Social citizenship, public art and dementia: Walking the urban waterfront with Paul’s Club

Among gerontologists and health researchers, there is growing recognition of the importance of social participation and inclusion towards the health, well-being and quality of life of people with dementia. This paper examines the role of public artworks to facilitate the social citizenship of people with dementia. It is based on a subset of data from a larger study on community-based programmes for persons living with dementia and examines how Paul’s Club, a social recreation group for people with young onset dementia, experience the public art they encounter on their daily walks through the downtown core and around the Seawall of Vancouver, Canada. Analysis suggests that public art not only helped members navigate urban spaces, but also provided a focus for curiosity that leads to meaningful social interaction and place-based conversations, clearly contributing to group enjoyment and a sense of community belonging. Implications of this study relate to community programming, social citizenship, community design, public art and community engaged art practice, as well as health and social care for persons with dementia. Subjects: Cities & Infrastructure (Urban Studies); City and Urban Planning; Community Planning and Planning Techniques; Art & Visual Culture; Health & Society


PUBLIC INTEREST STATEMENT
As "a form of collective community expression", what can public art tell us about how communities perceive people with dementia? Reporting findings from research conducted with Paul's Club, a social recreation group for people with young onset dementia in Vancouver, Canada, this article discusses social engagement and citizenship through community-based support for people living with dementia. In fieldwork, we noticed the group's interactions with the public art they encountered walking their downtown neighbourhood. We asked how public art provides opportunities for meaningful connections and came to understand that the art focused curiosity and playful interaction. Public art clearly contributed to the group's enjoyment of their day and sense of belonging in the community. We explore the idea that public art has a role to play in developing inclusive communities for people with dementia, recognizing their social rights and opportunities to fully participate in and contribute to the broader community.

Background
This paper explores ways public artworks contribute to the development of inclusive communities that are capable of respecting people with dementia as social citizens with requisite rights and opportunities for meaningful participation and contribution.
The impetus for this analysis developed organically over the course of our fieldwork as we spent time "hanging out" with the group and stems from our ability to take advantage of an inductive fluidity that is a hallmark of ethnographic study. We sought to understand the culture of Paul's Club and to discover and interpret what mattered deeply to them. In the course of this work, it became evident that the potential for public art to shape group members' encounters with the city was a significant finding. When the chance to take part in Maraya, a socially engaged, public art project, presented itself during data generation, we were keen to explore where the opportunity might lead. Partnering with the artists provided a means of linking dementia, public art and health research; as such, it allowed us to move our research onto an unexpected and exciting terrain, which we develop in this paper. This serendipitous relationship also benefited the artists. As Lowry, Tsang and Levin (a.k.a Maraya) (2016) note, the ability to work with the research team and Paul's Club and to bring them into the realization of a gallery-based installation of the project in downtown Vancouver challenged key notions about contemporary public art. The experience helped to elucidate the limits of social inclusion and public engagement in understandings of contemporary art practice.
Dementia affects people in significant, all-encompassing ways. More than this, because it affects individuals, families and communities, it is also a crucial social concern. In this light, we studied a community-based social recreation club for people living with young onset dementia in Vancouver, Canada. While dementia is predominantly associated with advanced age, members of Paul's Club live with young onset dementia, meaning that they were diagnosed before the age of 65. Findings developed in this paper have relevance to growing areas of health and social care research and practice. The Alzheimer Society of Canada [ASC] (2016) reports estimates that by 2031, there will be almost 1 million Canadians living with dementia, with Alzheimer Disease International estimating that between 2 and 10% of these will have been diagnosed before the age of 65 (Prince & Jackson, 2009). As diagnostic techniques improve and awareness increases, research across a spectrum of social and health disciplines deals with ways to address the needs of persons with dementia at the individual and community level. Because dementia in its many forms (with Alzheimer disease being the most prevalent) is a progressive disease, and to date, there is no cure, issues of management, quality of life, and well-being represent key areas of focus and intervention. With advancing age as a key risk factor for dementia, the numbers of those being diagnosed and living with the condition is on the rise worldwide. In terms of our study, we sought to add to research on social citizenship and inclusion by attempting to understand how public art practice might positively impact the experience of dementia by helping a marginalized segment of the population to participate more fully in the social life of the city.
In this way, our research also seeks to contribute to discussions of the intersections of health practice and contemporary art. The dialogue between creative practice and health care charts an important area of interdisciplinary study and methodological development that will be explored here.

