consultancy project: regular community singing … and... · consultancy project: regular community...

Belinda Sosinowicz Positive Consultancy May 2012

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CONSULTANCY PROJECT: Regular community singing for people with COPD

What Makes a Positive Singing Intervention?


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Contents 1. Executive Summary Situational Analysis

The Brief Proposed Objectives Key Findings

2. Background

Primary Client Programme Background

3. Contextual Framework

Approach Wellbeing

4. Situational Analysis Current Working Practice Key Findings: Highlights

The Role and skills of Facilitators Creating a Positive experience A Positive Workplace

5. Recommendations Key Summary

Cost Area 1: Creating a Positive experience that helps people to flourish

Priority 1: A Flourishing Programme Priority 2: Session Delivery Priority 3: Feedback to Choir

Area 2: The Role of the facilitators who deliver the sessions Area 3: A Positive Workplace. Developing Facilitator Wellbeing Priority 1: Training Priority 2: “Singing it all Together” Priority 3: Personal Development Priority 4: Positive Management

6. Theoretical basis and Evidence

Positive Psychology in the Workplace The Role of the Facilitator A Positive Experience

7. References 8. Appendices Appendix 1: Power Point Presentation Appendix 2: PowerPoint Script


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Appendix 3: Positive Employee Appraisal Appendix 4: Dunhill Protocol Executive Summary Situational Analysis The Brief This document is both a consultancy proposal for The Sidney De Haan Centre (SDHC) for Arts and Health, the client organization. This consultancy project is intended to complement the work already commenced by SDHC and inform their current research. The scope agreed with the key contact was:

• Examine how the experience of the choir is enhancing a sense of flourishing and wellbeing for participants and staff

• Present suggestions for a potential programme framework based on the

examination

• Actions for programme delivery and recommendation for practical steps that could be implemented that could inform the current SDHC research

Proposal Objectives

1. Literature review: existing research focusing on previous research by the primary client, positive psychology, arts research

2. Observe and participate with the programme in operation: attend choir sessions, meet staff and choir members

3. Review the singer’s and staff experience, current programme framework and management system

4. Survey stakeholders through survey gizmo and focus groups 5. Submit recommendations and a framework that could be implemented.

Key Findings

• The Role of the facilitators who deliver the sessions • Characteristics of a Positive Experience • A positive workplace

Background Primary Client “The Sidney De Haan Research Centre for Arts and Health is committed to researching the potential value of music, and other participative arts activities, in the promotion of well-being and health of individuals andcommunities” (http://www.canterbury.ac.uk/Research/Centres/SDHR/Home.aspx). It has completed systematic reviews and projects on “singing, well being and health”; including singing and mental health; for people with breathing problems and is currently conducting a randomized controlled trial of singing for older people with COPD.


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This RCT is the programme under examination for this consultancy project. Programme Background The research project runs from May 2011- September 2012, and is supported by a team forming an Advisory Group, which “includes experts in respiratory medicine, a patient with COPD, a director of public health, a research specialist in pharmacological interventions in COPD, and the Director of Nurse Training at the British Lung Foundation”. It aims to assess the effects of group singing on wellbeing and health and explore the potential cost savings from this kind of (Singing) activity for the NHS. (Clift, S. 2011)


