Together in song: Designing a singing for health group intervention for older people living in the community

ABSTRACT

Introduction

International research evidence on the physical, cognitive and social benefits of group singing for older people is growing rapidly. However, singing interventions are inconsistently reported, with details of intervention development, musical content and structure often omitted, impeding replicability and synthesis. This paper poses two research questions: (a) What specific guidelines for singing groups can the research team recommend for older people aged over 65 living in the community who have health and well-being concerns? (b) What recommendations can the research team make for singing group facilitators, building on two pilot studies and over 20 years of experience running singing groups?

Method

A detailed three-stage process of intervention development and evaluation was undertaken, following Medical Research Council (MRC) guidance.

Results

The findings of each stage of intervention development and the resultant tested intervention, which aims to meet the physical and psychological health and well-being needs of older people, are presented. Key features of the final intervention include flexible, person-centred musical content; opportunities for social interaction; and appropriate resources, such as large print songbooks. The results of the pilot studies indicate the capacity of group singing to benefit interpersonal relationships and social connection among older people, contributing to increased well-being.

Discussion

This intervention aims to contribute to the possibility of replicable large-scale studies of the impact of singing for health groups on the health and well-being of older people.

KEYWORDS:

• Singing
• older people
• choir
• singing for health
• community
• well-being

Background and objectives

International research evidence on the potential benefits of singing for the health and well-being of older people is expanding rapidly (Clift et al., 2018; Särkämö, 2018). Singing for health and well-being has become increasingly popular in recent years (Fancourt & Finn, 2019). Research to date on choral singing indicates many physical, cognitive and social benefits (Clift & Hancox, 2010; Clift et al., 2010; Moss & O’Donoghue, 2018). Studies suggest that singing can positively impact happiness and reduce levels of depression and loneliness in older adults (Bungay et al., 2010; Entezari et al., 2019; Johnson et al., 2020; Mathew et al., 2017). Johnson et al. (2013) discovered significant associations between choral singing and improved quality of life in 117 elderly Finnish choral singers, while controlling for age and depressive symptoms. Similarly, a study by Fu et al. (2018) suggests that a group-singing programme incorporating deep-breathing training and song-learning may promote aspects of cognitive function in older adults, including memory, language, speech information processing and executive function. Further, a study by Mansens et al. (2018) indicates that singing and music making are protective factors for cognitive decline and are associated with better attention, episodic memory, and executive functions. Hays and Minichiello (2005) also cite the contribution of music to positive ageing. A four-year case study by Lamont et al. (2018) highlights social relationships, meaning, and accomplishment as major reasons why older people perceive singing in a community choir to positively impact their well-being. These findings are supported by qualitative results of studies by Petrovsky et al. (2020), Skingley et al. (2016), and Davidson et al. (2014).

A systematic review by Williams et al. (2018) indicates that group singing could be a promising social intervention for people with mental health conditions. A randomised controlled trial by Coulton et al. (2015) reported that community group singing appears to have a significant effect on mental health-related quality of life, anxiety and depression of older people, in addition to being marginally more cost-effective than usual activities. Zhao et al. (2016) conducted a systematic review and meta-analysis of music therapy for older adults with depression, which suggested that music therapy can reduce depressive symptoms when added to standard care. This finding is supported by Murabayashi et al. (2019) who conclude that music therapy may improve physical function, depressive mood, and quality of life in frail older people.

Several empirical research studies have also explored the value of singing for older people with long-term health conditions, including Parkinson’s disease and stroke, respiratory illnesses, and dementia (Clift et al., 2017; Pentikäinen et al., 2021; Tamplin et al., 2019). A qualitative study conducted by Fogg-Rogers et al. (2016) found that participating in a community music therapy choir helped people with Parkinson’s disease and stroke self-manage social isolation, communication difficulties, low mood and other consequences of their conditions. Stegemöller et al. (2017) discovered that an 8-week singing intervention can significantly improve maximum inspiratory and expiratory pressure, as well as phonation time, voice quality of life, and whole health quality of life in people with Parkinson’s disease. This study suggests that singing may provide a beneficial and engaging alternative to voice and respiratory therapies for improving and maintaining vocal function for this population (Stegemöller et al., 2017). Similarly, a systematic review conducted by Lewis et al. (2016) suggests that singing has the potential to improve health-related quality of life of people with respiratory diseases, without causing significant side effects.

