Of 94 participants who completed the trial (12-month assessment)at the five sites, 31 opted to continue singing and participate ina focus group at their site. Of the 48 participants who completedthe trial but chose not to continue singing, 14 agreed to beinterviewed by phone within one month. All five of the musicprofessionals who delivered the choir intervention wereinterviewed, as were all five senior center administrators and themusic organization administrator. Table 1 summarizes thedemographic characteristics of each stakeholder group.
A conceptual framework for sustainment emerged, reflectingthemes at the intrapersonal, the intrapersonal, and theorganizational levels that served as facilitators or barriers tosustainment. These themes are grouped and presented by two broadcategories of facilitators and barriers, with subgroupings withineach of these by level.
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Facilitators were associated with both ongoing individualparticipation in the choir during the sustainment phase as well assustainment of the choirs themselves within the senior centers. SeeTable 2 for example quotes [note: minor details have been changedto preserve anonymity].
Emotional wellbeing and positiveemotions were identified as key facilitators tocontinuation by both the trial participants who continued and thosewho discontinued following the CRT, and this was observed by themusic professionals and the administrators. One trial participantexplained why she had wanted to continue participation in the choirby saying, “the act of being in the choir, music feeds the soul asthey say, but aside from that, it relaxes you. And aside from that,it transports you to wonderful memories. It makes you happy.”Positive emotions included overall enjoyment of the choir and withsinging, a strong sense of wellbeing, and enjoyment of specificaspects of participation such as visibility, connections with thepast, and the enjoyment of learning and physical exercises.
Social connection, belonging and socialsupport were emphasized as facilitators in all of thetrial participant focus groups. As one trial participant explained,“I think it’s that sense of belonging to a larger group. They’vemade friendships, again. It makes them feel empowered. They feelactive, you know, they have a sense of belonging… and so theycome, they’re anxious to come together to practice, to share andnow they’ve become friends.” The emergence of friendships withinthe choirs was observed by both music professionals andadministrators alike.
In addition to relationships among trial participants,relationships developed between the trial participants and musicprofessionals. Trial participants described deep admiration for themusic professionals through descriptions like the following: “andwith great teachers, because we have very good teachers, theydirect us well, they explain each thing to us, if we’re doing well,if we're not getting the tone. They always are careful that webring out our voice and I just love that.” The music professionalssimilarly highlighted the importance of the relationship betweentrial participants and their director. “What I’ve seen in thechoirs in general, is that that relationship between choir directorand participant and the creation of a social fabric within thegroup is very important. Because that sense of community is part ofwhat helps people to stay connected. So, it’s not an isolatedactivity. In fact, it brings people together. And that’s what helpsmake it fun and helps people to continue.” Strong relationshipsbetween the senior center directors and the music center director,were also identified as key facilitators to sustainment.
Organization factors related to the structure,format and programming of the choirs emerged as aprimary facilitator of choir sustainment. The “professionalism” ofthe choir directors and accompanists [music professionals] wassingled out as a critical factor, including one administrator’sobservation that the music professionals were “very patient, butalso very clear and firm. And I think the people follow their lead.I think you have to have that in order to produce results.” Thisincluded both the technical aspects of leading a rehearsal and theoverall organizational skills needed to prepare the group for choirperformances. As one trial participant explained, “The schedulesthat the teachers gave us were extremely well organized, very welldone. It had the whole year, with the vacations, when we were out,when we would go in.”
Beyond scheduling, organization skills at the level of the choirinvolved sophisticated musical and pedagogical aspects of choirdirection. The music professionals spoke in detail about ways inwhich the quality of the music led trial participants to continueduring the sustainment period, and of the need to create newarrangements appropriate to the vocal ranges of older adults.Reflecting on the refinement of the choir in the sustainment phase,one music professional observed that “the curriculum of the choirsessions got stronger, with a more codified approach to customizingthese choir sessions, which really came out of a communitydevelopment model or a community arts model, to be even morecustomized towards older adults.” The music professional noted thatthe sustainment period provided a time in which key stakeholders“learned more about how to deliver a choir program specifically forolder adults.”