Introduction
The idea that public art plays a role in social life is not new. Rather, "art in public spaces dates back to classical antiquity and it has evidently been part and parcel of civil societies and urbanization processes across the world" (Zebracki, 2014, p. 78). Public art might then be seen as grounded in, and a celebration of, civic life. Public artworks in their many forms tend to be commissioned for public spaces to serve various social functions-with statues of fallen soldiers, murals, fountains, gigantic birds, nests, raindrops, Lego™ whales and monuments to cultural icons all becoming part of the social fabric of contemporary urban environments. The current Vancouver Art Plan (https://vancouver.ca/parks-recreation-culture/culture-plan-2008-2018.aspx) indicates support for "projects that reflect civic priorities", and it presents a quest to place art in public spaces to help with their demarcation and to activate new urban developments (See also Bressi et al., 2008and City of Vancouver, 2002a, 2002b. The ability of public art to focus social connectedness, social participation, and bonds to place is an area of longstanding interest in urban planning. Beyond this, the opportunity to link public art and arts programming to health care has significant social potential. With the shift in emphasis away from institutional care to community-based supports and services for our aging population, the means of activating social inclusion through public programmes is an emerging and important area of interest in the realm of health and social care practice and research. Alongside this development is the more widespread recognition of the needs and opportunities associated with an aging population. Changing demographics in most parts of the world mean that a larger portion of city "users"/citizens are older adults, many of whom experience functional changes that might serve to limit access to public space. There is a widespread desire of many older adults to remain at home, in their neighbourhoods and communities, or in other words, to "age in place". With time, the onset of not only physical but also cognitive challenges significantly influences a person's engagement in the broader community. Although advanced age does not equate with dementia, living longer is a known risk factor. Dementia, an umbrella term for a number of progressive diseases (with Alzheimer disease being the most common form) results in a decline in memory, judgement and language abilities. Aging research has traditionally focused on physical and cognitive functioning, as opposed to social aspects of aging (Warburton, Ng, & Shardlow, 2013), and there is scant research on how persons with dementia negotiate the built environment of outdoor spaces in the neigbourhoods they inhabit (Keady et al., 2012). Blackman et al. (2003) highlight an important distinction in this literature: they argue that "accessibility" and beyond this, conceptualizations of the "open city" traditionally focus on physical rather than cognitive needs. This idea is further taken up by proponents of dementia-friendly communities (Crampton & Eley, 2013;Heward, Innes, Cutler, & Hambridge, 2016;Mitchell, Burton & Raman, 2004) who explore the social implications of creating the conditions to include people with dementia in everyday life as extending to health and social care practices, and beyond.
Social exclusion is a concept that relates to notions of citizenship and belonging that gained prominence in France in the 1960s (Warburton et al., 2013). This concern spread across western societies as a policy direction along with its corollary, social inclusion defined through concerns about "equality, rights and social cohesion" seeking to garner "attention to barriers or inequalities that prevent individuals or groups from taking a full role in society" (Warburton et al., 2013). Questions of social exclusion or inclusion have been taken up across disciplines. In Cultural Studies and Art History, the work of French Sociologists Pierre Bourdieau and Henri Lefebvre, along with the work of Michel Foucault and others, has been important, leading to what has been termed a "spatial turn" in contemporary cultural theory. And as the trajectory of this paper suggests, there is significant overlap between cultural criticism and recent advances in social and health sciences. The interdisciplinary exchange between professional artists and qualitative health researchers described in this paper offers insights into emerging debates around social engagement, cultural production and urban policy and planning. This paper grows out of a strong belief in the notion that to deny access to people living with impaired language, memory or reasoning is to disadvantage and discriminate against this segment of the population. Vaddiraju (2016), drawing on Lefebvre's work, writes that "urban governance" and the "right to the city" is more than just about access to resources: it has moral implications around the rights of marginalized people-in relation to gender, economics or ethnicity-and their ability to "reclaim public spaces" through "practices of citizenship" (p. 22). This is important to consider in the light of the discrimination and stigma experienced by people with dementia, and by association, their friends and families. The finding that people living with young onset dementia have unique challenges vis-à-vis social inclusion and are at particular risk for the negative impacts of stigma and attendant social isolation (Harris & Keady, 2009;Higgens et al., 2010;Lockeridge & Simpson, 2012) is also vital to consider. Indeed individuals' experiences of dementia differ "depending on where the person is in their life cycle" (Bartlett & O'Connor, 2010, p. 7), and younger people's association with a condition so closely linked to the idea of old age is uniquely stigmatizing. For older and boomer aged adults, how dementia influences a person's (or community's) use of the city and its public spaces, represents an area of growing social interest and concern.
Public artworks' contribution to public spaces and communities that are inclusive of persons with dementia, that facilitate meaningful social participation, is a new area of inquiry. To date, the need to consider how outdoor spaces and the built environment intersect to shape the lives of persons with dementia has received negligible research focus, especially in relation to the confluence of social citizenship, public health and outdoor environments. Increasingly, public, outdoor environments (non-institutional) are considered as spaces that are vital to the health and well-being of not only older adults, but also persons with dementia, and there is growing recognition of the need for policies and practices that prioritize urban spaces that include all citizens. Many of these spaces are identified by and with public art. Vancouver is an excellent example of this characteristic of developments in contemporary urban practice, as this paper asserts.

