joujrnal article review

134 RESEARCH Effects of creative and social activity on older people

JRSH 2006;126(3):134-142

Effects of creative and social activity on the health and well- being of socially isolated older people: outcomes from a multi- method observational study

Effects of creative and social activity on older people RESEARCH 135

May 2006 Vol 126 No 3 The Journal of The Royal Society for the Promotion of Health JRSH

Authors Colin J Greaves, Research Fellow in Primary Care, Peninsula Medical School, Smeall Building, St Luke’s Campus, Magdalen Road Exeter EX1 2LU Email: Colin.Greaves@ pms.ac.uk Lou Farbus, Research Fellow, Peninsula Medical School, Magdalen Road, Exeter EX1 2LU Corresponding author: Colin Greaves Received 7 November 2005, revised and accepted 27 January 2006

Key words Creative activity; mentoring; older people; social isolation; social networking

Competing interests The research was commissioned by Upstream HLC, although with the brief was to conduct an independent enquiry. Upstream staff were involved in collecting questionnaire data, but not in the interpretation of any of the outcomes data or writing the report.

JRSH Copyright © 2006 The Journal of The Royal Society for the Promotion of Health May 2006 Vol 126 No 3 ISSN 1466-4240 DOI: 10.1177/1466424006064303

INTRODUCTION The UK’s population is ageing. In the next 25 years the number of people over the age of 80 will treble, and those over 90 will double.1, 2 The expected future impact on healthcare resources has led to government policies which aim to increase ‘quality of ageing’ through joint NHS, Social Services and voluntary sector provision.1, 3

As the number of older people increases, more are living alone.4 A recent UK survey found that 12% of over 65s feel socially isolated.5 Social isolation and loneliness are consistently associated with reduced wellbeing, health and quality of life in older people.5, 6 Conversely, improved social functioning and social connectivity is associated with improved health and

wellbeing.7–9 Depression in particular is associated with social isolation5 and affects one in seven over 65s.10

EFFECTIVENESS OF SOCIAL NETWORKING INTERVENTIONS The few trials which have evaluated interventions designed to promote social participation in older people have produced mixed results.11–17 However, a careful review of this literature suggests that interventions which promote active rather than passive social contact, are more likely to impact positively on health and quality of life. Passive interventions, such as home-visiting, have been shown to have only limited effectiveness.11–13 However, ‘active’ interventions that promote the

development of meaningful social roles and active engagement in local communities have demonstrated positive impacts on older people’s quality of life and health.14–17 For example, 108 women who lived alone took part in a randomized controlled trial of small group meetings aimed at alleviating ‘emotional and social estrangement’.14 After 6 months the intervention led to an increased range of social contacts, increased self-esteem, and lower blood pressure. Another randomized controlled trial tested a Program to Encourage Active, Rewarding Lives for Seniors (PEARLS) for people aged 60 or over with depression. This communityintegrated programme consisted of problem-solving with an emphasis on

Abstract Depression and social isolation affect one in seven people over 65 and there is increasing recognition that social isolation adversely affects long-term health. Research indicates that interventions, which promote active social contact, which encourage creativity, and which use mentoring, are more likely to positively affect health and well-being. The purpose of this study was to evaluate a complex intervention for addressing social isolation in older people, embodying these principles: The Upstream Healthy Living Centre. Mentors delivered a series of individually-tailored activities, with support tailing off over time. Two hundred and twentynine participants were offered the Geriatric Depression Scale, SF12 Health Quality of Life, and Medical Outcomes Social Support scale at baseline, then 6 months and 12 months post intervention. Semi-structured interviews were conducted with 26 participants, five carers and four referring health professionals to provide a deeper understanding of outcomes. Data were available for 172 (75%) participants at baseline, 72 (53% of those eligible) at 6 months and 51 (55%) at 12 months. Baseline scores indicated social isolation and high morbidity for mental and physical health. The intervention was successful in engaging this population (80% of referrals were engaged in some form of activity). At 6 months, there were significant improvements in SF12 mental component, and depression scores, but not in perceived physical health or social support. At 12 months, there were significant improvements in depression and social support and a marginally significant improvement in SF12 physical component (p = 0.06), but the SF12 mental component change was not maintained. The qualitative data showed that the intervention was well-received by participants. The data indicated a wide range of responses (both physical and emotional), including increased alertness, social activity, self- worth, optimism about life, and positive changes in health behaviour. Stronger, ‘transformational’ changes were reported by some participants. Individual tailoring seemed to be a key mediator of outcomes, as was overcoming barriers relating to transport and venues. Key processes underlying outcomes were the development of a positive group identity, and building of confidence/self-efficacy. The Upstream model provides a practical way of engaging socially isolated elderly people and generating social networks. The data suggest a range of psychosocial and physical health benefits. Although there are limitations in attributing causality in uncontrolled studies, the data seem to indicate a reversal of the expected downward trends in some aspects of participants’ health, and suggest that this approach is worth further investigation.