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Contextual Framework Approach A whole systems, strength based, Appreciative inquiry and quasi participatory action research methodology (PAR) will be used to try and understand the experience of the programme, what works best and what could be extracted as positive experiences to create a framework. Participants were fully briefed on the project, assured confidentiality, and anonymised. The outcomes reported were explored and placed into themed wellbeing areas, incorporating the center’s previous research. (Clift, S.M., Hancox, G. 2001). Wellbeing There is an increasing acknowledgment that a range of interconnecting factors influences people’s health and wellbeing. The WHO 1 states “health as being a complete state of mental, physical, social wellbeing and not merely the absence of disease or infirmity” (WHO 1946). Within Positive Psychology, wellbeing has been defined as thriving within the world, having a perceived good quality of life and achieving optimal human potential, and that it can be further defined as “Eudemonia- a full life which is truly satisfying and Hedonic as the experience of positive affect while lacking negative affect with a focus on happiness” (Deci & Ryan 2006). For Keyes (2002), flourishing is having emotional vitality, and living rather than existing and being free form mental ill health. The New Economics Foundation (MWIA 2007) recognises that “ Wellbeing is more than just happiness. As well as feeling satisfied and happy, it means “developing as a person, being fulfilled and making a contribution to society”. Wellbeing is important not only for our psychological states but also for our physiological state. Helping or buffering the negative affects of stress and anxiety. Cohen, Doyle, Turner, Alper and Skoner (2003) suggested that positive emotion experiences were associated with greater resistance to developing the common cold, better health practices, lower basal levels of cortisol, and reports of fewer unfounded symptoms. Oxytocin contributes to our desire to build connections to others and is secreted in response to stress, touch and socially connecting. It is suggested it counterbalances the effects of stress within the human socializing process (Dickerson, S. S., Kemeny, M.E. 2004). Is also suggested that the arts contributes to positive wellbeing. In 1999 the Health Education Authority reported that their “evidence suggests that arts projects and initiatives make a unique contribution to building social capital and enhancing well-being and self-esteem but do so only where they are unique in what they have to offer and the way they deliver services” (HEA, 1999). Department of Health research also asserts “beyond reasonable doubt” that arts participation improved levels of empowerment among service users (Secker, J et al 2007).

1 World Health Organization


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Situational Analysis Current Working Practice 100 people throughout Kent are participating in 5 weekly singing groups, another 100 act as the control group. Measurements are being taken before, during and after the study to assess the impact. (See Appendix 4 for protocol). Facilitators currently run 1 session per week for 1 hour and are meeting a line manager 1 per month between 5- 180 minutes (if in a group). They discuss current and urgent issues, how the sessions are going and organisational issues. Key Findings: Highlights The Role and skills of the Facilitators A good facilitator is able to bring the group together and increase feelings of camaraderie through eliciting positive emotions and having a great sense of humour. Emotional literacy skills and wisdom are important to enable them to judge optimal functioning, when to increase or decrease repertoire challenge. Having excellent interpersonal skills, and being in control of the session, yet allowing singers to choose songs and keys helps build autonomy in singers. The facilitators display a range of strengths to draw on and appear knowledgeable about singing and music, though humble in their demonstration. Making mistakes can add to the experience of breaking barriers and group cohesion. Facilitators should not embarrass or make members feel guilty about their performance, singers must feel valued and not feel picked on. Creating a Positive Experience A number of factors were picked out as helping create the ‘right’ space to enable a ‘pleasant’ experience: When a session goes well, facilitators report they feel energized, motivated and feel that a job has been well done. Developing ‘connections’: belonging, seems to be the most important factor, e.g. not letting the side down. Strengths of humility and modesty are important for being able to listen to each other and work as a group. Singers had made new friends socializing with them outside of the group. Singers reported losing track of time, the hour passing very quickly and forgetting about their illnesses. It’s important that singers focus on the singing and not how they can talk about it afterwards, savouring and being mindful of the moment.


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The facilitator kept the momentum going with a range of different songs and kept the pace active and engaging. There was enough variation- diversity of themes chosen to keep interest, assist concentration and absorption and enable in depth focus. Some of the songs chosen were profoundly rich and meaningful to some singers. People experienced pleasure during a session with many resulting positive physiological health outcomes and motivation to return. Singers reported more able to cope with stress or anxiety through the singing, as it was uplifting. The focus on the positive emotions might offset a depressive downward cycle of negative affect (Fredrickson 2001) that was experienced by some singers, who spoke about reduction in depressive states in correlation with attendance at the group. People openly express enjoyment by smiling, laughter and through their body language, in just attending and comments afterwards. Often the feelings of pleasure and achievement stay with people for the whole day and into the following week. Being with peers whilst achieving seems to help build confidence. Singers were able to perform in other situations such as church choirs with greater confidence. Being in the choir raised their status with friends and family. A Positive Workplace Facilitators want to share their experiences and skills with other facilitators, participating in each other’s sessions, more time to spend preparing sessions and trying out new materials, which might help increasing intrinsic motivation. Satisfaction and energy. Facilitators reported sometimes feeling a full range of negative emotions during a session, which often impacted on them for the whole day. Travel is thought to be sometimes time- consuming and tiring. Administration is felt to be sometimes overwhelming, also tiring and there seems to be a feeling that some are struggling to keep up with the reporting, planning and delivery in their part time capacity.