Art as therapy
Arts and health research focused on dementia has largely explored "art as therapy" with the intention of using psychosocial (non-pharmacological) interventions to improve the quality of life and well-being of people with dementia, particularly for those living in indoor, residential care settings. Therapeutic uses of art are found to positively influence the person with dementia, for example, by achieving positive changes in mood and cognition (Rusted, Sheppard, & Waller, 2006;Tyack, Camic, Heron, & Hulbert, 2015). In a novel approach, Tyack et al. (2015) use touchscreen computer tablets to investigate visual art, well-being and dementia. They found that tablets allowed participants (people with dementia and their carers) to choose images of artworks from a range of genres (contemporary, traditional, objects, British photography) to positive effect. Specifically, participants showed an increase in cognitive, emotional and behavioural well-being, as well as an ability to strengthen interpersonal relationships.
Research into the positive effects of art making and encouragement of creativity and self-expression through the visual arts (Kinney & Rentz, 2005;Rusted et al., 2006) is also fairly common in dementia literature. This research tends to focus on personal growth through creative involvement in more or less conventional art practices, e.g. painting, photography, arts and crafts, and at times poetry and drama/performance. Koch's (2017) exploration of art therapies through a lens of "embodied aesthetics" explores both the expression, expressive (art-making) and impression (perception) side of arts-based approaches. Her research suggests numerous factors including "pleasure, play, beauty, authenticity, symbolization, (nonverbal) communication, imagery, and self-expression" (Koch, 2017, p. 17) that contribute to art therapy's "value" from a health perspective.
It is the ability of art to contribute to well-being at the affective, nonverbal level that is intensely exciting with respect to dementia. Indeed, there is a small body of research that reflects on how dementia impacts the professional artist who is diagnosed with progressive forms of dementia (see Gretton and ffytche (2014) and Fornazzari (2005), for examples). However, as our research suggests, there is an important social aspect to art and creative practice that also requires attention for people living with cognitive challenges. As dementia progresses, the onset of aphasia, an "acquired communication disability" that has "devastating impacts on everyday communication" (Brown, Davidson, Worrall, & Howe, 2013, p. 165) frequently occurs. The ability to express oneself in nonverbal ways might then be seen as critical for people so affected to remain "part of the communicative world" (Hubbard, Cook, Tester, & Downs, 2002, p. 160). As Anne Basting (2006) points out, the arts support people with dementia to express themselves through its ability to function at the level of emotion.
Should we develop dementia and have trouble expressing ourselves with words, it is important to know that our emotions will nonetheless remain readily available, as will our desire to communicate with others and remain a part of the public, social world.