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social and physical activation. After 12 months, depression had significantly reduced and health-related quality of life had significantly increased.16

A recent review of interventions to address social isolation in the elderly concludes that better evaluations are required.13 However, it also suggests that successful interventions may include elements of gate-keeping (identifying problems and connecting people with appropriate services), group support which enriches friendships and empowers participants, and other methods for active social network building.

EFFECTIVENESS OF INTERVENTIONS PROMOTING CREATIVE ACTIVITY Creativity has been described as a key factor in adaptation to ageing,18 and a number of community-based ‘art for health’ initiatives have been created recently in the UK.19 Some studies have suggested that engaging in creative activity has benefits for psychological well- being.20–22 One known mechanism is that creative interests can be used to increase and sustain social interaction among older people.22 However, creative activity is also held to be therapeutic in itself for psychological health.23–25 An association between attending cultural events (cinema, theatre, concert/live music, museums, art exhibitions and sermons) and physical health has also been reported. In a large prospective cohort study from Sweden involving 12,675 people,26 regular attendance at cultural events was independently related to mortality. In a qualitative study, Matarasso et al.24 identified 50 effects of participation in the arts, including increases in people’s confidence and sense of self-worth, increased involvement in social activity/reduced isolation, encouraging selfreliance, facilitating health education and building social capital.

The translation of such changes into health benefits has yet to be clearly demonstrated by high quality trials of specific interventions.19, 25 However, qualitative and observational evaluations of five community-based art and health projects in various parts of England25 indicate that participation in community arts projects may lead to less visits to GPs

particularly for depression, and a reduction in medication usage. In these studies, participation in art projects also helped people feel ‘part of a team’ and reduced social isolation. EFFECTIVENESS OF MENTORING APPROACHES The use of mentors has been recommended as a method for facilitating creative and social activity and to aid the promotion of psychological well-being and selfesteem.27– 29 Mentoring has also been demonstrated to be effective in facilitating behaviour change in elderly populations. A randomized controlled trial of using older people as mentors to educate and empower peers about their health found that those attending the mentor-led groups took more exercise and had better physical healthrelated quality of life than controls.30

In summary, interventions that promote active social contact, and encourage stimulating creative activity, with support and guidance from a mentor, seem to have potential for improving health outcomes in elderly, socially isolated people.

The research presented here forms part of the evaluation of the Upstream Healthy Living Centre. This is a mentored intervention for elderly socially isolated people, designed to provide individually stimulating creative activity and active (participatory and self-determined) social contact. This article focuses on the outcomes of the intervention, with the specific aims:

• to qualitatively identify the range and nature of impacts on participants; and

• to quantitatively assess the scale of likely impact in terms of participants’ physical and mental health.

METHODS

Design Qualitative research using semi-structured individual interviews and focus groups was conducted alongside an observational study with questionnaire-based health and social outcomes assessed at three time points (baseline, 6 months and 12 months).

Intervention The Upstream Healthy Living Centre is a community-based intervention operating on an outreach basis. Mentors work closely with participants, aiming to re-kindle their passion and interest in life by engaging in participant- determined programmes of creative, exercise and/or cultural activities, with an emphasis on social interaction. The intervention is individually tailored to suit each participant’s own interests and passions. Activity-based interventions are provided, with visits from mentors initially on a weekly basis, and regular telephone contact, which is gradually diminished as participants become more confident and able. A wide range of activities are provided including painting, print making, creative writing, reminiscence/living history, Tai Chi, movement/gentle exercise, computing, pottery, exploring sound and music, various craft work activities, quilting, falls awareness education, singing, hand bells, Walk and Talk groups, cookery, book clubs, and hearing school children read. Around 24% of referrals are signposted to existing community-based activities, with the remainder having activities arranged mainly by Upstream. Most participants attend group activities, although those with severe mobility problems receive intervention in their own home (around 9%). The mentors always seek to maximise opportunities for social interaction.

