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An increasing number of older people in the United Kingdom
(UK) account for a significant proportion of health and social care
service use,
1
and this requires novel approaches to maintain and
promote mental and physical health of this population. There is
evidence that maintaining an active lifestyle mentally, physically
and socially is important in contributing to ‘successful ageing’,
well-being and the ability to remain living independently.
2
Previous evidence-based reviews of interventions aimed at
maintaining or enhancing mental health and health-related
quality of life in older people found little evidence for a variety
of group-based interventions including exercise, t’ai chi and
reminiscence groups,
3
but a systematic review by Bridle et al
4
highlighted the benefits of tailored exercise in reducing depression
in older people. Recent years have witnessed a growing recognition
of the value of participatory arts activities in improving the mental
health and overall well-being of older people.
5
Within the area of
music, previous research with older people focused upon the effect
of music listening
6,7
or music therapy,
8
rather than music as a part
of everyday experience.
9
Clift et al
10
conducted a systematic
mapping of non-clinical research studies focusing specifically
on participatory singing and found only two studies, using
standardised measures within controlled trials for older people.
5,11
Both studies identified improvements in mental health for
participants in singing groups, but have serious methodological
limitations in terms of lack of justification for sample size and
failure to randomise to intervention or control group, issues that
limit the value of the evidence. Further reviews have pointed to
the value of singing as a therapeutic intervention for older people
with long-term physical health conditions,
12,13
including small
pilot randomised controlled trials of singing lessons for people
with Chronic Obstructive Pulmonary Disease in clinical
settings.
14,15
The focus of the current study is the evaluation of an
innovative community singing initiative, the ‘Silver Song Club
Project’, which provides opportunities for older people to come
together to sing with the support of professional musicians. Some
40 such clubs currently exist, mainly in South East England, which
are managed by a third sector organisation, Sing for Your Life Ltd.
Initially we completed a qualitative, process-orientated evaluation
which suggested potential positive benefits across psychological,
cognitive, social and physical domains,
16
and this provided a basis
upon which to develop a randomised controlled trial to evaluate
the effectiveness and cost-effectiveness of community singing on
the mental and physical health-related quality of life of older
people.
Aims of the study
(a) To assess the effectiveness of active engagement in community
singing on measures of mental and physical health-related
quality of life, depression and anxiety for older people.
(b) To evaluate the cost-effectiveness of active engagement in
community singing for older people.
Hypotheses
Primary hypothesis, stated as null hypothesis: singing groups
for older people are no more effective than usual activities in
increasing mental health-related quality of life in older people
250
Effectiveness and cost-effectiveness of community
singing on mental health-related quality of life
of older people: randomised controlled trial
Simon Coulton, Stephen Clift, Ann Skingley and John Rodriguez
Background
As the population ages, older people account for a greater
proportion of the health and social care budget. Whereas
some research has been conducted on the use of music
therapy for specific clinical populations, little rigorous
research has been conducted looking at the value of
community singing on the mental health-related quality of life
of older people.
Aims
To evaluate the effectiveness and cost-effectiveness of
community group singing for a population of older people in
England.
Method
A pilot pragmatic individual randomised controlled trial
comparing group singing with usual activities in those aged
60 years or more.
Results
A total of 258 participants were recruited across five centres
in East Kent. At 6 months post-randomisation, significant
differences were observed in terms of mental health-related
quality of life measured using the SF12 (mean difference
= 2.35; 95% CI = 0.06–4.76) in favour of group singing. In
addition, the intervention was found to be marginally more
cost-effective than usual activities. At 3 months, significant
differences were observed for the mental health components
of quality of life (mean difference = 4.77; 2.53–7.01), anxiety
(mean difference = 71.78; 72.5 to 71.06) and depression
(mean difference = 71.52; 72.13 to 70.92).