Public art, public health
Public art, as a contemporary art practice tends to be distinct from popular forms of art and more readily identified types of creative practice like painting, photography and crafts. Contemporary public art, as we will discuss in this paper, has strong interest in participation, i.e. involving members of the public. Though definitions of public art vary, broadly, the term "refers to either permanent or temporary artworks, including social and contextual art practices…commissioned for openly accessible locations…outside museums and galleries…" (Zebracki, 2013, p. 303). Access for people living with dementia and a focus on public engagement is also characteristic of museum programming and museum studies, and is evident in an emerging area of inquiry that explores visual art, public health, dementia and the art gallery (Camic, Baker, & Tischler, 2016;Camic & Chatterjee, 2013;MacPherson, Bird, Anderson, Davis, & Blair, 2009;Eekelaar, Camic, & Springham, 2012;McGuigan, Legget, & Horsburgh, 2015;Rosenberg, 2009;Young, Tischler, Hulbert, & Camic, 2015). For example, Rosenberg's (2009) study of the "MoMA Alzheimer's Project" involved bringing a group of 12 older adults (age range 60-80) to view art at the Museum of Modern Art, New York City: "one of the first museums in the country to offer programs designed to make its collection and special exhibitions accessible to people with Alzheimer's disease and their caregivers" (Rosenberg, 2009, p. 93). The MoMA project has become a nationwide initiative that offers programme models that can be used across sites and locations. The use of the art gallery to engage people with dementia might then be seen as an important means to connect this population with the wider community, of creating a space where people with dementia, like people without dementia, are invited.
Indeed, research suggests, art gallery-based programming is uniquely positioned to contribute to public health. Not only are art galleries often physically and socially positioned at the heart of a city, but they are also, as McKeown, Weir, Berridge, Ellis, and Kyratsis (2016) found, vital to citizenship. These researchers noted a growing emphasis on galleries as vehicles for mental health services and maintain that an ethos of inclusivity at the "iconic" Tate Modern, London (p. 31) was critical to producing health benefits for participants experiencing mental health issues. This linking of communitybased services with health care is consistent with what is referred to as social prescribing. As Hui (2012a, 2012b) argue, this "new model" (2012b, p. 580) has particular relevance to artsbased research. They write that social prescribing is a means to link "patients in primary care with non-medical sources of support within the community" (Stickley & Hui, 2012b, p. 580). Citing Brandling & House (2009), Stickley and Hui (2012b) further suggest social prescribing "makes available new life opportunities…" and "gives the patient a chance to…be creative" (p. 581). In their research, "arts on prescription" referrals came from primary care workers, secondary mental health care and the voluntary sector. Benefits to participants were personal and social in nature, clearly suggesting the need for further inquiry in this area.
Camic and Chatterjee (2013) point out, museum and art gallery-based interventions are distinct from the majority of "health-care" interventions that take place in medical settings like clinics and hospitals. Noting the social isolation of this segment of the population, MacPherson et al. (2009) suggest that where programmes do exist for persons with dementia, they have a tendency to overemphasize deficits and underestimate remaining abilities. Camic et al. (2016) also examine the effects of a gallery-based public health intervention, describing the gallery as a "physically valued place" (p. 1). These researchers offer a theoretical understanding of this setting's potential benefits for persons with dementia, furthering Smith's (2014) idea of the "museum effect" (Camic et al., 2016, p. 7) that highlights the social interaction made possible by the space: "The stimulation of viewing and making visual art, in conjunction with a supportive group environment, created opportunities for individuals with dementia to be perceived differently by their caregivers and gallery staff" (Camic et al., 2016, p. 7). In combination, these findings might be seen as vital to addressing and challenging the stigma of dementia and as important initiatives towards social inclusion and participation.
This paper seeks to build on this body of research by adding an expanded view of the social and spatial dynamics of art practice. Looking at the social engagements of people with dementia beyond the institutional realms of the care facility/clinic or art gallery/museum, our research charts everyday/quotidian interactions with public spaces through contemporary public art in Vancouver.