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Recommendations Key Summary

• Embed ‘The characteristics of a Positive Experience’, in session delivery and the role of facilitators in programme delivery

• A feedback opportunity for singers to be part of an active programme development during a choir ‘away day’

• A Positive Workplace developing Facilitator Wellbeing: Training, induction, away day, personal development and positive line management

• Create a delivery tool kit Cost Support in Strengths based recruitment. £1200 Design and delivery of induction training day £1800 Design and Delivery of “Singing it all Together” staff £1800 Design and Delivery of “Singing it all Together” choir £1800 Development of plan and Delivery Toolkit £3000 Total £9600 Area 1: Creating a Positive experience that helps people to flourish Priority 1: “A Flourishing Programme” The Characteristics of a Positive Experience 1 Action: Give opportunities for singers to choose songs or keys 2 Action: Enable group harmonies, splitting group into two group harmonies.

Increase the positive emotions in the group; including opportunities for humour and laughter (but not at the expense of members)

3 Action: Shape activities so that flow can be achieved. Matching the right (Singing) skills with the right challenges, and increasing the challenge each time the skill set is achieved. Explore which types of music and songs will induce the state of flow more and which songs singers have experienced ‘chills’ or reported tingling.

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Action: Ensure that skills should match the challenge- but the challenge should be incrementally increased so that singers don’t get bored and let their minds wander. Warm up activities at the start, focus on breathing and exercise. The group can be brought back to the task in hand during the session, through breathing, being mindful of the breath, being aware of the diaphragm- which muscles etc

5 Action: Gently encourage singers to try new material, perhaps listening to it first.

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Action: Use a range of different songs, ranging from sad to happy, culturally and thematically diverse.


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Keep the pace active and lively; yet explore some songs in depth. The range of songs should be evocative as well as light-hearted.

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Action: Create an atmosphere of joy and interest. Warm up activities are fun and silly to encourage laughter. Accept when singers feel sad as well as happy emotions.

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Action: Give the right support to achieve good musical standard and to improve to a point where good performance is possible in order to inspire people. The challenge should not be perceived out of the reach of singers. It is important that self-esteem is not shaken by being criticized or teased - the facilitator must be aware of who can be teased.

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Action: Be awareness of the singing apparatus is vitally important. Tension and nervousness kill pleasure so make sure singers and facilitators check their shoulders or stomach and try to let go of tension and relax

10 Action: Feelings of pleasure come from a well-delivered session, natural affinity and empathy from the leader, the connections people have made.

11 Action: Informally teach learned optimistic strategies such as appreciating the moment, overcoming adversity, achievement, seeing learning new songs as positive challenges. The diversion from the stresses of worries can be achieved during a focused singing session. The distraction method can help stop ‘the loop in your head’. Singing could be seen as useful technique to help adults change their explanatory style from pessimistic to optimistic.

12 Action: Ensure the experience is always positive, with emphasis on positive emotions

13 Action: Ensure singers experience positive emotions frequently. Ensure new goals are achievable to increase confidence. Hitting some high notes and associated breathing problems could be a challenge for some, but the feelings of achievement outweighs the negative affect.

14 Action: Reward (verbally) the effort put in as well as the final result Priority 2: Session Delivery

• Adequate preparation time built- in for facilitators • Clear boundaries 1-hour sessions with rules of appropriate behaviour • Access to song sheet packs, currently generic to all the choirs in the

programme, future could allow for group preferences • Facilitators should arrive early enough to set out the room and have 5

minutes of mindfulness time preparing. A warm welcome. Individual rapport, use of names, eye contact, to reduce potential nervousness experienced by some when they first

• Fun, joyful and engaging exercises to start, encouraging humour, laugher and positive emotions.

