 17). We suggest that it is for all these reasons that we observed significant social and health benefits in our RCT.

Social isolation is a major problem in Canadian society. The proportion of Canadians aged 65 and over who report experiencing social isolation is high: in 2018, it was estimated to be around 20% of the older population, representing 1.5 million people (27, 28). Social isolation in combination with health challenges, which are often prevalent as we age, expose older individuals and the wider community to a variety of adverse outcomes with deleterious effects (5, 6). For instance, lack of contact between members of a family or within society may hamper or break down intergenerational relationships, increasing feelings of social isolation (29, 30). The physical and mental health issues known to arise as a result of social isolation may increase people's needs for health and social services, which puts pressure on those who work in these systems. This may in turn increase service expenditures (5, 6). Indeed, in 2016, the International Federation on Aging reported that “the main new problem facing seniors in Canada is maintaining their social contacts and activities” (31). This highlights the need for effective interventions that promote the social inclusion of older adults before they experience social isolation. The 3-month cycle of weekly virtual MMFA tours examined in our study seems to be one example of an intervention that effectively created social connection, the opposite of social isolation.

Many museums offer participatory arts-based activities (19, 32–37). The United Kingdom was one of the first countries to consider museums as partners in social and health policy. This gave rise to a consortium known as National Alliance for Museums, Health and Wellbeing, “(2015-2018), which became a driving force in the British Ministry of Health and Social Services ¹ and is now known as the Culture, Health and Wellbeing Alliance. The interventions offered in British museums are most often interactive and participatory group activities ¹. In the same period in Canada, the MMFA began developing participatory, arts-based activities in 2015 (19). Like their British counterparts, the MMFA focused on participatory, art-making workshops, for which improvements in the quality of life and wellbeing of community-dwelling older adults, as well as a reduction in their physical frailty, were reported (19, 31, 32). Our RCT reproduces and confirms previous studies that demonstrate the benefits of thoughtful, interactive, participatory arts-based programming on the physical and mental health of older adults interested in art and culture. The observation that arts-based activities can be beneficial to physical and mental health is not a new one, as exemplified by the field of art therapy (32–35). Improvements in wellbeing and quality of life have been reported in patients with cancer, neuropsychiatric diseases, or physical disabilities (32, 35). Unlike previous studies, this investigation of the MMFA and the guided tours that they developed during the COVID-19 pandemic is the first time, to the best of our knowledge, that these benefits have been documented and reported on virtual museum tours. Taken together, these findings suggest that arts-based activities, even when delivered online, retain their health benefits for older adults. A causal explanation of these complex health benefits is likely attributable to the dynamic interaction between wellbeing, health-related quality of life and physical health. Indeed, a sequence of health benefits has been suggested in previous studies (19). To summarize, the positive experiences engendered by arts-based activities delivered online may improve wellbeing, which improves quality of life and finally, physical and mental health when they incorporate into this virtual environment the principles mentioned previously: an emphasis on group activities; goal-oriented, purposive endeavors; and activities with a creative component.

The RCT design and the standardization of the 3-month cycle of weekly virtual MMFA tours were the main strengths of our study. However, some limitations need to be considered. First, the RCT was carried out in the older population living exclusively in Montreal. Second, even if benefits were reported for social isolation, physical and mental health, it is not possible to identify and isolate respective causal mechanisms. For example, mental and physical health benefits may result from the break in social isolation experienced because of participants', engagement in the study itself. Third, how much “control” we had over the control group was impossible to monitor with precision. Over the study period, the control group may have been exposed to activities that may have influenced the RCT outcomes. We tried to limit this effect by asking the control group participants to withhold participation any in arts-related interventions and social programs over the study period. No participants in the control group reported arts-related or social program activities, however, it was beyond our mandate to monitor. Fourth, there were significant differences between the intervention and control groups' baseline characteristics. In both groups there was a high proportion of females. However, this proportion differed significantly, with fewer females in the intervention group. Sex is a biological characteristic that may differentially impact the outcomes assessed in our RCT. Furthermore, there were also fewer Caucasians in the intervention group and this difference in ethnicity also could affect the results. However, it should be noted that all linear regression models were adjusted based on these baseline characteristics in order to limit their impact.

Our RCT suggests that a 3-month cycle of weekly virtual MMFA tours may decrease social isolation, foster a sense of connectedness and, thereby, improve mental and physical health in community-dwelling older adults. Like other arts-based activities, this particular program, delivered online, appears to have been an effective digital cultural intervention to mitigate social isolation and the progression of physical frailty, positioning museums as key stakeholders for social and health prevention, and for fostering social connectedness, in the aging population.

The datasets used and analyzed in the current study will be made available by the corresponding author upon reasonable request. Requests should be sent to the corresponding author: OB, PhD; Research Centre of the Geriatric University Institute of Montreal, Montreal, QC, Canada; olivier.beauchet@umontreal.ca. All requests need a cover letter explaining the objective, justification, and referent Ethics Committee.

The study received approval from the CIUSSS Centre-Sud-de-l'Île-de-Montréal (Quebec, Canada) Research Ethics Committee approved the study (# 2022-1338 – CÉR VN 21-22-08). The patients/participants provided their written informed consent to participate in this study.

OB: principal investigator, study conception and design, obtaining funding, drafting the manuscript, revision of the manuscript, and final approval of the manuscript. JM, KG, CL, and KS: drafting the manuscript, revision of the manuscript, and final approval of the manuscript. All authors contributed to the article and approved the submitted version.

This trial was funded by Fonds de Recherche du Québec Société et culture; Actions concertées / Action sur le vieillissement actif de la population au Québec / Projet de recherche-action – Project 281107. The funding source had no role in the design of the nor on execution, data management, analyses, interpretation, or publication of the results.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.