Research methods
This paper presents analysis of a subset of qualitative data from a larger study exploring community-based programmes for people with dementia in relation to social citizenship. Drawing on data from fieldwork we conducted with Paul's Club, a social recreation group for people with young onset dementia located in Vancouver, Canada, we detail how Club members experience an urban space and the public art therein. Spending time with Paul's Club led us to grapple with public art as something that "is there for everyone, a form of collective community expression" (Bach, 1992), and related to this, we came to consider how communities perceive and understand people with dementia as active, engaged citizens.

Introducing Paul's Club
Paul's Club meets three days a week in a hotel in the heart of downtown Vancouver. The members include people with dementia, group leaders, volunteers, and at times students and researchers. There are approximately 15 people with dementia who attend on any given day, men and women between 50 and 75 years old who are living with some form of dementia (most have Alzheimer disease). While they are physically healthy, they have fairly significant cognitive impairment, such as memory loss, disorientation or difficulty with language. However, the three group leaders will repeatedly say that these kinds of problems are "left at the door". The Club's emphasis is on having fun and enjoying each other's company. An important part of this is their regular afternoon walk. Each day after lunch, the group departs for a long leisurely stroll along city streets and through the "green and blue spaces" (Finlay, Franke, McKay, & Sims-Gould, 2015) of their downtown neighbourhood. A central focus of these walks is often the "Seawall", a walking path that follows the shoreline of False Creek, a shallow harbour in the middle of Vancouver that provides recreational opportunities in an area of highrise residential towers.

Data generation and analysis
While the methods and analysis for the larger study have been described elsewhere (Phinney, Kelson, Baumbusch, O'Connor, & Purves, 2016), for the purpose of this paper we are drawing from the 100 + hours of observation we conducted while accompanying the group during these afternoon walks. Data were recorded as field notes and "walking vignettes" (brief snippets of conversation and interaction that occurred during the walks) (p. 384). We also had access to numerous photographs (many taken by the group leaders), which allowed us to conduct two photo-elicitation focus groups to draw out group members' reactions to the people, activities and places they experienced on these walks. We extracted from this large corpus of data all the excerpts that showed some aspect(s) of the group's encounters with public art, and used methods of interpretive description (Thorne, 2016) to analyse the data by extending beyond mere description of events, to a deeper understandings of patterns and relationships that exist in the data. These associations were then considered in light of our study's overarching research questions about social engagement and inclusion.

Research Ethics
Approval for this research was obtained through the University of British Columbia's Behavioural Research Ethics Board (BREB) in 2014. The majority of study participants provided informed consent directly; for a few Club members, consent was obtained by proxy. In all cases, we followed a process consent method (Dewing, 2007) whereby consent was revisited and reestablished with each research encounter. Consent for visual data generation was obtained through BREB, however, in order to align this research with confidentiality protocols in place at the research site, any photographs of members were obtained through the Paul's Club community. Meetings between Maraya and Paul's Club to ascertain interest and review and establish consent were held prior to and on the days of interaction. Again, the voluntary nature of participation and the right to opt out was highlighted.
Following fieldwork, Maraya's photographs and artwork were shared with Paul's Club as part of a gallery exhibition programme thereby involving Club members in Maraya's social engagement/public programming.

Findings
Paul's Club members interacted with public art on a regular basis. Because of their downtown location, public art shaped the Club's walks in significant, largely seamless ways. Here we develop members' experiences with three pieces of public sculpture: Douglas Coupland's (2011) Terry Fox Memorial, Jerry Pethick's (2006) Time Top, and Kim Cooper and Marten Sims' (2014 Nest. We then go on to explore the group's involvement with Maraya, a community engaged art media project by artists Henry Tsang and M. Simon Levin, and cultural theorist Glen Lowry (one of the authors of this paper).
Daily walks most often take Club members through the downtown core, through waterfront greenways, along the Seawall, and then back towards the Club through city streets. On these walks the first and most frequent piece of art encountered by the group is Coupland's (2011) Terry Fox Memorial (Appendices 1 and 2). The memorial is composed of four bronze statues of Terry Fox running westward towards the Pacific Ocean, which was to be his final stop on his cross-country "Marathon of Hope". Each statue increases in stature as it moves westward. Fox, a Canadian icon in whose name significant awareness and funds for cancer research continue to be raised, occupies a significant place in the national identity of Canada.
The Memorial is located next to a popular sports arena (BC Place), whose organizers sponsored the work (BC Pavilion Corporation), and is passed through by Club members almost every day on their way to the Seawall. Walking through the memorial often evokes comments about Terry Fox the person, his courage and contribution to society. The space also regularly stimulates remarks by members about the beauty of the sculpture, as well as the many people who gather in this space. The Terry Fox Memorial creates an animated environment that attracts tourists, kids from the nearby school, walkers and skateboarders.
During a focus group, members shared the following insights when viewing a photograph of the memorial:

