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Effects of creative and social activity on the health and well-being of socially
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Article  in  The Journal of the Royal Society for the Promotion of Health · June 2006
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134 RESEARCH Effects of creative and social activity on older people
Effects of creative and social
activity on the health and
well-being of socially isolated
older people: outcomes from a
multi-method observational study
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
ISSN 1466-4240 DOI: 10.1177/1466424006064303
JRSH 2006;126(3):134-142
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 twenty-
nine 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.
May 2006 Vol 126 No 3

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 well-
being, health and quality of life in older
people.5, 6 Conversely, improved social
functioning and social connectivity is
associated with improved health and well-
being.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 community-
integrated programme consisted of
problem-solving with an emphasis on
social and physical activation. After 12
months, depression had significantly
reduced and health-related quality of life
had significantly increased.16
May 2006 Vol 126 No 3
Effects of creative and social activity on older people RESEARCH 135
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 self-
reliance, 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.
The Journal of The Royal Society for the Promotion of Health JRSH
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 self-
esteem.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 health-
related 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
136 RESEARCH Effects of creative and social activity on older people
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.
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 self-
efficacy (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
JRSH The Journal of The Royal Society for the Promotion of Health
their own groups if they desire. This has questionnaire with reliability and validity
involved help with finding venues, established in numerous studies.32, 33 It
fundraising, setting up management provides separate scores for physical and
committees, providing contacts for mental well-being. A combined (physical
community transport schemes and for and mental) health utility score can also be
appropriate activity providers. derived for use in health economic
The evaluation focused on those analyses.34
receiving substantial mentoring input Geriatric depression scale (GDS-15): The
(excluding those who received simple Geriatric Depression Scale is a widely used
signposting only). and validated 15-item measure of
depression symptoms, designed for older
Measures people.35, 36 It is self-administered, and can
Qualitative measures be used as a screening tool with 92%
Semi-structured interviews were developed sensitivity and 89% specificity when
through consultation with ‘key informants’ evaluated against diagnostic criteria.36 The
(Upstream staff, other researchers and scale can be used to identify mild
participants from a prior pilot study).31 depression (scores of 5–10) and severe
These were revised as needed to allow depression (11–15).
exploration of emerging themes. Relevant MOS social support survey (MOSSS): The
extracts from the topic guides are provided Medical Outcomes Study Social Support
in Figure 1. Most were individual Survey (MOSSS)37 is an 18-item self-
interviews, although some participants administered questionnaire, measuring
were interviewed with their carers, and one overall social support and four sub-scale
focus group was conducted. Data were concepts (emotional/informational
collected at different time-points, reflecting support, tangible support, affectionate
changes in the Upstream system over an support, positive social interaction). The
18-month period. Data were collected on MOSSS is not as widely used or well-
processes as well as outcomes. However, validated as the SF12 or GDS-15, but has
this article is focused only on participant been shown to be sensitive to differences
outcomes and factors that mediated these between patients with depression and with
outcomes. other chronic illnesses.38 Following
feedback that participants found the
Quantitative measures questionnaires repetitive and somewhat
Short form 12 (version 1): The SF12 is a tedious, it was decided to use only the three
widely used, self-administered 12-item ‘positive interaction’ items, and three
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?
May 2006 Vol 126 No 3

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
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.
May 2006 Vol 126 No 3
Effects of creative and social activity on older people RESEARCH 137
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 within-
interview 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,
The Journal of The Royal Society for the Promotion of Health JRSH
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, self-
worth 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.
138 RESEARCH Effects of creative and social activity on older people

Figure 2 don’t have any children’ . . . She doesn’t

read and she doesn’t have hobbies . . ., and
Range of benefits reported by Upstream participants so her life was absolutely a barren desert.
So then I got Upstream involved and they

Reductions in depression and loneliness did some home visits and gradually

Increased alertness or cognitive awareness introduced her to this little art group and

Potentially reduced risk of falls (related to alertness) . . . she’s made friends and she’s a new
woman. She’s not depressed and withdrawn

Increased well being and optimism
as she was. She’s got confidence and I think

Less dwelling on concerns or worries, that’s terrific . . . She’s cheerful, she has got

Better sleep a brighter step and . . . it’s just opened up

Increased social interaction and community involvement new horizons for her and made her life
better. It gives them confidence. It gives

Increased quality of social interactions
them value.’