The effects of music and singing on older people living with dementia has been a major focus of research. Elliott and Gardner (2018) conducted a systematic review, which found that music offers a promising alternative therapy for older adults with dementia living in community settings. Music was shown to have the following benefits: decreasing agitation, improving cognition, and fostering social connections (Elliott & Gardner, 2018). A systematic review of live and recorded group music interventions with active participation for people living with dementia by Clare and Camic (2020) similarly reported a positive impact on some behavioural and psychological symptoms experienced by people living with dementia. It indicated that group music interventions can maintain elements of cognitive function, improve aspects of voice-related quality of life and reduce stress (Clare & Camic, 2020). This review included studies in both community and residential settings. However, van der Steen et al. (2018) systematic review of music-based therapeutic interventions for people with dementia discussed that most research has been carried out in long-term care facilities and acknowledged the potential for community-based strategies. Similarly, a systematic review by Young et al. (2016) recommended additional research into therapeutic and non-therapeutic community-based music interventions for people living with dementia.

The effects of community singing groups on people living with dementia and their family carers and spouses has been explored qualitatively in several studies (Camic et al., 2011; Clark et al., 2018; Osman et al., 2016; Unadkat et al., 2017). Findings suggest that they can help participants to accept and cope with their diagnosis; positively impact relationships, social confidence, memory, mood, and well-being; and may provide the opportunity for the development of empathetic friendships and mental stimulation (Camic et al., 2011; Clark et al., 2018; Osman et al., 2016; Unadkat et al., 2017). Quantitative measures, such as pre- and post-psychological measures, have also been utilised in studies to investigate the effects of community singing groups on the well-being of these populations (Camic et al., 2011; Mittleman & Papayannopoulou, 2018; Tamplin et al., 2018; Walters et al., 2019). However, the results have been mixed, and issues raised around the suitability and relevancy of the measures utilised (Camic et al., 2011; Tamplin et al., 2018).

The majority of singing for health groups are designed to be condition specific (for example Huang et al., 2021). However, a study by Price and Whitfield (2018) suggests that people may prefer attending a general singing for health group, as opposed to a condition specific one, as it can remove the stigma of their condition, foster feelings of empathy, be a distraction from ill-health, generate larger numbers and reflect society as a whole. Provision of a general singing for health group may also be more cost-effective.

Although research suggests that group singing is an effective way to engage older adults in the community and can benefit their health and well-being, the recurring limitations of studies in this area need to be acknowledged (Petrovsky et al., 2020). Heterogeneity of methodological design regularly prevents the synthesis of results in systematic reviews and meta-analyses, and issues with methodological rigor, quality of reporting, quality of evidence, bias, and sample size have been highlighted (Clift, 2012; Daykin, 2019; Lewis et al., 2016; Van der Steen et al., 2018; Williams et al., 2018). For example, in the latest Cochrane review on music-based therapeutic interventions for people with dementia (Van der Steen et al., 2018) the evidence was largely described as low-quality (with the exception being moderate-quality evidence that the interventions reduce depressive symptoms). Considerable further research which addresses these limitations is warranted before the benefits observed in the studies described can be generalised.