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The creative aspect of the intervention aims to maximize ‘stimulation’ (higher cognitive functioning). Tailoring activities to individual abilities and interests is intended to maximise the level of personal meaningfulness, thereby making activities more likely to be engaged with and sustained. There is also an explicit acknowledgement of the need to build selfefficacy (confidence about a participant’s ability to conduct activities and to maintain them as mentoring is withdrawn).

Despite differences in individual intervention pathways, the intervention is consistent in terms of the training given to mentors and the approach used. The mentors are trained in the Upstream ethos, mentoring principles and techniques (six hours over three sessions), working with elderly clients (five–six sessions with a clinical psychologist), risk management for home visiting, falls awareness and prevention, giving state benefits advice, and some basic first aid (as required). This is augmented by peer development sessions encouraging the sharing of ideas and solutions to problems. At least one mentor is in attendance at activities (usually in addition to the activity provider) to facilitate the participants’ enjoyment.

Upstream encourages participants to work towards maintaining and sustaining their own groups if they desire. This has involved help with finding venues, fundraising, setting up management committees, providing contacts for community transport schemes and for appropriate activity providers.

The evaluation focused on those receiving substantial mentoring input (excluding those who received simple signposting only).

Measures Qualitative measures Semi-structured interviews were developed through consultation with ‘key informants’ (Upstream staff, other researchers and participants from a prior pilot study).31 These were revised as needed to allow exploration of emerging themes. Relevant extracts from the topic guides are provided in Figure 1. Most were individual interviews, although some participants were interviewed with their carers, and one focus group was conducted. Data were

collected at different time-points, reflecting changes in the Upstream system over an 18-month period. Data were collected on processes as well as outcomes. However, this article is focused only on participant outcomes and factors that mediated these outcomes.

Quantitative measures Short form 12 (version 1): The SF12 is a widely used, self-administered 12-item questionnaire

with reliability and validity established in numerous studies.32, 33 It provides separate scores for physical and mental well-being. A combined (physical and mental) health utility score can also be derived for use in health economic analyses.34

Geriatric depression scale (GDS-15): The Geriatric Depression Scale is a widely used and validated 15-item measure of depression symptoms, designed for older people.35, 36 It is self-administered, and can be used as a screening tool with 92% sensitivity and 89% specificity when evaluated against diagnostic criteria.36 The scale can be used to identify mild depression (scores of 5–10) and severe depression (11–15). MOS social support survey (MOSSS): The

Medical Outcomes Study Social Support Survey (MOSSS)37 is an 18-item selfadministered questionnaire, measuring overall social support and four sub-scale concepts (emotional/informational support,

tangible support, affectionate support, positive social interaction). The MOSSS is not as widely used or wellvalidated as the SF12 or GDS-15, but has been shown to be sensitive to differences between patients with depression and with other chronic illnesses.38 Following feedback that participants found the questionnaires repetitive and somewhat tedious, it was decided to use only the three ‘positive interaction’ items, and three additional

items selected to represent aspects which we expected the Upstream intervention might affect (‘someone to do things with’; ‘someone to confide in’; and ‘someone to turn to for suggestions about personal problems’).

Demographic variables Data were collected on age, gender, perceived financial pressure, and any longstanding illnesses. Further demographic data were collected for the first 45 participants about health and social services usage, marital status, living arrangements (this was then stopped to reduce questionnaire burden).

Participants Upstream seeks participants ‘from their 50s onwards, whose lives may have changed or are about to change in some way (perhaps through retirement, moving home, age or illness), or people with time on their hands, or who might, for whatever reason, find it

Figure 1

Topic guide for participant and carer interviews (main questions with possible prompts in brackets)

What has been your experience of the Upstream Intervention? (description, evaluation, feelings)

What are the strengths and weaknesses of Upstream? (any difficulties with access, mobility, other barriers)

Have you noticed any changes in yourself since you became involved in Upstream? (physical and mental health, confidence, feelings)

Is there anything you feel you can do now that you couldn’t do before you got involved with Upstream?