S.
These pictures are fantastic…I like Terry Fox D.
In his day, which was a very short day…he was a fantastic athlete… E. He looks cool! These words show them as members of the community, with a sense of belonging and shared history. Their fondness and admiration for Terry Fox is apparent, as are the positive effects of being part of this energized, active urban space.
Another example of public art that Club members encounter on almost every outing is Pethick's (2006) Time Top (Appendices 3 and 4). Located on the north side of False Creek, this sculpture changes with the tides, with low tide exposing its barnacle-encrusted base. During fieldwork, this piece tended to evoke a variety of responses from members ranging from admiration to derision-in words and gestures. Here is a sample of comments made by members in a focus group as they viewed a photograph of Time Top.

C.
That's that weird looking thing, it looks like it's from outer space… L. It's a really old thing, yes.

S.
We walk by that thing all the time.
C. It looks like it could float.
The sculpture piqued people's curiosity and imagination. It evoked lively responses, even when words failed. Below is a walking vignette recorded following an encounter with Time Top: This is the first time I have walked with C. He works out, runs, on a regular basis and is extremely fit. He has significant word finding challenges…walking together beside the Time Top, C. points at the base of it. It's low tide and the base of the structure is exposed, "oh and on the left it's up and the others too," He exclaims with great energy. "Well um…that's amazing." He is smiling. We walk on for the next long while in silence.  Walks that take Paul's Club to the south side of False Creek occur less often, but when members pass by the Nest, they step inside and everyone takes a seat and laughter and conversation soon follow (Appendix 5). Supported by the City of Vancouver's Community and Neighbourhood Development Programme, Cooper and Sims' (2014) Nest is described as providing … neighbourhood residents with a beautifully crafted object; a meeting space to connect with their community; it is designed to be entered, and from within, visitors have the chance to experience the world from the uncanny perspective of a hatchling, … a previously unconsidered 'birds-eye-view. (Cooper & Sims, 2017) For Paul's Club, this public artwork is indeed a meeting space, offering a welcome break from the Seawall path. Encountering the artwork en route, members take turns entering the Nest as it invites embodied engagement and connection between people.
Rather than visually representing a public figure, as with Coupland's Terry Fox, or documenting the urban landscape or geographic locations, as with Pethick's Time Top, Cooper and Sims' Nest presents itself as a platform for social engagement. It provides a context for social activities and dialogue in a manner that is tacit in the earlier works discussed above. In so doing, Nest also provides a material example of a growing concern in contemporary art practice around issues of participation and civic engagement.
These issues are further revealed in the members' involvement in Maraya, an interactive multimedia art project that was in large part situated along the Seawall. The project is described as one that looks at the relationship between urban waterfronts in Vancouver and Dubai. Through photography, video, public art, public programs and an interactive online platform, new forms of urban living pioneered in both countries are explored, showing how these geographically distant spaces are connected in ways that are both familiar and surprising. Maraya -from the Arabic m'raya for "mirror" or "reflection" -connects the glass and steel residential towers that line the seawall walkways of Emaar's Dubai Marina and Concord Pacific Place along False Creek. (Museum of Vancouver, 2012) While the Maraya project extended over several years, in this iteration it involved The Sisphyean Cart, a heavy wagon containing a set of mirror-faced structures modelled after the towers along the seawall. Members of the public participate as "pulls", drawing the wagon along the Seawall. As it moves, the cart takes video of the environment, and when it stops, people gather round to investigate. Being attracted by the cart, they are invited to move the mirrored towers around, imagining a new city and creating new social arrangements.
Both being "users" of the Seawall, Maraya and Paul's Club came to hear of each other, and it was arranged that there would be a meeting of the artists and the Club during one of their walks. On two occasions members took turns pulling the cart along the south side of the False Creek Seawall. An important aspect of members' involvement in this project is that it allowed for non-verbal participation. It was experiential and capable of capitalizing on members' physical abilities and creative imaginations. While many members participated by pulling the cart, others walked along beside or behind it, much the same way they would on a regular walk with the Club. When the cart stopped, others stepped forward to consider the towers more carefully (Appendix 6).