Additionally, there is a relative paucity of researched and developed singing interventions for the health and well-being of older people in the community. Conceptual clarity regarding the nature of singing and an understanding of which approaches might be most useful is recommended (Dingle et al., 2019; Linnemann et al., 2017; Williams et al., 2018). Guides published by the Sidney de Hann Research Centre for running specific clinical health singing groups and project evaluations provide valuable insights into designing a singing intervention for older people (Morrison & Clift, 2012a, 2012b; Page, 2014; Vella-Burrows, 2012; Vella-Burrows & Hancox, 2012). However, music interventions are inconsistently reported in studies of programmes for older people, with many providing very limited information and others describing some aspects in detail while other aspects are omitted. Areas of omission frequently include details of development of the intervention design, musical content and the qualifications of the facilitator (Vink & Hanser, 2018). This can impede their replicability, synthesis, and the opportunity for sub-group analysis (Van der Steen et al., 2018). Some notable exceptions exist (Buetow et al., 2014; Harris & Caporella, 2019; Mittelman & Papayannopoulou, 2018; Tamplin et al., 2018). However, details of musical content and structure of sessions are generally limited. The insufficient attention given to musical content of most interventions in research to date indicates the need for a well tried and tested structure for singing groups for older people in the community. The aim of this paper is to answer two research questions:

• 1. What specific guidelines for singing groups can the research team recommend for older people aged over 65 living in the community who have health and well-being concerns?

• 2. What recommendations can the research team make for singing group facilitators, building on two pilot studies and over 20 years of experience running singing groups?

Method

This singing intervention seeks to meet the needs of older people who are referred to community singing groups to address physical and psychological health and well-being needs, including reducing social isolation, preventing cognitive decline and increasing exercise and motivation. Referrers to such groups include family members, clinical staff discharging older people from hospital, community clinical therapists, link workers connecting older isolated people to community resources and public health nurses.

Design

This paper follows the Medical Research Council (MRC) influential guidance on developing and evaluating complex interventions (O’Cathain et al., 2019). Three activities informed the intervention presented here. The process of development is set out in Figure 1

Figure 1. Diagram of the development of the singing intervention

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Ethical considerations

Ethical approval for this work was provided by the Arts, Humanities and Social Sciences Research Ethics Committee at the University of Limerick and the University Hospital Limerick Ethics Committee. Informed, written consent was obtained from all participants.

Designing the singing intervention

The initial design of the group singing intervention for older people in the community was based on:

• 1. Literature review (see introduction)

• 2. The findings of semi-structured individual interviews with three music therapists and three community musicians with specialisms in dementia care; three people living with dementia; and three family carers. The interviews with music therapists and community musicians included questions that explored their experiences of working with people living with dementia and the practicalities of facilitation. Use of music before and after diagnosis; experience of diagnosis and living with dementia; and opinions of non-pharmacological interventions were discussed in interviews conducted with people living with dementia and family carers. Results of these interviews are presented in Lee (2021).

• 3. The reflections of the first author, a music therapist with over 20 years of experience, on her work and practice. This was collected via journal notes of over 30 groups she has worked with and the interventions she used while working.

• 4. Examination of existing protocols/guides for facilitating group singing with older people in the community

Piloting the singing intervention

Two singing groups for older people in the community were piloted from 2019 to 2020.

Pilot 1 was conducted with 10 older people (n = 10) in the community who had recently been discharged from hospital. It aimed to test the intervention and the feasibility of the singing group as a support for the health and well-being of this population (Clifford et al., 2021). The group ran for twelve weeks. Pilot 2 was for older people living with early-stage dementia in the community and their family carers (Lee et al., 2020). It sought to investigate the effects of group singing on the well-being of these populations and elicit feedback on the intervention. This group ran for six weeks and had a maximum of 12 participants (n = 12). Participants in both Pilot 1 and Pilot 2 were people aged over 65 and their family carers, living in the community with a long-term complex health condition that interrupted regular social interaction with others. All were at risk of social isolation due to dementia or recent hospital stay. People excluded from the study were cognitively unable to complete assessments and undertake an interview. Details of participant inclusion and exclusion criteria, sampling and each group’s aims can be found in the individual reports of these projects (Clifford et al., 2021; Lee et al., 2020).

These projects were part of a wider suite of research activities by the authors. Design of this intervention arose from an awareness that the testing of these two group interventions simultaneously afforded an opportunity to distil learning into a replicable group format for use by others facilitating community singing groups for older people with complex health needs.