Conclusions
Community group singing appears to have a significant
effect on mental health-related quality of life, anxiety and
depression, and it may be a useful intervention to maintain
and enhance the mental health of older people.
Declaration of interest
S. Clift is a board member of Sing For Your Life Ltd, a not-
for-profit third sector organisation which played a role in
developing and implementing the intervention reported.
Copyright and usage
BThe Royal College of Psychiatrists 2015.
The British Journal of Psychiatry (2015)
207, 250–255. doi: 10.1192/bjp.bp.113.129908
measured 6 months after randomisation assessed by the York
SF12.
Secondary hypotheses, stated as null hypotheses:
(a) singing groups for older people are no better at reducing
anxiety and depression when compared with usual activities
at 6 months after randomisation assessed by the Hospital
Anxiety and Depression Scale;
(b) singing groups for older people are no more effective than
usual activities in increasing physical health-related quality
of life in older people assessed 6 months after randomisation
by the York SF12; and
(c) singing groups for older people are no more cost-effective
than usual activities.
Method
A prospective, pilot, pragmatic, randomised, controlled trial in
which eligible, consenting participants were randomised with
equal probability to either singing group participation or usual
activities. Randomisation was conducted by a secure remote
randomisation service independent of the research team.
Randomisation employed random permuted blocks of variable
length and was stratified by centre and gender. Participants were
followed-up at 3 and 6 months by post. The study was approved
by the Surrey NHS ethics committee (ref: 10/H1109/5) and
registered (ISRCTN62404401). The study was undertaken in
accordance with the Declaration of Helsinki.
Sample size
The primary outcome measure was the mental health component of
quality of life measured by the SF12 at 6 months post-randomisation.
A clinically important difference on this dimension is estimated as
a difference of five points between intervention and control group,
equivalent to a medium effect size difference of 0.5.
17
To detect
this difference using a two-tailed test, alpha of 0.05 and power
at 80% requires 63 participants in each of the two arms, a total
of 126 participants. We anticipated five singing groups and five
controls, and had to take account of any clustering effect in
calculating sample size. We used a conservative estimate of
intra-class correlation coefficient of 0.02, similar to other
community-dwelling older people and a harmonic mean cluster
size of 12. This inflated the required sample size by a factor of
1.2, a total of 154 participants. Previous research suggested that
the loss to follow-up at 6 months for this population would be
in the order of 20%, and this further inflated the sample size to
184, 92 participants in each of the intervention and control
groups.
Participants
As the intervention focused on maintaining or enhancing the
mental health status, experiencing current mental health issues
was not a specific inclusion criteria. The study was publicised
widely within the local areas. Researchers attended day centres
and other venues where older people met for group activities to
provide information on the study. In addition, advertisements
were placed in the local media, general practices and community
venues. Inclusion and exclusion criteria were kept to a minimum
to maximise the generalisability of the population. All those
expressing an interest and aged 60 years or more were eligible to
participate. Only those unable to provide informed consent were
excluded.
Procedure
All individuals indicating an interest in taking part in the study
were sent a baseline questionnaire, an information sheet outlining
the purpose of the study and a consent form to be returned with
the questionnaire. Eligible and consenting participants were
randomised to either a singing group or usual activities.
Intervention
Control group
Individuals in the control group continued with their normal
activities. To address any potential resentful demoralisation,
members of the control group were informed that they would
be welcome to join a singing group at the end of the research
study, after completion of the primary outcome assessment at
6 months.
Intervention group
The Silver Song Club model is an established format for
participative singing for older people that was selected for
inclusion as one out of three UK examples of good practice for
the Health Pro Elderly international project.