Discussion
This analysis draws attention to the arts and health in relation to dementia, public art and social inclusion. Our research has led us to consider how Paul's Club creates opportunities for social citizenship, specifically in terms of supporting members' continued participation in the community and that members' access to and engagement with public art is an important means by which this can be achieved. Being with Paul's Club has allowed us to see the city and the neighbourhood in new ways as places for people with dementia to be and to thrive. Accessibility in this context highlights the need for urban planners to consider cognitive abilities, moving beyond the physical in consideration of city "users"/citizens.
When we began this study we didn't anticipate encountering public art with the Club members nor did we foresee the opportunity to join with them in the Maraya project. But in the early days of the research, we had an animated exchange with a Club member who was responding to an artwork, and a light bulb went off. When it happened again, and again, we began to consider more carefully members' access to public spaces and art in relation to social citizenship. During fieldwork, our interactions with the Paul's Club community have suggested the importance of art in enlivening a public space by creating opportunities for people with dementia to participate more fully in the wider urban community.
The public artwork and public engagement interactions as developed in this paper are all located in and around the Seawall. Paul's Club regularly accesses the Seawall and because of this, they encounter many City-commissioned artworks. The Seawall offers members a way to foster health and well-being; it provides a supportive environment for persons with dementia to walk safely, interact with one another as well as other community members. Beyond this, as we discovered, members have increased access to public art and art projects, as they walk together in the community.
Pethick's Time Top was commissioned by a development company as part of The City of Vancouver's Public Art Programme. As stated in the brochure, this City programme "incorporates contemporary art practices into city planning and development processes", with the intent being to "encourage a conversation … that expresses the spirit, diverse visions, and poetry of place that collectively define Vancouver" (https://vancouver.ca/files/cov/public-art-brochure-time-top.PDF). Paul's Club members' interaction with Time Top suggests this artwork's ability to accomplish these ends. Not only was Time Top a familiar landmark that facilitated orientation and provided a sense of place, it also had a unique ability to prompt conversation in individuals who are often challenged to do so. Certainly when members encountered this and other pieces of public art while out walking, the artwork seemed to evoke spontaneous, emotional responses. We found, as did Young et al. (2015), that members were able to articulate in words their judgement of the work. More than this, members with aphasia were frequently motivated to communicate feelings about the work in gestures and through bodily engagements, in a relaxed, informal manner. This is an important finding, and it suggests a vital area for further inquiry.
Our findings around Paul Club's engagement with public art is in keeping with work done by researchers on inclusivity and design. As noted earlier, how people with dementia experience public spaces is a growing area of research. Mitchell and Burton (2006) in their exploration of dementiafriendly outdoor spaces found that participants with mild-moderate stages of dementia demonstrated a preference for "vibrant spaces full of activity" (p. 29). In their study, they found that participants with dementia perceived outdoor environments that attracted people and might be described as informal and animated as "less intimidating" than a more formal setting. In this vein, with respect to art, one might imagine a gallery space as "formal" and a park as "informal". Mitchell and Burton's (2006) assertion that people with dementia are challenged to understand what is expected of them in certain spaces echoes other research in the area of built environment and dementia, and is an intriguing finding that relates to the current project. Certainly Paul's Club makes daily use of Vancouver's active spaces such as parks with seating, public art and other interesting features that serve to enliven a space and stimulate users.
Furthermore, our experiences with Paul's Club in relation to dementia and the potential of contemporary art to contribute to social inclusivity for its members suggest ways in which engagement with public art might be considered a useful means to address marginalization and stigma. According to Zebracki (2014): Public-art encounter may implicate a pedagogical process crucial to making contact with the "other" and to see, embody and organize the everyday living environment from different and reciprocally challenging vistas. Thus, public art can provide agency to mediate social differences and relationships… (p. 11) In this vein, in order to help address the enduring stigma of dementia and harness the perspectives of persons with dementia towards shaping urban spaces that embrace all citizens, public art might be seen as an untapped social resource.
We also found that participating in Maraya was a stimulating group activity; it was intriguing, if kind of strange. For some members, the chance to pull the cart and create "a city" with the buildinglike objects was engaging. For others, this new activity was perhaps too out of the ordinary, or of little interest. As this paper suggests, not all participants may respond favourably or indeed be interested in contemporary public art. We did find that for most, the chance to meet new people, create something and enjoy an activity as a group was a welcome experience. The benefits of this project extended to an invitation to the opening reception held at the 221a Gallery in Vancouver's Chinatown. Here, members were invited to view their photographs alongside members of the broader community who joined in the cart pulling along the Seawall, in both Vancouver and Dubai (Appendix 7). The event was a celebration of the city, of being out and about, and of being involved in the community. The benefits were shared. Paul's Club had a significant impact on Maraya, offering to the project an important perspective on health and well-being: it forced the project to expand their consideration of community, of participation in an art project, of the role of memory and language in urban design, of urban access and rights to social inclusion (Lowry et al., 2016).