Both groups were facilitated by credentialed music therapists. Previous work by the first author has presented a continuum regarding music and health practice, whereby many music professionals facilitate singing for health groups (Moss, 2016, 2020, 2021). In this case, music therapists were chosen for their evidence-based approach (applying clinical evidence of benefit to practice and having clinical as well as artistic aims) and their Masters level training in the field of music and health.

Refining the singing intervention

Feedback on the piloted singing interventions was captured through semi-structured interviews with participants and clinicians. All participants who completed Pilot 1 and seven participants of Pilot 2 participated in an exit interview. Data in Pilot 1 were analysed using thematic analysis. Data in Pilot 2 were analysed using Interpretative Phenomenological Analysis (IPA). Different analysis methods were used as these were separate studies with other research aims, which warranted this research method. Pilot 1 was a feasibility study combining quantitative and qualitative data, so the qualitative data was analysed using thematic analysis as part of a larger study (Clifford et al., 2021). Pilot 2 was an in-depth exploration of the experience of fewer people with dementia and family carers who engaged in a singing group and IPA was selected to explore participants’ in-depth lived experience (Lee et al., 2020). The full method for IPA analysis is provided in a separate publication (Lee et al., 2020).

The analysis process to combine learning from the interviews in both pilot studies, journaling of the first author and the literature review followed steps 1–6 of Braun and Clarke’s (2006) six steps of data analysis, namely: (a) Become familiar with the data; (b) Generate initial codes; (c) Search for patterns or themes in your codes across the different interviews (and in this case, literature and journal notes); (d) Review themes (in this case review group interventions previously used and refine); (e) Define and name themes; (f) Produce your report (in this case the intervention).

Details of this process included comparing group design for similarities and differences; comparing themes from qualitative feedback with journal notes from the first author; and cross referencing the literature in this area. In both studies, several researchers engaged in data analysis to verify results.

The first author also reviewed, through journaling and previous publications, all the group singing interventions they had worked on previously. These data were used as part of an iterative process to refine the group intervention, combining findings from interviews, and review the evidence of existing interventions and literature review, to determine a structure for a singing group intervention for older people living in the community.

The resulting intervention is presented as a result of an iterative data analysis process, including discussion between researchers, rereading of the data and reading literature.

Results

Thematic analysis of the interviews from Pilot 1 revealed three themes of importance to those engaged in the community singing group: (a) Pleasure and Purpose; (b) Anticipation and Social Inclusion; and (c) Health Benefits: Physical and Emotional Well-being (Clifford et al., 2021). Thematic analysis of clinician evaluations included: (a) Importance of Enjoying the Arts; (b) Interpersonal Relationships; and (c) Supports and Scaffolds (Clifford et al., 2021). IPA analysis of Pilot 2 revealed revealed four superordinate themes: (a) Social Connection; (b) Happiness and Rejuvenation; (c) Reconnection with the Self; and (d) Supporting the Carer–Cared-for Relationship (Lee et al., 2020).

Both pilot projects were positively received by the participants (Clifford et al., 2021; Lee et al., 2020). There was general consensus from participants and stakeholders of the potential for the singing interventions to benefit interpersonal relationships and social connection, contributing to increased participant well-being. Similarly, the singing groups were identified as being highly enjoyable and their ability to enhance mood was widely recognised.

“I would come back. I feel it’s good for me. It gets me out doing something and meeting people.”

“It helped me get back up to speed, you know, back to before I got sick there. Now I can go for a walk in the evening.”

“I don’t know whether it was that the singing sort of lightened your mood or whether it was just seeing my Dad just enjoying what he was doing and talking to other people.”

The social element of the music intervention was of particular interest. This supported the decision to design group, as opposed to individual, singing interventions, and to support social connection in the musical content (naming participants in songs; social warm-ups etc.), encourage discussion between songs and provide a space for informal conversations by offering refreshments before/after the singing session.

“It’s great… you get to meet people and mix with others.”

“When you’re coming into a new thing you don’t know what to expect and the people you’re going to meet […] Everything turned out perfect […] Everybody seemed to enjoy it, and everyone was able to participate in it.”