18
Details are available
on the Sing for Your Life Ltd website (www.singforyourlife.org.uk/
sites/default/files_new/SSC%20FormativevEvalulation%20Summary.
pdf). Trained and experienced facilitators under the guidance
of Sing for Your Life Ltd met to compile a 14-week 90-minute
programme comprising songs from different eras and a variety
of genres. This was followed by a series of ‘unification’ meetings,
to ensure that all facilitators were aware of how to access the
material and deliver it in the same way (e.g. accompaniment,
musical key and acquiring copyright). The programme was
developmental, progressing from singing melody lines to
harmonising, layering and singing in rounds. Chime bars were
also introduced where appropriate, and there was an opportunity
for participants to request particular songs. All clubs delivered the
same programme concurrently, and at the end of the 14 weeks the
clubs disbanded. A programme manager, who made unannounced
visits to each group during the intervention period, monitored
fidelity. A songbook was produced for the trial and a register of
attendees was maintained.
Study measures
Primary outcome
The primary outcome measure was mental health-related
quality of life assessed by the York SF12
19
at 6 months post-
randomisation. The SF12 contains 12 items addressing both
mental and physical health components of quality of life and
has established psychometric properties including reliability,
validity and sensitivity to change.
Secondary outcome measures
The SF12 was also used to generate physical health-related
components of quality of life. Anxiety and depression were
measured using the Hospital Anxiety and Depression Scale.
20
This
scale is validated for community samples and provides both an
increasing severity score ranging from 1 to 21, with higher scores
indicating greater severity.
Economic outcome measures
Health utility was measured by the EQ5D.
21
This is a short, five-
dimensional instrument with three levels which allows the
generation of quality-adjusted life years (QALYs). It is routinely
251
Effectiveness and cost-effectiveness of community singing
Coulton et al
used in the economic evaluation of healthcare and recommended
for cost-effectiveness analyses. Health and social care service
utilisation was measured by a specially designed service use postal
questionnaire used previously in a number of evaluations
including older people
22,23
and measures units of health and social
care resources including general practice visits, social care
involvement, in-patient stays and out-patient attendance.
All outcomes were measured at baseline, before randomisation
and then at 3 and 6 months by post. If a participant failed to
respond to a follow-up questionnaire, a reminder and an
additional questionnaire were sent 4 weeks after the scheduled
follow-up date. In addition, we collected process measures
consisting of individual attendance at singing groups and fidelity
information on the delivery of singing groups.
Analysis
As a study of effectiveness, the primary analysis was by intention-
to-treat where participants were analysed as part of their allocated
group irrespective of the actual treatment received. The primary
outcome measure, SF12 mental components at 6 months, was
analysed by an analysis of covariance adjusting for baseline age
and gender which are known covariates. As the intervention
involved groups, we adjusted the analysis using the Huber-White
sandwich estimation technique to generate robust standard errors.
Secondary outcomes were analysed in a similar manner.
The incremental cost-effectiveness of singing groups
compared with usual activities was assessed from a health and
social care perspective in accordance with the National Institute
of Clinical Excellence guidelines.
24
The costs associated with
setting up and running singing groups were assessed from the
actual local costs including the cost associated with premises
and managerial overheads. Units of service utilisation in the 6
months before and 6 months after randomisation were assessed
from the service use questionnaire, and the net costs for each
arm of the study were derived by multiplying these by national
sources of unit costs,
25
as all costs were collected within a
12-month period and no discounting was applied. The EQ5D
was used with population values to calculate the QALY change
using the area under the curve method.
26
As economic data tend
to be skewed, we used an established bootstrapping technique,
resampling with replacement, to derive more robust confidence
interval estimates.
27
We divided the differences in the net costs
for each arm by the difference in QALY gains to yield an
incremental cost-effectiveness ratio. We estimated the sampling
distribution from 1000 bootstrapped samples and derived the
cost-effectiveness acceptability curves.
28
These curves plot the
resulting probability that one arm is better than the other, against
the maximum policy-makers may be willing to pay for an
additional QALY.