(how does that make you feel) Do you think your attitude towards your health and/or happiness has changed since you became involved with Upstream? What impact, if any, has Upstream had on your social life?

(any new friendships, activities, group memberships) What are the key things that make it work/stop it working?

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difficult to keep in touch with the local community and would enjoy the opportunity to share their interests, skills and enthusiasm with others’ (from Upstream’s guidance for referral sources). Participation is restricted to people in the Mid Devon Primary Care Trust area, with no mental or physical health problems which might make them a danger to others or that require special nursing care when attending activities.

Upstream recruits participants through a community networking approach. This includes approaching health and social services staff, churches, voluntary organizations, existing local groups, and the residential care/assisted accommodation sector. Introductory leaflets and posters are also distributed through these outlets.

Participants for qualitative research Between July 2003 and December 2004, a sample39 of Upstream participants were purposively selected to maximise variation in age, gender, level of mobility and financial status. Where applicable, carers were also invited to take part. This produced individual interviews with 18 Upstream participants (11 female, seven male) five carers (three with participant present), and one focus group involving a further eight participants (all female). Four health professionals referring into Upstream were also interviewed. Participants for quantitative research All (229) of Upstream participants who took up Upstream’s offer of support, and who were not immediately ‘signposted’ to community-based activities, were invited to complete questionnaires.

Analysis Qualitative analysis The qualitative data were taped and transcribed and subjected to qualitative content analysis40, 41 by an experienced qualitative researcher (LF), who also conducted the interviews. This involved extracting concepts and broader themes from the interview transcripts and constant comparison between emerging themes and the raw data. Some theoretical sampling (selection of participants or new questions to develop emerging ideas) was used, and the data were frequently revisited to crosscheck and develop ideas. Participants’ responses were partially validated within interviews by periodically

asking them for confirmation or refutation of withininterview summaries provided by the interviewer. Participants were also asked to discuss themes that were emerging from the ongoing analysis.42 Extensive memos and a reflexive diary were kept to monitor the researcher’s thought processes and to minimize the subjectivity of the analysis. Two further qualitative researchers at the Peninsula Medical School were asked to comment on detailed draft reports and to validate the connection between the analytic themes and the quotes used to ‘ground’ these interpretations.43, 44 Any queries about interpretation were resolved by discussion, with agreement being reached in all instances.

Quantitative analysis Data were entered into SPSS V11.0. Data entry was double- checked and range and outlier analyses used to identify errors. Questionnaires were scored according to the developers’ instructions, with missing values imputed where 75% or more of other items in the scale had been completed. Mean outcome scores were compared from baseline to follow-up with separate analyses at 6 and 12 months, using two-sided related samples t-tests.

Procedure For the quantitative research, Upstream mentors invited participants to take part, and assisted completion of questionnaires if required (appropriate training was given). Follow-up measures were administered 5–6 months and 10–12 months after the first mentor visit. The Upstream administrator provided monthly reminders to trigger follow-up questionnaires. For the qualitative research, inspection of an anonymized version of the Upstream database was used to facilitate the purposive sampling. Candidates were then approached by letter with a follow-up phone call to arrange appointments. Ethical approval was provided by N&E Devon NHS Local Research Ethics Committee.

RESULTS Qualitative results The feedback from participants, carers and health professionals was generally positive, with the vast majority speaking highly of the quality and appropriateness of activities, and their enjoyment of them. A wide range

of benefits was reported, which could be broadly classed as psychological, social and physical health benefits. Only three of the 18 individually interviewed participants reported no change in their mood or health-related behaviours since they became involved with Upstream.

Psychological and social benefits Within the data, one of the strongest themes was the perception of psychological benefit, which was reported by carers and health professionals, as well as participants. This was tied up to a large extent with increased social interaction and the perceived quality of these interactions. The range of psychological and social benefits is summarized in Figure 2. The vast majority of participants reported increased confidence in engaging in new activities, and in interacting socially with others. (Key to quotes: P = Upstream participant; C = carer; HP = health professional.)