Participants in both studies identified several barriers that could impede the successful delivery of these interventions. These related to both practical aspects of organising the intervention, and the musical content. For example, late morning or early afternoon was identified as the optimum time for the singing group to run for this population, due to issues with transport, light, and diminished ability in the evenings and early mornings. Similarly, the participants valued the intervention being situated locally in a community setting, and ease of access, parking, and a consistent suitable space were identified as important elements for the success of the intervention. A space where light refreshments could be provided was also recognised to enhance the social aspect of the intervention. Additionally, one hour of music was seen to be an appropriate length for the intervention, and succeeded in rejuvenating the participants, as opposed to tiring them.

In relation to musical content, the flexibility of the music facilitators and their abilities to tailor the musical content to the participants was valued and recognised as a major contributing factor to the success of the interventions. In Pilot 2, for example, family carers expressed their appreciation that the participants could choose songs, share stories, and bring along a musical instrument if they liked, supporting their autonomy.

“It was great the way it was just very relaxed and free flowing [.] If someone wanted to play, they could. If someone wanted to sing, they could. If someone wanted to dance, they could […] He [FC’s Dad] could just be himself.”

It was also identified that the delivery of the singing session by the same music facilitator each week promoted feelings of stability and familiarity, and enabled participants to build a relationship with the facilitator. The lack of lyrics provided in Pilot 2 (until the final session) was identified as a potential barrier to participation by some participants.

“Having the words gave him the confidence to join in and sing new songs.”

However, other participants recognised that learning and remembering new lyrics by ear could provide cognitive stimulation, and that sharing songs encouraged social engagement, and suggested that both approaches should be employed together. The success of the large print song book in Pilot 1 similarly supports the use of printed lyrics for this population. Positive responses to the addition of instruments in both pilots (hand-held percussion instruments in Pilot 1; Irish traditional instruments in Pilot 2) similarly supports their inclusion. However, it was suggested that the quality of the sound should be monitored by the music facilitator.

Results from these two sets of data were combined iteratively with journal notes. Key recommendations incorporated in the final intervention include:

• 1. A large print songbook with large page numbers is needed. Songbook repertoire should be selected to give a wide variety of genres and artists, age appropriate to this client group, and consultation with participants should be encouraged in creating this songbook so as not to assume preferences based on age. Space to add additional songs suggested over the course of the sessions should be provided.

• 2. A flexibility and willingness is needed by the facilitator to improvise songs suggested by participants of the group and to alter the group structure and musical content to adapt to participants’ concerns, interests, needs, or wishes.

• 3. Flexibility about attendance and time-keeping is necessary. The aim of the group is to create a friendly, supportive space for all, and an awareness of how difficult some people might find it to attend the group is needed.

• 4. There should be no pressure to sing. People should be invited to choose songs or sing but there should be no pressure to participate.

• 5. Confidentiality and privacy should be maintained where possible. Participants attending may have a health condition that they do not wish to publicly disclose.

• 6. Practical aspects (location, space, transport, time of day, session length) need to be considered carefully, in line with the recommendations above. For example, consistent facilitator, time and day of session, creating a safe space in which people can relax and express themselves.

• 7. Time for social connection and interaction is important. For example, identifying songs of importance to individuals in the group, time for reminiscence and meaningful exchange of memories and meaning associated with songs, and opportunity for creative, spontaneous self-expression. Any group structure needs to have flexibility to allow for person-centred facilitation and spontaneous music making.