• No tea break during a 1-hour session as this is seen to break the flow. • Explaining why singers are doing certain exercises


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• Authentic, positive praise and picking out what singers did best • Materials should be Light-hearted, familiar songs, interspersed with new

material • Caution in taking on favourite songs suggested by participants. These are

usually not appropriate for choir/group singing, and may hold a rather romantic view

• Group should not be too small as it is difficult to keep a cohesive, inspirational and positive atmosphere. Around 30 seem good.

• Space is important, as a ‘dingy hall’ is not appropriate to a positive experience. Good acoustics are appreciated and located where transport is easy to access and it’s not hilly.

Priority 3: Feedback to Choir Outcomes of the research reflected back to the choirs to enable people to explore, challenge and feel ownership. This may encourage sustainability e.g. finding ways to continue its delivery (fund raising, etc). Action: A modified version of “singing it all Together” for all the choirs (see Area 3, Priority 2 below) Area 2: The Role of the facilitators who deliver the sessions Action: Strength based recruitment of new facilitators including matching with the characteristics below in addition to current programme recruitment requirements.

• Sense of humour and ability to inspires interest and positive emotions • Be knowledgeable about singing and music, not necessarily classically

trained, and humble in their demonstration • Emotional literacy, good interpersonal skills, sensitively, authenticity and self

regulation • Demonstrate a range of strengths in response to difficult and challenging

situations such as prudence, creativity, and wisdom. • Good leadership skills, be in charge of the group but allow some autonomy of

group members • Supportive and encouraging and give authentic praise

Area 3: A Positive Workplace. Developing Facilitator Wellbeing Priority 1: Training Action: An induction training for all facilitators and accompanists at the start of a programme including:

• Understanding and application of the characteristics identified in the positive characteristics table in Priority 1, the characteristics that support the role of the facilitator in Area 2 and Priority 2.

• Basic medical training to understand the condition/s of members in order to avoid harmful activities or implement useful techniques- in this case, activities should relate to the anatomy and physiology of COPD and safe pulmonary rehab

• Learn some stress coping strategies for dealing with personal difficulties that could impact. Such as coping via thought disputation (Lyubomirsky 2007)


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and building positive experiences (Writing about positive experiences (King, L. 2001)

• Short training on savoring and mindfulness for personal use and input of the warm up routine.

Priority 2: “Singing it all Together” Away Day Action: Whole team managing and delivering the programme facilitated participative strategic planning away day to assess the impact and explore designing the next stage through:

Visualization and Appreciative style strategic planning methods. 2. Designed as ‘World Café’ meets “Open Space” 3.

The facilitator produces a plan for further discussion and co produces a ‘Delivery Toolkit’. Suggested Outline Select top

3 priorities

AM session

View research, displayed on the walls to inspire discussions in the day Fun musical group activity to bring out positive emotions, to enable the group to be more creative and brainstorm better

Discovery- discussion and art based activity exploring past achievements. ‘You at your best’ (Seligman 2005), and modified to ‘the organization at its best’ Strength based card (Ryan 2008) activity for individuals to assess their own strengths within the group and match tasks to strengths

SOAR 4 performance assessment: Greatest assets- discussion and written

Dream- individual and group arts Visualization exercises. ‘Best Possible Self (Team)’ (King 2001), future optimistic thinking. Includes SOAR opportunities and aspirations

Lunch View research, displayed on the walls to inspire discussions in the day

OPM Session

Design- arts based practical design activity incorporating all the top 3 priorities from each and

2 Discovery, Dream, Design, Destiny 3 Open space is a method for holding meetings that means people self-organise and focus on a key question that matters to everyone. (www.openspaceworld.org 2012) 4 Strengths- what are our greatest assets, Opportunities, Aspiration- what is our preferred future, results- what are our measurable results


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looks at designing a whole systems programme Destiny- including results, what are our measurable

results of our design?