Results
Sample characteristics
Recruitment to the study took place across five localities in East
Kent. A total of 393 potential participants expressed an interest
to participate and were sent information on the study and a
baseline questionnaire. Of these only 258 (66%) were eligible
and consented to participate in the study, 127 (49%) were
allocated to the control and 131 (51%) were allocated to the inter-
vention. Follow-up rates at 3 and 6 months were 222 (86%) and
204 (79%), respectively, and no differential follow-up rate between
the groups was observed. Of those allocated to the singing groups,
106 (81%) attended at least 50% of the sessions and attendance
was similar across all centres. A full CONSORT diagram is
provided in Fig. 1.
Baseline demographics and outcome measures are provided in
Table 1. The mean age was 69 years (s.d. 7.14); the majority were
female (84%) and White (98%). No statistical differences in
baseline demographics or baseline outcome measures were
observed between the groups.
Primary outcome
At baseline, SF12 mental health-related quality of life was similar
across the groups, with 50.0 (95% CI 47.9–52.2) and 48.8 (46.8–
50.8) for the control and intervention groups, respectively.
Although these were similar in the control group at 6 months,
49.9 (48.2–51.7), they had improved in the intervention group,
252
393 potential participants
258 of these eligible
and consenting
131 of 258 (51%)
allocated to
intervention
106 of 131 (81%)
attended at least 50%
of sessions
113 of 131 (86%)
followed up
at 3 months
105 of 131 (80%)
followed up at
6 months
and included
in the analysis
127 of 258 (49%)
allocated to
control
109 of 127 (86%)
followed up
at 3 months
99 of 127 (79%)
followed up at
6 months
and included
in the analysis
Fig. 1 Trial CONSORT statement.
Table 1 Baseline description of the sample
Overall
(n= 258)
Control
(n= 127)
Intervention
(n=131)
Demographics
Mean age (s.d.) 69.2 (7.14) 69.5 (7.13) 69.2 (7.18)
Female n(%) 214 (83.9) 108 (87.1) 106 (80.9)
Smoking n(%) 11 (4.3) 3 (2.4) 8 (6.2)
White n(%) 250 (98.0) 120 (96.8) 130 (99.2)
Employed n(%) 25 (11.0) 9 (8.1) 16 (13.8)
Education after 16 n(%) 162 (62.8) 79 (64.8) 83 (63.8)
Outcome measures
Mean SF12
– physical score (s.d.) 39.4 (6.63) 39.8 (6.69) 39.1 (6.58)
Mean SF12
– mental score (s.d.) 49.4 (11.7) 50.0 (11.9) 48.8 (11.5)
Mean EQ5D score (s.d.) 0.74 (0.22) 0.74 (0.22) 0.74 (0.22)
Mean HADS – anxiety (s.d.) 6.40 (4.46) 6.41 (4.57) 6.40 (4.46)
Anxiety case n(%) 49 (19.1) 24 (19.0) 25 (19.1)
Mean HADS
– depression (s.d.) 4.62 (3.52) 4.28 (3.52) 4.95 (3.52)
Depression case n(%) 20 (7.8) 8 (6.3) 12 (9.2)
Effectiveness and cost-effectiveness of community singing
52.3 (50.7–54.0). The mean difference between intervention and
control at 6 months was 2.35 (0.06–4.76), and this was significant
(P= 0.05; Table 2).
Secondary outcomes
At 6 months, no significant differences were observed between the
groups in terms of SF12 physical components of health-related
quality of life, anxiety or depression (Table 2). At 3 months,
significant differences between the groups were observed in terms
of mental components of SF12 health-related quality of life and
mean difference intervention compared with control 4.77 (2.53–
7.01), anxiety 71.78 (72.50 to 71.06) and depression 71.52
(72.13 to 70.92). No other significant differences were observed
between the groups at 3 months (Table 2).
Economic outcomes
The costs of implementing and training staff to conduct the
singing groups are shown in Table 3. Training costs were estimated
over a 12-month period where the average facilitator would
deliver 80 sessions, two per week, to avoid an overestimation of
training costs. The total cost per session was estimated at
£176.84 and the cost per participant over 14 sessions was
estimated at £18.88.