Recommendation: The final intervention

Duration, time of day, group size and environment

The authors recommend a session duration of 1 hour per week, with consistent and confidential time, place and facilitator. Longer sessions are difficult for older people with limited energy and concentration. Mid-morning/early-afternoon is recommended. Timing is important for people with dementia who often experience exacerbated symptoms in the evening. Mornings can be difficult for older people with physical difficulties as it can take them longer to get up and ready for the day. By mid – late afternoon sleeping/naps can be an issue if conducting a group. Flexibility regarding participants’ timekeeping is recommended, given the many factors that can affect attendance. The authors recommend a group size of 8–10 participants. This allows enough participants to create a group but is small enough to have time for individual attention and flexibility of structure. A private room in a community arts centre is a suitable environment. Large windows to let in natural light and radiators to ensure comfortable temperature are recommended. Moving away from health care centres is significant in signalling a different sort of engagement (one participant noted: “Here, I am a musician, not a patient”). The authors recommend that participants’ chairs be arranged in a semi-circle, with the facilitator’s chair at the top.

Musical content

Each singing session should include a musical element (or several elements) that promote social connection, expression and creativity in-the-moment, as well as reminiscence and cognitive stimulation. For example, social warm-ups/games, singing in parts, and a goodbye song with participants’ names to promote social connection; improvisation and song-writing to encourage expression and creativity in-the-moment; familiar songs and storytelling to foster reminiscence; and the addition of harmony lines, songs in different languages and song rehearsal (dynamics/phrasing), where possible, to provide cognitive stimulation. During each session, the facilitator should strive to promote well-being; be person centred; create meaningful experiences for the participants; be flexible with the content and structure to respond to the participants (energy/mood/requests/needs); and promote interaction between participants, and within family dyads, where appropriate.

Session structure

Each session should follow a flexible structure, driven by the participants. Sessions should have a regular ritual at their beginning and end. Sessions should include a warm-up, welcome song, choosing songs to sing, discussion, goodbye song, and refreshments. However, distinctions between groups will always exist, reflecting both the nature of the facilitators and their responses to the participants.

The warm-up should include gentle physical upper and lower body stretches and movements, warming-up facial muscles, and a vocal warm-up. Physical warm-ups could include lifting arms to a comfortable level, being mindful of the differing capabilities of participants. We recommend physiotherapy input to advise on suitable stretches. Breathing exercises should be used to ease anxiety and relax any tension in the body. A range of vocal warm-ups are available to facilitators. However, pitch should be considered carefully to ensure that group members are singing in a comfortable vocal range. Warm-ups can be completed in a seated or standing position.

The facilitator should focus the first activity on making each participant feel welcome and comfortable. A song may be used to welcome the group, singing each person’s name and introducing them to the group (for example, Hello Dolly adapted to sing “Hello Mary” … “Hello Sean”). Ideally, the group should sing together, and the facilitator should include each participant’s name to welcome them individually. Each participant can also be offered an opportunity to talk about their week when their name is sung. This is an important technique in music therapy as it uses music to promote and validate the individuality of each person in the group, whether cognitive understanding levels are high or low. It is something that may differ from a choir director’s regular approach. Another option is to greet and chat to each participant as they arrive and connect with each participant verbally in the welcome section.

During each session, all the participants should be given an opportunity to pick a song for the group to sing, which in turn may evoke conversations and memories of the past. A songbook should be provided at the project outset and the participants encouraged to pick songs from the book or to choose and sing songs from memory and learn new songs by ear. Again, use of books and lyrics can cause anxiety in some people with cognitive difficulties while for others this can be very useful, so facilitators should follow the group to meet this need appropriately. The participants can be encouraged to perform songs they like for the group, or suggest songs for the group to sing together. The music facilitator should also select familiar and new songs to sing. The facilitator may wish to choose a theme for each session and select songs in relation to this. At the final session, each participant can be presented with a songbook or recording to keep containing the lyrics and chords to the songs that have been sung during the intervention, including any songs that the participants composed together.

The facilitators should gently encourage discussion between songs by asking participants to name their favorite songs, talk about the songs or any memories they sparked, or to react to verbal or musical material provided by other participants. This can be a free-flowing experience. For example, participants may choose songs, describe their memories of live-performances/concerts and share their concerns and struggles. Facilitators should gently support participants with structured suggestions or step back to allow peer support to flourish, depending on the situation. If a person is bereaved, or brings up a painful experience to the group, the facilitator should support this by listening, singing a relevant song where appropriate, or conducting a mindfulness and music-based relaxation exercise. It is important to note that we recommend training in verbal interventions and mentoring or supervision to debrief after sessions. Close liaison with relevant clinicians is also recommended should a participant reveal issues that need to be supported after the group. Ideally, the facilitator will have therapy skills to be able to respond to verbal interactions meaningfully and to support emotional expression.