Closing comments, sound mindful meditation to close Priority 3: Personal Development Action:

• Facilitator Co- developed large-scale performances. • Planning and writing new material

Action: Peer- review appraisals

• Sharing with other practitioners- a reflective informal confidential monthly 2- hour group discussion

• Post session 10 minutes de- brief with the musician or accompanist. • Co- training, participation in other facilitators’ sessions, share musical ideas,

positive appraise and develop new material. Action: Administration

• A shared database of online music/scores, facilitators can download their own lyrics/backing tracks/recordings of the songs

• Named administrator, to allow facilitators to spend time repairing the materials and themselves to run the sessions

• Sessions scheduled in advance where possible and familiar permanent accompanists

Priority 4: Positive Management

• Action: set up a group facilitators Facebook page to share ideas or communications

• Action: Set up a blog for reporting the sessions

Line Management Action: Positive appraisal, Shifting focus away from weaknesses and focusing on strengths. (Details in APPENDIX 5) • At least 30 minutes allocated to each meeting, 1 face to face monthly; and

Facebook group to communicate regularly


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Theoretical Basis and Evidence Using whole systems participatory approaches encourages engagement and ownership (Stairs and Gilpin 2010). Here the suggestion is incorporating Strength based methods, making use of strengths before addressing the weaknesses (Linley 2008), Appreciative Inquiry exploring what works well, clarifying conditions of success and then strengthening them, Sharing values and building on strengths and that whatever you want more of already exists in the organization (Hammond, S. A 1998). Open Space and World Cafe enables authentic open dialogue and self-organising. (www.openspaceworld.org 2012). “Participatory Action Research is a recognized form of experimental research that focuses on the effects of the researcher's direct actions of practice within a participatory community with the goal of improving the performance quality of the community or an area of concern”. (Dick, 2002; Reason & Bradbury, 2001; Hult & Lennung, 1980; McNiff, 2002). Positive Psychology in the Workplace Employee Engagement and Strengths The many benefits to employee engagement include less time off and higher commitment (Stairs and Gilpin 2010). It is important to find what will engage facilitators, matching tasks to strengths and talents which been linked to employee engagement and satisfaction (Harter, Schmidt, & Hayes, 2002). Strengths based approaches enable people to work consistently and be more energized, as they are using their innate talents. (Hodges, T D. & Asplund, J. 2010). The Role of the Facilitator Studies by Barsade (2002) showed that leaders are often seen as role models and as such caninfluence member’s behaviour. If a leader can display positive emotion this is likely to affect the singers and spread throughout a group. (Frederickson 2003). Facilitators are able to create positive environments that help retention of members. (Eley, R, Gorman, D & gately, J 2010) Emotional literacy also has a key role, working instinctively, and being able to notice and recognize facial expressions and re direct the session accordingly (Mayer & Salovey 1990), managing strong feelings like anger, fear and disappointment, amplifying positive emotions, recognizing and understanding the feelings of others and showing empathy and support (Toni Noble, T., & Helen McGrath, H. 2011). By fostering a growth mindset Carol Dwek (2002) suggests that praise should be centered on the effort made to improve achievement. Praise only (to boost self esteem may feel good but ultimately it devalues praise and confuses people to what the legitimate standards are- indiscriminate praise is more likely to contribute to self- inflated self-esteem. A Positive Experience Key Characteristics A number of proposed characteristics can be observed in a perceived positive experience such as pleasant feelings, positive emotions, being absorbed, interest,