Increased sense of self-worth and willingness to engage in life Overall, the data suggest that Upstream

Collateral benefits for carers and family (seeing loved ones enjoying life more, was successful in socially re-integrating
and respite opportunities) people who were previously isolated. This

Increased physical activity, more energy seemed to be facilitated by providing a
non-threatening forum in which people

Healthier diet and less heavy drinking
could be offered and mutually share social

Less health visits, reduced medication use support (for example, sharing transport,

Facilitated the rehabilitation of co-ordination /mobility post-stroke material, skills, encouragement,

Increase in hobbies and activities outside of Upstream information). No significant negative
outcomes were reported, although this

Increased enjoyment of life
information was actively sought.

‘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.
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
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

JRSH The Journal of The Royal Society for the Promotion of Health May 2006 Vol 126 No 3
 Effects of creative and social activity on older people RESEARCH 139

of mentors to empower participants
(building confidence and self-
determination) 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
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 non-
engagement were ill-health, or participants
deciding that Upstream was not suited to
them.
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%

Response rates
On 30 September 2005 (the data collection Table 1
cut-off date), Upstream had engaged 229
Baseline health status scores
participants in activities (excluding
signposting). Of these 172 (75%) provided Measure Mean (SD) N
baseline data. At this time, 136 participants
SF12 MCS 47.0 (11.1) 166
were eligible for 6-month follow-up and 72
(53%) provided data (mean follow-up time SF12 PCS 35.3 (11.2) 166
5.5 months). For 12-month follow-up, 93 GDS-15 5.35 (3.42) 169
participants were eligible and 51 (55%) MOSSS (six-item) 1.79 (1.13) 164
provided data (mean follow-up time 12.0
months).
Table 2
Response bias analysis
There were no significant differences Mean SF12 scores for Upstream participants and population norms
between responders and non-responders SF12 Domain Upstream US over-75s UK general population
either at 6 months or at 12 months in
terms of age, financial status, gender or Mental health 46.8* 50.1 52.1
baseline SF12 or social support scores. Physical health 36.4* 38.7 50.9
Non-responders at 6 months had more Note: * Data converted to 1998 Scoring system for comparison purposes
depressive symptoms at baseline than

May 2006 Vol 126 No 3 The Journal of The Royal Society for the Promotion of Health JRSH
140 RESEARCH Effects of creative and social activity on older people