The session should conclude with the same song each week. This song can be chosen from a relevant genre or created for the group. For example “Hit the road jack” (using altered words “hope to see you next week”) with each individual name could be used. This aims to encourage participants to come back the next week and to create a sense of belonging to the group. Tea, coffee, biscuits and social time should be provided before and/or after the session. This is important for the development of peer support and community, and to provide a space for informal connections to be made that could last beyond the life of the facilitated group.

Additional elements

“Homework” could be considered. Participants could be asked to listen to the music they enjoyed and sing along at home, make a playlist of favorite music, or do 10 minutes of music and mindfulness each day. However, whilst this is common practice for other community-based clinical therapy programmes, it is not something reported frequently in community singing groups. We recommend considering “homework” as a way to integrate benefits of singing group into life outside the group and to encourage independent use of music for health and well-being beyond the life of the group.

Musical instruments might also be used. Hand-held percussion instruments can be provided for each participant and used to accompany songs. Participants may also elect to bring their own musical instruments to the singing session. The facilitator should support these participants’ interest in instrumental music, and encourage them to perform and accompany songs, where appropriate. Facilitators may also consider song writing, with the aim of fostering social connection.

Discussion

This paper presents the process of developing a group structure for a singing group for older people that aims to reduce social isolation, promote cognitive stimulation and enhance motivation and physical activity. A combination of practical work experience, knowledge of the evidence base and full consultation with participants and colleagues is considered essential when devising an arts and health intervention for people living in the community. A lack of one of these three factors will, in our opinion, reduce the integrity, appropriateness and usefulness of such a group process.

The authors recognise that much of the benefit of community groups comes from peer support and mutual learning, rather than the facilitator, and we encourage a subtle guiding of the group rather than overly structured or directed group experiences. Nonetheless, music can invoke strong emotion, distress, and sadness, and we recommend that trained, high-quality music facilitators are essential. It is important to note that music can cause harm when unskillfully used in healthcare contexts (Moss, 2021). The subtle variations in group approach emphasise the need for flexibility in facilitation, depending on the client group and needs of participants. We recommend clarity of group aims, consultation with all stakeholders, and flexibility and creativity in facilitation style in order to adapt this structure to meet the specific needs of service users. Facilitators should also be aware that these groups are creative music sessions rather than a class or teaching opportunity.

The groups in both pilot studies were facilitated by credentialed music therapists. It is beyond the scope of this paper to discuss the benefits and issues arising regarding the variety of facilitators available to run singing for health groups. However, community singing is a shared terrain, with community musicians, choir directors, music therapists and singers leading singing for health groups. The need for specialised training is paramount, whatever the approach and background of the facilitator (Moss & O’Neill, 2009). Claims by one professional group to ownership of singing for health work is, in our opinion, unhelpful. Our experience indicates that where a professional is sensitive, well-trained, and engaging in mentoring or clinical supervision, they can successfully facilitate a singing for health group. Whilst we chose music therapists to facilitate such a group, given their training in evidence-based practice and clinically focused use of music, we recognise that other music professionals are also able to facilitate singing for health groups. Organisations such as the Singing for Health network are providing useful networks and resources for all engaged in singing for health work (Singing for Health Network, 2021).

The importance of employing a flexible structure, and a person-centred approach was confirmed during the process of developing this intervention. Vella-Burrows (2012) identifies that assumptions about which music is relevant to participants can limit or stereotype members of the group. This highlights the importance of including song choices by all the group members and we recommend a Public Patient Involvement (PPI) approach to every singing group developed. Guides published by the Sidney de Hann Research Centre for running specific clinical (dementia, Parkinson’s, COPD), mental health and health singing groups provide useful insights into designing a singing intervention for, and with, older people (Morrison & Clift, 2012a, 2012b; Page, 2014; Vella-Burrows, 2012; Vella-Burrows & Hancox, 2012).