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being present, depth, intrinsic, relatedness, Qualia (feeling something), liveliness, novelty, openness and feeling alive (Nash 2012). This section explores the presence of some of these characteristics with those that supports wellbeing outlined in previous research (Clift & Hancock 2001) to develop its framework. Developing ‘connection’ and a sense of ‘camaraderie’ between the group members. Evidence confirms that social connecting is strongly linked to subjective well being, which relates robustly to happiness and life satisfaction, both directly and through their impact on health and wellbeing. (Helliwell & Puttman 2004). People in positive mood are more likely to connect (Coalition and friendships; (Frederickson et al (2003) 9/11). Autonomy or the perceived control people have is cited as a “primary need and source of Satisfaction to people across diverse cultures” (Sheldon, Elliot, Kim, & Kasser, 2001). Flow and absorption is one of the areas Csikzentmihalyi (1997) postulates can create flow experiences. Creative projects have the capability to challenge and stimulate people, develop their skills. It is this challege skills balance that extends and stretches that is one of the key attributes to experiencing flow. (Csikzentmihalyi 1997. It is reported that music was connected with significant moving experiences (Hunter, B, C. 1999). Studies also report that this tingling or ‘emotional chills’ can be indicative of emotional peaks and that there may be a relationship between this and subjective wellbeing (Panksepp, J, (1995) Studies show that having positive experiences might over time also build resilience, not just reflect it. Positive emotions could enhance people’s emotional wellbeing (Fredrickson 2001) and are also seen as facilitators of posttraumatic growth, factors of which were presented by singers (Linley and josephs 2004a). Additionally humour may play an effect in being able to distance oneself from distress (Leftcourt, 2005). As positive emotions can buffer against anxiety (Fredrickson 2001), self- esteem can also be energized to reduce the death anxiety and feelings of vulnerability that humans feel (Joshua Hart, Phillip R. Shaver, and Jamie L. Goldenberg 2005). Associated is self-efficacy defined by Bandura (1986) as “the belief in one’s capabilities to organize and execute the source of action required to manage prospective situations”. When self-efficacy is high, and a person believes that that can do what is required then they are more likely to succeed. Having hope supports wellbeing, as having a pessimistic explanatory style is found to be correlated with greater illness (Peterson, Seligman & Vaillant 1988; Peterson 1988). People are motivated by very different factors (D and R 1991). In this case, although many singers are initially extrinsically motivated due to potential lung function improvement, the experiences they have whilst there, results in all other distracting information such as thoughts and worries to exit consciousness. It could also be that on par with the self- Determination continuum (Ryan & Deci, 2000) that their extrinsic motivation to go to the class is developing into intrinsic motivation by


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means of introjection, internalization and integration of what is occurring during positive states. Singers identified with many of the main growth perceived changes such as becoming stronger, more confident, being more open, more alive, humble, connected, with post traumatic growth. (Tedeschi & Calhoun, 1995, p. 456). “It is through this process of struggling with adversity that changes may arise that propel the individual to a higher level of functioning than which existed prior to the event” (Linley & Joseph, 2004b, p.11). Past research has shown that training in mind fullness helps well-being outcomes in a variety of populations. Kabat-Zinn and colleagues have shown that a standardized 8-week mindfulness-based stress reduction (MBSR) program can help reduce psychological symptoms among anxiety (Kabat-Zinn et al., 1992)


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APPENDIX APPENDIX 1 PowerPoint Presentation


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APENDIX 2 PowerPoint Script Slide 1 Welcome to this presentation. Today I am presenting a study looking at developing a practical guide for running community singing projects for people with COPD, intended to complement the research already commenced by SDHC. I focused on understanding how your project contributes to a sense of flourishing for participants and staff, and recommendations in creating a guide. Slide 2 I met Professor Stephen Clift in December 2011 to discuss the project. A carefully designed questionnaire on Survey Gizmo was distributed to staff and choir members and a focus group held, to find out a bit about the project. I used a recognised strength based method to try and understand the experience of the programme, what worked best and what could be extracted as positive experiences to create a guide. I was lucky enough to sing with choirs: Whitstable and Folkstone. I had a great time, and really experienced some of the positive benefits. Slide 3


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A Major finding and supported by evidence, was that the facilitator seems key to the choir’s experience. Strong, fun and empathetic and able to create a positive experience. There are some recognized characteristics that help create the ‘right’ space in which to feel good, so when a session goes well, facilitators report that they feel energized and motivated and feel that a job has been well done. Staff management support and peer- review structure was also a finding: notably those facilitators wanted a chance to meet with each other more often and develop music together. Slide 4 I hope that the guy on the slide is not indicative of this experience! A number of characteristics have been perceived such as pleasant feelings, positive emotions, being absorbed, interest and feeling alive. The main one cited by the group was a sense of ‘camaraderie’ between the group members, reported in different ways and again, supported by evidence that tells us this is a really important feature of having a good experience. Singers report the strengths of humility and modesty as being important to help this, listening to each other and work as a group. Slide 5 Following an analysis of the experiences and existing research, I developed a list of characteristics that could be embedded into the programme. Some of these you do already- but it was useful to include all your current work and the ones I came up with. So for example: Increase the positive emotions in the group; including opportunities for humour and laughter (but not at the expense of members) The whole team should have a facilitated participative strategic planning away day to assess the impact of the programme and spend time together As the role of the facilitator is so essential I would also recommend some training in understanding the experiences and include this in all induction training for new recruits. There are also some ideas for blog based feedback and Facebook communications I would also suggest the development of a delivery toolkit reflecting the responses from the away days and additional meetings I would have with the team. Thank you for listening to my presentation. Any questions?