‘P2018: I’m doing something different. I’m achieving something in me old age that I didn’t think I’d be able to do.’

The sense of increased optimism, selfworth and willingness to engage in life evident in the data suggests that the intervention was particularly effective in ameliorating depressed mood and loneliness. Indeed four participants talked specifically about Upstream acting like a ‘catalyst’ that speeded their recovery from depression.

‘P3014: What Upstream has done is make me feel that I belong, whereas coming down as a stranger . . . I feel more part of [this town] now. I really do because I was dissolving into tears for my old friends, but that hasn’t happened now for 4, 5 months, which is a good thing.’

‘P3001: I really do feel I’m that lucky that, for whatever reason, the switch has turned and I’m now doing things I never dreamed I would be doing before, like working at the volunteer bureau. . . . I think it [Upstream] accelerated my recovery. . . . Having started to suddenly feel better, everything I did made me feel it all has a knock on effect.’

Psychosocial benefits were apparent in the vast majority of cases, with all but two participants voicing their enjoyment of the social interaction. Several participants reported calling each other between sessions.

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Physical health benefits Evidence of improvement in physical health was not as common, but there were indications that Upstream had encouraged a number of participants to take better care of themselves, and improvements in a range of health behaviours were reported. These included better adherence to medication/self-care regimes, better quality of sleep, reduced alcohol consumption, increases in the amount and type of exercise, and greater attention to diet.

‘P3007: Instead of only having an hour at a time like before, I’ll sleep 5 or 6 hours at a time now. I wake up feeling that much better.’

‘C001: This is a man who would only eat banana sandwiches up until last October. Now he’s cooking himself proper meals, and steaming all his vegetables.’

Four of the 18 individual interviewees provided striking testimonies of stronger, ‘transformational’ change, affecting multiple aspects of their lives. These reports typically included an increased sense of meaning in life, increased social and physical activity, and more attention to self- care.

‘P3001: I still have osteoporosis, I still have collapsed vertebrae . . . I can’t walk more than 40 yards . . . But I’m better now than I was in 1999 before I was ill . . . I don’t get agitated about things. I think I’m much more able to sort loads and loads of different things . . . Now I’ve woken up from the fog it’s like I’m really enjoying my life as though this is what I’m meant to be doing now.’

‘HP003: She said, ‘I never go out except to the shops every day because all my friends are dead. My husband’s dead, I

don’t have any children’ . . . She doesn’t read and she doesn’t have hobbies . . ., and so her life was absolutely a barren desert. So then I got Upstream involved and they did some home visits and gradually introduced her to this little art group and . . . she’s made friends and she’s a new woman. She’s not depressed and withdrawn as she was. She’s got confidence and I think that’s terrific . . . She’s cheerful, she has got a brighter step and . . . it’s just opened up new horizons for her and made her life better. It gives them confidence. It gives them value.’

Overall, the data suggest that Upstream was successful in socially re-integrating people who were previously isolated. This seemed to be facilitated by providing a non-threatening forum in which people could be offered and mutually share social support (for example, sharing transport, material, skills, encouragement, information). No significant negative outcomes were reported, although this information was actively sought.

Factors mediating the impact of Upstream

Issues of access and availability of appropriate activities were crucial prerequisites for engagement. Transport in particular was a frequently reported barrier preventing people from being able to see each other or attend activities as much as they would like. The appropriateness of the venue was also important.

Enjoyment of activities also seemed to be mediated by the extent to which mentors could tailor activities to individual abilities, preferences, health status, social skills and confidence. The issue of health/ability also mediated the amount

of mentor input needed, and those with more severe health problems/disabilities required ongoing mentor support.

‘P3002: It’s something to do, something I’m interested in. Like participating in that magazine thing was a brilliant idea. I’ve never . . . written anything or put anything in words like that in my life! I’m not very good, but I like it and that’s it . . . it’s going to become a hobby soon.’

The main factors which mediated the maintenance of activities and the derivation of benefits seemed to be building confidence/self-efficacy in the individual, and the creation of positive social dynamics. A key factor was the ability of mentors to empower participants (building confidence and selfdetermination) to (1) try out and succeed at engaging in activities, and (2) to be able to engage socially in their groups.