Service use was measured at baseline and 6 months, and costs
of units consumed were derived from national sources. Service use
costs were estimated only for those who were followed-up and are
presented in Table 4. Service use costs increased in both groups
between baseline and 6 months, but although the increase was
greater in the intervention group, £315.89 versus £281.14 for
the control group, this difference was not significant. Participants
in the control group gained 0.008 QALYs between baseline
and 6 months compared with a gain of 0.023 QALYs in the
intervention group, the difference between the groups of 0.015
(95% CI 0.014–0.016) was significant.
A cost-effectiveness acceptability curve was constructed
(Fig. 2). This indicated that at a willingness to pay threshold of
zero, the control group would be the preferred economic option.
At a willingness to pay threshold of £20 000, the intervention has a
60% probability of being the more cost-effective option, and at
recommended willingness to pay thresholds of £30 000 (24), this
probability increases to 64%.
253
Table 2 Baseline, 3- and 6-month outcomes adjusted for baseline values, age and gender
Baseline Month 3 Month 6
Mean
(95% CI)
Mean
(95% CI)
Mean difference
(95% CI) P
Mean
(95% CI)
Mean difference
(95% CI) P
SF12 – physical
Control 39.8 (38.6–40.9) 39.2 (38.3–40.0) 39.6 (38.6–40.7)
Intervention 39.1 (37.9–40.3) 40.0 (39.1–40.8) 0.83 (70.39–2.05) 0.18 39.9 (38.7–40.9) 0.26 (71.75–1.23) 0.73
SF12 – mental
Control 50.0 (47.9–52.2) 50.7 (49.1–52.3) 49.9 (48.2–51.7)
Intervention 48.8 (46.8–50.8) 55.5 (53.9–57.1) 4.77 (2.53–7.01) 50.01 52.3 (50.7–54.0) 2.35 (0.06–4.76) 0.05
HADS – anxiety
Control 6.41 (5.62–7.20) 6.01 (5.41–6.42) 5.83 (5.30–6.36)
Intervention 6.40 (5.62–7.18) 4.14 (3.64–4.64) 71.78 (72.50–1.06) 50.01 5.26 (4.75–5.76) 70.57 (71.31–0.16) 0.13
HADS – depression
Control 4.28 (3.67–4.89) 4.15 (3.72–4.56) 4.22 (3.71–4.73)
Intervention 4.95 (4.53–5.57) 2.63 (2.21–3.05) 71.52 (72.13–0.92) 50.01 3.69 (3.20–4.18) 70.53 (71.24–0.18) 0.14
EQ5D – QALY
Control 0.76 (0.72–0.81) 0.78 (0.74–0.82) 0.77 (0.72–0.82)
Intervention 0.76 (0.71–0.80) 0.80 (0.76–0.85) 0.02 (0.01–0.03) 0.05 0.78 (0.73–0.83) 0.01 (0.01–0.02) 0.01
Table 3 Implementation and training costs associated with
singing groups
Resource
Unit cost
per session
(£)
Cost per
participant
(n= 131)
Training costs
Facilitators (5 facilitators,
3 days at £75/day) 2.81
a
0.30
Facilitator expenses (5 facilitators,
3 journeys at £35/journey) 1.31
l
0.14
Trainer (3 days at £100/day) 0.75
c
0.08
Trainer expenses
(3 journeys at £35/journey) 0.26
d
0.03
Venue hire (3 days @ £100/day) 0.75
e
0.08
Capital expenditure
Hand chimes 1.25
f
0.13
Keyboard 1.75
g
0.19
Song sheets 0.22
h
0.02
Indirect cost
Advertising 2.14
i
0.23
Management 9.64
j
1.03
Administration 12.86
k
1.37
Session costs
Facilitator 75.00
l
8.01
Facilitator expenses 35.00
l
3.74
Venue hire 30.00
l
3.21
Refreshments 3.00
l
0.32
Total 176.84 18.88
a. Total training cost for facilitators is £1125. Training estimated per annum
at 80 sessions delivered per facilitator, cost per session £2.81.