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APPENDIX 3 POSITIVE EMPLOYEE APPRAISAL When appraising facilitators a method Cameron describes as ‘Best Self Feedback’ could be used in order to raise the self esteem of the facilitators. Rather than appraise them against a pre- determined set of values and goals set out by the job description, but rather create pictures of the unique contribution made by the facilitator to the project and to the lives of the choir members and the other staff members. This method can elicit feelings of pride, gratitude and aspiration. (S Lewis 2011). The facilitator chooses 20 people they know in their lives and asks them to respond to 3 questions about themselves. I would suggest:

• When you have seen me be at my best, which strengths do you think I was using?

• When have you seen be doing something and admired me for it? • When do you think I am truly engaged and absorbed by something- and

what was I doing? • When have you seen me displaying a real sense of energy and

engagement? • When have you seen me make a valuable contribution to something?

The person draws out the key themes and develop their best- self strengths (Linley A+)- can put their best energy towards achieving their jobs People can capitalise on those strengths and work with them. They will play to their strengths, have consistent positive feedback and feel as though they are flourishing (Lewis 2011) People can start to recognise their own remarkable abilities, internalising this improving their own self worth and self esteem (Lewis 2011)


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APPENDIX 4 Regular community singing for people with COPD: A quasi-experimental evaluation to assess effectiveness, Cost-effectiveness, feasibility and acceptability

“I am an ex-coal miner who also smoked, resulting in emphysema. The classes help me to control and live with my problems. The breathing exercises are calming and soothing, relieving the pain of breathlessness and fear of the future. I find singing surprisingly beneficial. Learning to breathe at the right time may sound laughable, but to anyone with a lung problem it can be a great help.” Sid, Brighton Breatheasy Singing Groupi

1 BACKGROUND COPD is an umbrella term for a number of specific conditions leading to irreversible airflow obstruction including bronchitis and emphysema. Diagnosis relies on a combination of history, physical examination and confirmation of airflow obstruction using spirometry.ii Four stages of COPD severity can be distinguished– mild, moderate, severe and very severe.iii Severe COPD is indicated by an FEV1 of <50% and >30% of expected values for age and sex, and very severe indicated by an FEV1 value of <30%. The most common debilitating symptom of COPD is breathlessness,iv which often leads to inactivity, isolation and dependence. Pulmonary Rehabilitation can improve physical activity and quality of life, although the benefits depend upon continued adherence to physical activity.v COPD is associated with other, often smoking-related long-term health conditions including cardiovascular disease, osteoporosis and depression.vi As Jones notesvii COPD is characterised by ‘a spiral of decline’: ‘As COPD progresses, patients fail to exercise, feel depressed, and experience low self-esteem.’ In England, approximately 835,000 people have been diagnosed with COPD, but the true prevalence is likely to be over 3 million.viii In an average UK health district of 250,000 people, GPs will have 14,200 consultations a year from patients with COPD and 680 patients will be admitted to hospital.ix Exacerbation of COPD is the second most common cause of emergency admissions to hospitals in the UK and one of the most expensive conditions treated by the NHSx with direct costs of £810-930 million per year, which are expected to rise.xi COPD mainly affects people beyond retirement age, but 24 million lost working days a year are due to COPD.xii The Department of Health consultation on a strategy for COPD in Englandxiii highlighted the need to improve prevention efforts, support early identification, ensure accurate diagnosis and ensure high quality care of people with the disease and at the end of life. The strategy ‘lays great emphasis on local health and social care and the third sector taking responsibility for contributing to service change and improvement.’ Such trends will receive stronger emphasis given the current government’s ‘Big Society’ agenda and the provisions of the 2010 White Paper on the NHS.xiv Innovative, cost-effective initiatives are needed to help people with COPD engage in physical and social activity to support independence and quality of life. This proposal outlines a study to explore the value of regular group singing in promoting wellbeing. Currently this is an under-researched field. Surveys have shown that choral singers believe that singing improves their breathingxv but comparison of lung function in professional singers versus wind and percussion players, failed to show significant differences in standard spirometric parameters.xvi There is some