‘P2015: If you do something strange or new you’ve got to start at the bottom. It’s no good trying to go in half way up.’

‘P2012: The fact that somebody was going to come and see me on a regular basis because the other thing that I’ve

Figure 2

Range of benefits reported by Upstream participants

• Reductions in depression and loneliness

• Increased alertness or cognitive awareness

• Potentially reduced risk of falls (related to alertness)

• Increased well being and optimism

• Less dwelling on concerns or worries,

• Better sleep

• Increased social interaction and community involvement

• Increased quality of social interactions

• Increased sense of self-worth and willingness to engage in life

• Collateral benefits for carers and family (seeing loved ones enjoying life more, and respite opportunities)

• Increased physical activity, more energy

• Healthier diet and less heavy drinking

• Less health visits, reduced medication use

• Facilitated the rehabilitation of co-ordination /mobility post-stroke

• Increase in hobbies and activities outside of Upstream

• Increased enjoyment of life

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suffered really with is a fear of abandonment. . . . It makes you feel . . . like somebody’s bothered about you. Yes, somebody cares. I would say it’s things like that that give people a bit of purpose, a bit of encouragement. . . . Going back to [all the new things I’ve be doing], I wouldn’t have the confidence to do half those things a couple of months ago.’

Quantitative results Engagement in activities Progress was tracked over 6 months for 320 participants who had been referred to Upstream by the end of February 2005. This showed that 255 (80%) had been engaged in some kind of activity, with 62 of these being directly signposted to community-based activities. Of the 193 receiving ongoing input from Upstream, 171 (89%) were still engaged in activities after 6 months. The main reasons for nonengagement were ill-health, or participants deciding that Upstream was not suited to them.

Response rates On 30 September 2005 (the data collection cut-off date), Upstream had engaged 229 participants in activities (excluding signposting). Of these 172 (75%) provided baseline data. At this time, 136 participants were eligible for 6-month follow-up and 72 (53%) provided data (mean follow-up time 5.5 months). For 12-month follow-up, 93 participants were eligible and 51 (55%) provided data (mean follow-up time 12.0 months).

Response bias analysis There were no significant differences between responders and non-responders either at 6 months or at 12 months in terms of age, financial status, gender or baseline SF12 or social support scores. Non- responders at 6 months had more depressive symptoms at baseline than responders (MD = 1.2, t(131) = –2.17, p < 0.05), but there was no significant difference at 12 months. No significant response/dropout biases were detected between 6 months and 12 months in the 6 month SF12, GDS-15 or social support scores.

Sample characteristics Of 172 participants providing baseline data, 76% were female, and the mean age was 77 (52

to 96). The baseline health status scores are shown in Table 1. A quarter (25%) reported having some financial pressures. Participants had poor physical and psychological health at baseline, commensurate with high levels of loneliness and social isolation in that:

• 74% had at least one longstanding physical health impairment which limited activities. The most common reported problems were musculoskeletal/mobility problems, diabetes and heart disease (inc stroke), and respiratory illness.

• SF12 health quality of life scores were

significantly lower than norms for US over-75s and the general UK population (Table 2) for both mental and physical health (one-sample t-test, p < 0.001, p < 0.01, respectively). As SF12 general population means are better in the UK for mental health (52.1 vs. 50.0 in the

USA) and similar for physical health (50.9 vs. 50.8),45 Upstream’s population

are also likely to be substantially below UK norms for over-75s.

• 53% had clinical depression based on their GDS-15 scores (45% mild; 8% severe).

Further demographic data from the first 45 participants showed high levels of

service usage in the last 3 months (73% used the NHS with a mean 2.5 GP visits; 53% used social services). Of this early sample, 64% were widowed, 73% lived alone and 93% were retired.

6-month follow up The data (Table 3) showed a statistically significant increase in SF12 mental component score (MD = 3.02, 95%CI: 1.01 to 5.04, p < 0.005). There was also a statistically significant reduction in depressive mood (MD = 0.60, 95%CI: 0.14 to 1.05, p < 0.02). However, there was no significant increase or decline in SF12 physical health, overall health utility, or

social support scores.