Loneliness is a common issue for older people and people living with dementia and is recognised as a significant factor in health and well-being for older people. Diagnosis and hospital stay can result in loss of friends and increased isolation (Moss et al., 2015; O’Connell et al., 2013). This paper confirms previous work, which indicates that music-making is an appealing opportunity to develop meaningful relationships and build social networks. Sustaining population-based singing groups, particularly time-limited groups, is an issue in the sector. The need for sustained funding for such groups is vital and currently provision can fall between health and social care services with neither prioritising this activity. Authors report issues with long waiting lists and sustainability (Clark et al., 2018; Fancourt & Finn, 2019; Osman et al., 2016). The benefit of the arts for health and well-being is gaining traction (Fancourt & Finn, 2019) and it is exciting to see social prescribing of the arts on the increase. We hope this will be a useful guide for facilitators and welcome further research on the benefits of singing as social prescription for older people. Further research is warranted to develop the intervention in keeping with the full approach of the MRC (O’Cathain et al., 2019) and it is imperative that facilitators maintain a flexible, creative and responsive approach despite the intervention plan they choose. Consultation and adaptation to service user needs and wishes is more important, ultimately, than sticking to any structured intervention, to achieve health and well-being through a group community activity.

This paper contributes one of few specific guides for singing groups for older adults in community settings. The aim of this paper was to bring together experiences, evidence and practice to present a well-tested and evaluated intervention for singing groups with a health and well-being focus for older people living in the community. Future research could focus on testing and validating this group structure; adapting the format to other age groups and clinical conditions; and the significance of place on levels of engagement.

Acknowledgments

We acknowledge the participants who gave their time, opinions and reflections freely. We thank music therapists Marguerite Collins and Marie Therese Tierney, who facilitated the pilot studies, and physiotherapists and researchers Joanne Shanahan and Triona Cleary.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

This study received funding from the Irish Research Council [GOIPG/2019/3222].

Notes on contributors

Hilary Moss

Dr Hilary Moss is Senior Lecturer in Music Therapy and Course Director of the MA Music Therapy at the University of Limerick. She is a musician and Music Therapist and has an MBA in Health Service Management. Her research focuses on the role of music in dementia, chronic pain, and the aesthetic environment of hospital, and music therapy in mental health.

Sophie Lee

Sophie Lee is a doctoral student in music therapy at the University of Limerick, supported by the Irish Research Council. She holds a MSc in Performance Science from the Royal College of Music, London and a BA(Mod) in Music from Trinity College Dublin. Her PhD research investigates the effects of music psychosocial interventions on the well-being of people living with dementia and their family carers.

Amanda M. Clifford

Dr Amanda M. Clifford is a physiotherapist and Senior Lecturer at the School of Allied Health and Course Director of the MSc in Physiotherapy programme at the University of Limerick. Her current research includes the design and evaluation of evidence based interventions to optimise health and well-being, increase levels of physical activity and prevent falls in older people and people with neurological conditions.

Orfhlaith Ní Bhriain

Dr Orfhlaith Ní Bhriain lectures on the BA in Irish Music and Dance at the University of Limerick. She holds a Masters in Ethnochoreology and PhD from UL. She is a registered Irish Dance teacher T.C.R.G. and adjudicator A.D.C.R.G and works internationally as a tutor and dance accompanist. Orfhlaith is vice-chairperson of Dance Research Forum Ireland and Treasurer of I.C.T.M. Ireland.

Desmond O’Neill

Prof Desmond O’Neill is a consultant geriatrician at Tallaght University Hospital, founder chair of the National Centre for Arts and Health, and co-chair of Medical and Health Humanities in Trinity College Dublin. He has a leading international profile in research and advocacy in ageing and the neurosciences, with particular emphasis on how these link with the arts and humanities.