b. Total travel cost for facilitators is £525. Training estimated per annum
at 80 sessions delivered per facilitator, cost per session £1.31.
c. Total trainer cost estimated at £300 to train five facilitators. Training estimated
per annum at 80 sessions delivered per facilitator, cost per session £0.75.
d. Total trainer travel estimated at £105 to train five facilitators. Training estimated
per annum at 80 sessions delivered per facilitator, cost per session £0.26.
e. Venue hire estimated at £300. Training estimated per annum at 80 sessions
delivered per facilitator, cost per session £0.75.
f. Hand chimes unit cost of £500. Expected use 5 year, £100 per year, expected
utilisation estimated at 80 session per annum, cost per session £1.25.
g. Keyboard unit cost of £700. Expected use 5 years, £140 per year, expected
utilisation estimated at 80 sessions per year, cost per session £1.75.
h. Song sheets unit cost of £180 across five groups, £36 per group. Expected use
2 years, £18 per year, expected utilisation at 80 sessions per year, cost per session
£0.22.
i. Advertising cost per group per year at £120. Cost over 3 months £30 per group,
for 14 sessions estimated at £2.14 per session.
j. Management cost per group per year £540. Cost over 3 months £135 per group,
for 14 sessions estimated £9.64 per session.
k. Administration cost per group per year £720. Cost over 3 months £180 per group,
for 14 sessions estimated £12.86 per session.
l. Actual cost.
Coulton et al
Discussion
The reported study is the first pragmatic randomised controlled
trial of community singing groups for older people, focusing on
their mental health and quality of life. The interest shown in the
groups and the willingness of participants to engage in singing
groups is a clear indication of both feasibility and acceptability
of community singing for the older people. Our primary
hypothesis explored the potential benefits of singing groups on
maintaining the mental health-related quality of life of older
people. The results suggest that participation in singing groups
confers significant benefits in terms of mental aspects of quality
of life derived using SF12 and appears cost-effective when
compared to usual activities 6 months after randomisation and
3 months after the groups had ceased to meet. No differences were
observed at 6 months in terms of physical aspects of quality of life,
anxiety or depression. At 3 months, at the end of the intervention,
levels of anxiety and depression were significantly lower in the
singing group. This suggests that the greatest benefit occurs when
participants are engaged in singing groups and continued access to
singing groups may confer important benefits on the mental
health of the older population.
Qualitative feedback from participants through written
comments and interviews was highly positive. People indicated
their enjoyment of the experience and highlighted the benefits
on mental health, well-being and social relationships.
A clear marker of the value participants placed on the singing
groups is the fact that four of the five groups established for
research purposes were reinstated at the end of the 6 month
follow-up and continue to meet and have grown in membership
with support from a new charity Living Lively (http://www.
livinglively.org.uk/). The study adds weight to the notion that
meaningful, social and pleasurable activities can confer mental
health benefits to participants identified in other studies of music
therapy.
8
In conclusion, the provision of opportunities to meet and sing
together provide an opportunity to maintain and enhance the
mental health of older people that is cost-effective and acceptable
to the population, and should be considered as an important
element in any public mental health strategy for this population.
Limitations of our study include the fact that it was conducted
in one geographical area where the population is predominantly
White British. We do not know, therefore, whether our findings
could be generalised to other areas with different demographic
characteristics. The groups also ran for a relatively short period of
time and it is possible that longer involvement in singing could lead
to more substantial and sustained benefit. As the study reported was
pragmatic, we did not explore in detail the processes of change that
may underpin any observed changes and understanding these
processes may be important in understanding the relationship
between group musical activity and improvements in well-being.