Individual benefits/clinical meaningfulness A clinically meaningful change for SF12 scores is considered to be 2 points,46–48 and 60% of participants experienced this level of change in mental

component score. We assumed that a six- point change in mental component score (equivalent to a 25 percentile shift in population ranking48) represented strong change, and 30% experienced this level of change. The number with clinical levels of depression fell from 32 (45%) to 25 (35%).

12-month follow up

Table 2

Mean SF12 scores for Upstream participants and population norms

SF12 Domain Upstream US over-75s UK general population

Mental health 46.8* 50.1 52.1

Physical health 36.4* 38.7 50.9

Note: *Data converted to 1998 Scoring system for comparison purposes

Table 1

Baseline health status scores

Measure Mean (SD) N

SF12 MCS 47.0 (11.1) 166

SF12 PCS 35.3 (11.2) 166

GDS-15 5.35 (3.42) 169

MOSSS (six-item) 1.79 (1.13) 164

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The 12-month data provided a slightly more mixed picture. The improvements in depression scores were maintained (MD = 0.57, 95%CI: 0.02 to 1.11. p < 0.05). The difference in SF12 physical component scores now came close to (but did not quite achieve) significance (MD = 1.57, 95%CI: – 0.08 to 3.22, p = 0.06). MOSSS scores also improved significantly (MD = 0.20, 95%CI: 0.03 to 0.37, p < 0.05). However, the improvement in SF12 mental component scores decreased and was no longer significant (Mean improvement = 0.71 points, n.s.). Overall health utility scores (combining SF12 mental and physical components) improved significantly between baseline and 12 months (MD = 0.027, 95%CI: 0.002 to 0.052, p < 0.05).

DISCUSSION Both qualitative and quantitative data indicated that the health status of elderly socially isolated people taking part in creative and social activities with individualized mentor support improved meaningfully over time. The initial benefits seemed to be primarily in psychological well-being and reduced depression, with perceived social support and overall health utility benefits emerging after 12 months. Although the improvement in depression scores was maintained at 12 months, the improvement in SF-12 mental component score was not. The qualitative feedback indicated a range of benefits, with psychosocial benefit and depressed mood being the most widely reported.

Possible explanations of the data Do these data represent improvements in health status caused by the Upstream intervention?

It is worth considering the expected trends in mental and physical health for this

population, and to ask to what extent their health might have improved in the absence of the intervention. We do not have detailed information about physical health problems in the sample at baseline, although there was a high prevalence of longstanding, non- remitting illnesses (see sample characteristics). Life expectancy at age 77 is only 5–8 years,49 and so a downward trend might be predicted. Indeed, longitudinal studies of ageing in the general UK population show a clear trend of declining physical and mental health with age, with a more dramatic decline in women.50–52

It is also worth considering the specific issue of whether depression would be expected to improve in the absence of the intervention. To address this we conducted a brief review of the literature, looking at outcomes for control groups in randomized controlled trials of treatments for depression in older populations, which used

the GDS as an outcome measure. Six such studies were identified in which the control

groups had no intervention provided (and no information about their depression status was passed to their care providers, thereby prompting treatment). These studies involved 1,027 control subjects, with follow-up times of 2 to 9 months.53–58 The weighted mean effect size (the difference in means divided by the standard deviation) was –0.002, indicating no change in depression scores.

Given the above data on normative trends, it seems possible that the reported results may tend to underestimate, rather than overestimate the benefits. The qualitative data also seem to support the hypothesis that Upstream had beneficial effects. However, without a

control group to provide data on a rigorously matched population, we must be cautious not to over-interpret the data.

No short-term changes in social support were observed, although a significant improvement emerged after 12 months. This is consistent with the idea that improvements in perceived social support which generalised beyond the context of Upstream activities (and would therefore be detected by the MOSSS scale) take longer than 6 months to develop.