Organizational involvement emerged asan understated but critical aspect of sustainment. The involvementin and support of senior center personnel related to the choirprogram were viewed as essential for success over time. Without thewillingness of the senior center to schedule, reserve rooms andprovide space for rehearsals, the choirs could not have continuedafter completion of the trial. Strong senior center involvement,however, did more than make sustainment possible, it ensured thesuccess of the program. As one music professional explained, “Whenthe centers took over, they [the senior center administrators]pretty much nursed us through the transition because we didn't haveto worry about the room, they would help set it up, and it was abig choir.”
The music professionals and administrators also described theimportance of strong and supportive relationships at theorganizational level. One administrator acknowledged this saying,“I think that one nice thing that we see is, the choir members dofeel an affection for the senior center. They appreciate theenvironment.” One administrator explained thatorganizational-level relationships are important “because oneorganization cannot do it by themselves. It takes a couple oforganizations getting together to make sure that these thingshappen, so we all put a little piece in the pot, and it works. Ilove it.” These multiple and overlapping relationships were foundto be essential in the sustainment of the choirs.
Unlike the facilitators, which the stakeholders identified ascritical for sustainment of the choirs, none of the barriers wereassociated with discontinuation of the choirs. Barriers listedbelow were either identified as causing difficulties withattendance, or with the discontinuation of a specific trialparticipant. See Table 3 for example quotes [note: minor detailshave been changed to preserve anonymity].
Health issues were identified as aprimary reason for trial participants to attend less frequently inthe choirs or to drop out entirely during the sustainment phase.These included serious life events such as cancer, chronic illnessmanagement requiring regular medical appointments, and intercurrentillnesses (see reasons for discontinuation below). The impact ofcold and flu season on attendance was described by an administratorwho observed that, “by the holidays it [attendance] has kind ofdrizzled down a little bit, and then like I said, the weather, andyou know, them being a little under the weather.”
Negative social interactions weredescribed in the focus groups and interviews, although with lessfrequency than the positive interactions listed above. During choirrehearsals, there were isolated complaints of interruptions of thesessions by specific trial participants. One trial participant feltthat there were insufficient opportunities for social interaction.When new members were allowed to join the choirs after the trialended and the sustainment period began, several trial participantsexpressed frustration with the singing abilities of the newcomers.For one choir, a music professional initially reported that “atleast the group… absorbed the newcomers,” but then qualified thestatement, noting that there “was a bit of friction with the newerpeople that did stay, when it opened up to community groups.”
Competing family obligations werefrequently cited as a reason for discontinuing the choir or asbarriers to attending rehearsals. When one trial participantobserved that “a few of our seniors, they had still caregivingpositions, or taking care of grandbabies,” another trialparticipant chimed in with “taking care of grandbabies,” followingwhich the first speaker continued, “great grandbabies –great-great-grandbabies.” Trial participants described in detailthe need to help adult children as well as the next generations,prioritizing familial relationships over those created throughparticipation in the choir, while expressing regret that thefamilial relationships interfered with choir participation.
Transportation/Access issues. As mightbe expected in an urban environment, a primary structural barrierinvolved travel to the senior center. Some trial participantsstruggled to navigate public transportation. One participantexplained his complex situation as follows: “I don’t have easyaccess to a car, even though I have one. My daughter has a nanny,and she gets the car. And I could easily call a cab…. But I justhate spending money when I don’t really have to. So, if I can walksomeplace, it’s great. But, at night, in the dark, in thewintertime, I don’t want to be walking alone in the street, to andfrom the bus stop.” Stakeholders specifically identified limitedparking as barriers to timely arrival for rehearsal, summed up mostsuccinctly by a music professional as “The parking, just theparking.”