It may be the case that any group activity confers similar
benefits and that singing groups are just one form of group
254
Table 4 Mean (s.e.) service use costs for the 6 months pre-baseline and 6 months post-baseline
Social care (£) Primary care (£) Secondary care (£) Total (£)
Baseline
Control 2.58 (1.57) 66.38 (7.83) 273.62 (64.70) 342.59 (67.39)
Intervention 4.06 (2.23) 60.45 (5.51) 229.58 (50.39) 294.09 (52.87)
Month 6
Control 5.04 (3.05) 85.21 (8.66) 533.48 (126.91) 623.73 (131.16)
Intervention 3.24 (1.82) 78.16 (8.25) 528.58 (208.70) 609.98 (210.15)
1.0 –
0.9 –
0.8 –
0.7 –
0.6 –
0.5 –
0.4 –
0.3 –
0.2 –
0.1 –
0–
Probability cost-effective
£0 £5000 £10 000 £15 000 £20 000 £25 000
Maximum WTP per additional QALY
£30 000 £35 000 £40 000 £45000 £50 000
Treatment
Control
Fig. 2 Cost-effectiveness acceptability curve comparing the probability of cost-effectiveness for intervention and control at different
QALY valuations.
Effectiveness and cost-effectiveness of community singing
activity and further research is needed to address the relative
effects of group singing versus other group activities. Yet it is
important to note the ease with which the sample was recruited
and the high levels of engagement would suggest that group
singing is both feasible and acceptable to older people. In addition,
the design of the study involved a waiting list control group, where
participants allocated to the control group had the intervention
made available at the end of the study. The reasons for this
involved addressing an issue of resentful demoralisation. It may
have been the case that the control group was perceived as a
delayed intervention for some participants and this may have
impacted on their reporting of the outcomes. If this was the case,
then the reported effects at 6 months may have been under-
estimates of the true effect. In addition, it is important to be clear
that the sample was a self-selecting population, people who
wanted to engage in singing groups, but the ease of recruitment
and the numbers of expressions of interest suggest there are large
numbers of individuals who would like to engage in singing
groups if they were more widely available.
Further, as our focus was on mental health-related quality of
life, the study population was not specifically experiencing severe
mental health issues. We have undertaken an observational study
of group singing for people with enduring and severe mental
health issues over a year, and this demonstrated clinically
important improvement in mental health outcomes. The next step
in building on the pilot trial reported here should be a larger scale
multi-centre trial running over a longer period of time.
Funding
This is a summary of independent research funded by a National Institute for Health
Research (NIHR) Research for Patient Benefit grant. The views expressed are those of
the authors and not necessarily those of the NHS, the NIHR or the Department of Health.
Acknowledgements
We thank our collaborators and all the participants who contributed to the conduct of this
study.
Simon Coulton, MSc, Centre for Health Service Studies, University of Kent,
Canterbury; Stephen Clift, PhD, FRSPH, Sidney De Haan Research Centre for Arts
and Health, Canterbury Christ Church University, Canterbury; Ann Skingley, PhD,
RN, Sidney De Haan Research Centre for Arts and Health, Canterbury Christ Church
University, Canterbury; John Rodriguez, MBMA, MRCP, MFPM, FFPH, NHS Kent and
Medway, Ashford, UK.
Correspondence Simon Coulton, Centre for Health Service Studies, University
of Kent, Canterbury CT2 7NZ, UK. Email: s.coulton@kent.ac.uk
First received 29 Mar 2013, final revision 5 Nov 2014, accepted 6 Nov 2014
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10.1192/bjp.bp.113.129908Access the most recent version at DOI:
2015, 207:250-255.BJP
Simon Coulton, Stephen Clift, Ann Skingley and John Rodriguez
controlled trial
mental health-related quality of life of older people: randomised
Effectiveness and cost-effectiveness of community singing on
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