The rise and then fall of SF-12 mental component scores over time requires careful consideration. One possible explanation is that any psychological wellbeing effect is only short term. However, this is not consistent with the depression scores, where benefit was maintained. A further explanation is that there may be a degree of ‘normalization’ of benefits, as a number of SF-12 items relate

Table 3

Baseline and follow-up scores for responders at 6 and 12 months

Measure Baseline N 6 months p value for mean (SD) mean (SD) t-test*

SF12 MCS 48.1 (9.94) 70 51.1 (10.8) 0.004

SF12 PCS 36.1 (10.9) 68 36.1 (11.3) 0.996

SF12 Combined (health utility)

0.627 (0.099) 68 0.643 (0.128) 0.140

GDS-15 4.46 (2.88) 69 3.86 (3.17) 0.011

MOSSS (6-item) 1.98 (1.11) 68 2.04 (1.03) 0.464

Baseline N 12 months

mean (SD) mean (SD)

SF12 MCS 47.7 (10.0) 51 48.4 (11.6) 0.654

SF12 PCS 35.6 (10.7) 50 37.1 (11.1) 0.062

SF12 Combined (health utility)

0.606 (0.089) 51 0.633 (0.117) 0.035

GDS-15 4.84 (3.05) 51 4.28 (2.74) 0.041

MOSSS (6-item) 1.88 (1.18) 50 2.08 (0.99) 0.021

Note: *All t-tests were two-sided

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current health status to the participant’s ‘usual’ state (for example, limitations are expressed in relation to regular daily activities). With no control group against which to contrast results, it is not possible to determine the true explanation. Relation to other literature The findings are consistent with the literature discussed in the Introduction. The qualitative data support the idea that mentoring is a useful technique for motivating social interaction, and health behaviours in older people. Both qualitative and quantitative data supported the idea that increasing active social participation improves psychological well- being, with possible knock-on effects for physical health in the longer term. The creative aspect provided a useful and enjoyable way to engage people, as creative activities are very amenable to tailoring to a wide range of individual abilities and interests. The qualitative data indicated that this individual-level tailoring was key to engaging people in activities, and thereby in social situations. Discussion of participants’ creative efforts and created works also provided a basis for ongoing social interaction and mutual support. Further value may derive from the sense of achievement and self-esteem imbued in successful completion of creative works.

The qualitative data suggest that the association between physical health and creative/social activity may stem from increases in mild physical activity, as well as from improvements in self-care and health behaviours following improved psychological outcomes. It is known that positive effects on health are associated with even small changes in physical activity.59–61 Encouraging social interaction and creative activity may also increase cognitive activity, and the generation of positive group identities may lead to further increases in self-esteem and self-worth.62, 63

The data seem consistent with the conclusion of a recent review of the literature that (although rigorous controlled studies are lacking) there is ‘contingent evidence that participation in leisure and social connections produce social inclusion and mental/physical health benefit’.64

Methodological strengths and weaknesses

The use of qualitative and quantitative data together was useful in that the qualitative data reinforce and add depth to the quantitative results, as well as helping to understand the processes by which benefits may accrue. The quantitative data in turn help to establish the transferability (at least within the Upstream population) of the qualitative data about outcomes. In terms of broader transferability/generalizability, it is likely that the findings would be applicable to similar interventions in a range of contexts, although some issues like transport as a barrier may apply less in more urban settings and alternative barriers may arise. The dedication and abilities of the mentors delivering the intervention is also a key contextual factor that would affect transferability.

Further limitations of this study include the lack of a control group, and the relatively low sample size at 12 months (where the power to detect differences was diminished). While some comparisons with external control groups/data sets were possible, this technique has its limitations.65

Future directions Despite the difficulty of conducting controlled trials of community-based interventions, future studies may be designed to apply the intervention techniques in a more controlled fashion. The use of a quasi-experimental design, whereby older people with similar baseline characteristics could be identified in different areas, intervened with differentially and outcomes compared may be feasible. The data from this study provide a good deal of useful background information for planning future trials of this kind of intervention.

CONCLUSION Engaging older people in creative activities, using an individualized, mentor- based approach may be one way of improving social networks, re-connecting people with their local communities, and ultimately improving their psychological and physical well-being. Although this study does not provide clear proof of this principle, the data seem to indicate a reversal of expected downward trends in some aspects of participants’ health, and are suggestive that this approach is worth further investigation.

Acknowledgements Participants. Dr Alyson Huntley who reviewed the depression literature for the Discussion. The Big Lottery for providing funding for Healthy Living Centres. All the dedicated and hard-working staff at Upstream HLC who helped to collect data. References

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