Choir rehearsal and schedule issues.Issues related to choir rehearsal organization and schedulingsometimes undermined relationships and created barriers toparticipation. Several trial participants raised concerns aboutscheduling and communication issues. One of the music professionalsnoted that scheduling and communicating with the senior centers wascomplicated by the transition from a university to a communitypartner coordinator after the trial ended. As this transition wastaking place, one music professional noted the critical nature ofthis position in sustainment “Easier, would be to have definitely acoordinator, someone that's not a director, not an accompanist…Otherwise it's just – it's too much for one or two persons to do.”(Music professional). Another music professional noted that, oncethe trial was over, the choirs began to receive local invitationsto perform. These invitations were accepted, but the performancesled to schedule changes on short notice. Additionally, some trialparticipants identified the change in rehearsal time as a criticalobstacle to continuation and others disliked a summer break, whichwas added to conform to the long-standing schedule at the musiccenter. Communication issues between the music and senior centerorganizations created minor friction, but were reported rarely.
Senior Center environment issuesincluded both modifiable and unmodifiable barriers. The clearestexample of ongoing attempts to reduce modifiable barriers waspresented by a music professional who described issues of noisethat were ameliorated but not entirely fixed by a change in seatingrearrangements during the sustainment phase: “So everything – thathas all improved in the extension. Now if we could just get rid ofthe fans, things would be really great. Super loud fans.” Incontrast to seating arrangements, which were altered in severallocations, the size and availability of the rooms were notmodifiable. In one case, the move to a smaller room causedfrustration for several trial participants, and led another trialparticipant to discontinue because the room had been used for afamily member’s memorial service.
Issues due to transition of choir management fromacademic to senior center. Although the transitionwas overwhelmingly described as positive by trial participants,both the music professionals and the administrators identifiedbarriers to sustainment associated with this change in management.In one case a music professional identified that one senior centerhad “a very difficult time at having choir retention [i.e.attendance and recruitment] in general. I don't know why.” Anothermusic professional described a specific transitional issue, theneed for water (which had been provided during the trial by theresearch staff) during the social break in the middle of therehearsals. The music professional said that initially, “I felt thepulling away of the support of UCSF around the food,” but that,ultimately the issue was resolved through support of the seniorcenter.
Funding. In contrast to musicprofessionals and trial participants, all administrators identifiedfunding as the critical factor underpinning sustainment of thechoirs or any other community-based program. One administratorsaid, “what happens over and over again, I mean, time and timeagain, is that there’s funding that comes down for programs thatare good concepts. People get behind them, they organize them andall that and they’re great for a while, and then the funding driesup. And then, there’s no more programs.” Every administratorexpressed the desire to support the choirs but noted that theywould require additional funding in order to do so. As onesummarized, “It all comes down to resources, because we have theframework.”
Reasons for discontinuing after the end of thetrial. All reasons for discontinuation are includedhere, whether or not they reached the level of thematic saturation.Among participants who completed the trial and then elected not tocontinue during the sustainment phase, the reasons for notcontinuing fell into three major categories: serious illness,competing caregiving responsibilities, and disliking singing in thechoir. Several trial participants reported more than one primaryreason for discontinuation. Nearly two thirds of thetelephone-interviewed trial participants noted that they hadenjoyed the choir and wanted to continue but were unable tocontinue during the sustainment phase due to health issues orfamilial responsibilities. One third cited health issues includingcancer, surgery, acute infection, chronic “dizziness,” worseninghearing loss, arthritis, and acute bereavement issues. One thirdcited external family and caregiving relationships, such as movingout of the area to live closer to adult children, and providingdirect care to young children in the family. One third citedreasons involving the choir intervention itself. These includedpreferring to sing alone, finding the singing to be “stressful,”disliking unexpected changes in scheduling, feeling frustrated whena music professional arrived late, and disliking the musicselections.