Table 3 health with age, with a more dramatic

decline in women.50–52
Baseline and follow-up scores for responders at 6 and 12 months It is also worth considering the specific
Measure Baseline N 6 months p value for issue of whether depression would be
mean (SD) mean (SD) t-test* expected to improve in the absence of the
intervention. To address this we conducted
SF12 MCS 48.1 (9.94) 70 51.1 (10.8) 0.004 a brief review of the literature, looking at
SF12 PCS 36.1 (10.9) 68 36.1 (11.3) 0.996 outcomes for control groups in
randomized controlled trials of treatments
SF12 Combined (health 0.627 (0.099) 68 0.643 (0.128) 0.140
for depression in older populations, which
utility)
used the GDS as an outcome measure. Six
GDS-15 4.46 (2.88) 69 3.86 (3.17) 0.011 such studies were identified in which the
MOSSS (6-item) 1.98 (1.11) 68 2.04 (1.03) 0.464 control groups had no intervention
provided (and no information about their
Baseline N 12 months depression status was passed to their care
mean (SD) mean (SD) providers, thereby prompting treatment).
SF12 MCS 47.7 (10.0) 51 48.4 (11.6) 0.654 These studies involved 1,027 control
subjects, with follow-up times of 2 to 9
SF12 PCS 35.6 (10.7) 50 37.1 (11.1) 0.062
months.53–58 The weighted mean effect size
SF12 Combined (health 0.606 (0.089) 51 0.633 (0.117) 0.035 (the difference in means divided by the
utility) standard deviation) was –0.002, indicating
GDS-15 4.84 (3.05) 51 4.28 (2.74) 0.041 no change in depression scores.
MOSSS (6-item) 1.88 (1.18) 50 2.08 (0.99) 0.021 Given the above data on normative
trends, it seems possible that the reported
Note: * All t-tests were two-sided
results may tend to underestimate, rather
than overestimate the benefits. The
experienced this level of change. The seemed to be primarily in psychological qualitative data also seem to support the
number with clinical levels of depression well-being and reduced depression, with hypothesis that Upstream had beneficial
fell from 32 (45%) to 25 (35%). perceived social support and overall health effects. However, without a control group
utility benefits emerging after 12 months. to provide data on a rigorously matched
12-month follow up Although the improvement in depression population, we must be cautious not to
The 12-month data provided a slightly scores was maintained at 12 months, the over-interpret the data.
more mixed picture. The improvements in improvement in SF-12 mental component No short-term changes in social support
depression scores were maintained (MD = score was not. The qualitative feedback were observed, although a significant
0.57, 95%CI: 0.02 to 1.11. p < 0.05). The indicated a range of benefits, with improvement emerged after 12 months.
difference in SF12 physical component psychosocial benefit and depressed mood This is consistent with the idea that
scores now came close to (but did not quite being the most widely reported. improvements in perceived social support
achieve) significance (MD = 1.57, 95%CI: which generalised beyond the context of
–0.08 to 3.22, p = 0.06). MOSSS scores also Possible explanations of the data Upstream activities (and would therefore
improved significantly (MD = 0.20, 95%CI: Do these data represent improvements in be detected by the MOSSS scale) take
0.03 to 0.37, p < 0.05). However, the health status caused by the Upstream longer than 6 months to develop.
improvement in SF12 mental component intervention? It is worth considering the The rise and then fall of SF-12 mental
scores decreased and was no longer expected trends in mental and physical component scores over time requires
significant (Mean improvement = 0.71 health for this population, and to ask to careful consideration. One possible
points, n.s.). Overall health utility scores what extent their health might have explanation is that any psychological well-
(combining SF12 mental and physical improved in the absence of the being effect is only short term. However,
components) improved significantly intervention. We do not have detailed this is not consistent with the depression
between baseline and 12 months (MD = information about physical health scores, where benefit was maintained. A
0.027, 95%CI: 0.002 to 0.052, p < 0.05). problems in the sample at baseline, further explanation is that there may be a
although there was a high prevalence of degree of ‘normalization’ of benefits, as a
DISCUSSION longstanding, non-remitting illnesses (see number of SF-12 items relate current
Both qualitative and quantitative data sample characteristics). Life expectancy at health status to the participant’s ‘usual’
indicated that the health status of elderly age 77 is only 5–8 years,49 and so a state (for example, limitations are expressed
socially isolated people taking part in downward trend might be predicted. in relation to regular daily activities). With
creative and social activities with Indeed, longitudinal studies of ageing in no control group against which to contrast
individualized mentor support improved the general UK population show a clear results, it is not possible to determine the
meaningfully over time. The initial benefits trend of declining physical and mental true explanation.

JRSH The Journal of The Royal Society for the Promotion of Health May 2006 Vol 126 No 3

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
May 2006 Vol 126 No 3
Effects of creative and social activity on older people RESEARCH 141
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.
The Journal of The Royal Society for the Promotion of Health JRSH
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