Implications
Our focus in this paper is grounded in our experiences with a unique group of people: Paul's Club regularly engages with outdoor spaces, with the life of the city in which it is embedded. The practice of being outside, and by implication this analysis, contrasts with much research on dementia care, which overwhelmingly takes place in health care or residential care settings. For the general public, when we think about people with dementia, if we do at all, we tend to think of doctor's offices, hospitals and nursing homes, and much of the research on dementia care is restricted to consideration of the indoor spaces of institutional settings (Mitchell & Burton, 2006). Art in this context has been taken up either for its therapeutic potential, or in relation to the built environment itself-as a way to support wayfinding within the institution, as a means of conveying biographical information to formal carers, or of making a space more homelike.
Art galleries are increasingly considered as important spaces for the social inclusion of people with dementia and their carers, with implications for public health, social care and art gallery policy and programming. The idea of an arts-based social prescription is particularly intriguing as a means to move beyond boundaries of conventional biomedical responses to dementia and dementia care. The findings of our research have implications for public art that exist in outdoor urban environments. With the aging of the population and the shift towards a growing number of older adults who desire to age in place, there is vital need to consider the outdoor environments of the broader community, and their ability to support the health and well-being of this population generally, and people with dementia specifically. Because of the recent higher profile of dementia, through activism and initiatives like "dementia friendly communities", there has been emerging recognition of the economic, political and cultural changes that come with an aging population. The notion that people can continue to live well with dementia is part of this philosophical direction, and reminds us that we need to know better how to respond to the needs of people with dementia, that they might continue to do the things they enjoy and contribute to the community.
Being with Paul's Club and experiencing public art during fieldwork led us to consider public art, whether it be as objects, installations or co-creative practices, as a means to support the social citizenship of persons with dementia who live in the community. Dementia is a particularly stigmatizing condition. This is important work that coincides with growing recognition of discrimination against persons living with dementia that has been taken up by social justice advocates locally, nationally and internationally.
Understanding public art as a means to create inclusive urban spaces capable of supporting the participation of people with dementia in social life represents an exciting area of health and social care practice. Ideally, this objective would be grounded in the involvement of people with dementia in conversations and decision-making at the municipal level around public art commissions. This would of course entail recognizing and engaging people with dementia, of all ages, through "active forms of citizenship" (Bartlett & O'Connor, 2010, p. 34) by harnessing remaining strengths, abilities and interests through participation in decisions that impact the life of the city.