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evidence, however, that group singing may be beneficial for people with chronic respiratory disease by modifying breathing patterns, reducing breathlessness, and improving quality of life and social and psychological wellbeing. Engen (2005)xvii recruited participants from a gerontology clinic and pulmonary rehabilitation clinic who had a diagnosis of emphysema. Twelve participants met in small groups twice a week for six weeks. None of the physical health and quality of life measures employed showed improvements over the six weeks of the study, but measures of breath control and voice intensity both improved significantly. In addition, breathing mode changed from being ‘predominantly clavicular to 100% diaphragmatic that was maintained two weeks after the treatment sessions ended.’ Bonilha et al. (2008)xviii report a small randomised controlled trial assessing the impact of singing groups on lung function and quality of life among patients diagnosed with COPD. This study randomised 43 patients to a programme of singing or handcraft classes. Fifteen participants in each group completed 24 sessions. While the control group showed a decline in measures of maximal expiratory pressure, the group involved in singing showed a small improvement. Both groups showed increased quality of life scores with no significant difference, emphasising the benefits of group work. A small trial examining the effects of singing lessons for patients with COPD has been completed at the Royal Brompton Hospital, London. xix Thirty-six COPD patients (mean FEV 37.2% predicted) were randomised to either 12 one-hour sessions of singing lessons over six weeks, or usual care. Following attrition 15 patients in the singing group were compared with 13 controls. Significant improvements were found in levels of anxiety and self-assessed physical wellbeing in the singing group. No differences were found between the groups for ‘single breath counting, incremental shuttle walking test (ISWT) scores or recovery time following ISWT and intriguingly breath-hold time increased more in the control group than the singing group. To date, therefore, research on singing and COPD has been limited, with small sample sizes and short interventions in clinical settings focused on the teaching of singing. The study proposed here is timely. It will address the limitations of previous research through a community-based study with a larger group of participants in five singing groups meeting weekly over a longer period of time. In addition to teaching singing techniques and rehearsals, the groups will work towards combined performance events.xx 2 THE PROPOSED STUDY: Community singing and COPD The MRC has set out a framework for the development and evaluation of complex interventions.xxi This study represents the modelling stage in the framework and is necessary to establish the potential for effectiveness and cost-effectiveness, the nature of the likely effect sizes and the feasibility of the intervention in normal clinical community practice. 2.1 Aims The study is a quasi-experimental pilot evaluation of the potential effectiveness, cost-effectiveness, feasibility and acceptability of regular singing for people with COPD. 2.2 Objectives Specific objectives of the proposed study are to provide evidence relating to:

i. The effect of participation in regular singing on clinical measures of COPD (see below).


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ii. The variability of the standard deviation of any effect in order to calculate appropriate sample size for future studies.

iii. The effect on measures of health related quality of life. iv. Interactions between demographic and clinical factors that may impact on

observed outcome. v. Recruitment and retention rates and preferences for singing as an

intervention in this population. vi. Costs associated with delivery of the intervention and costs (savings)

associated with the intervention in order to model the potential cost-effectiveness of the intervention.

vii. Patient satisfaction with the intervention (measured by questionnaire and explored by interview).

2.3 Design A non-randomised quasi-experimental design will be employed. Following the NIHCE guidelines on ‘person-centred care’ in COPD,xxii this study will recruit individuals into singing groups who express a preference for participating in this activity. A ‘usual care’ control group will consist of individuals meeting the same inclusion criteria, who are willing to participate in the study, but who do not wish to sing. Five singing groups will be established in or near Ashford, Whitstable and Ramsgate, areas of Kent known to have a high prevalence of COPD.xxiii 2.4 Recruitment

i. A mailed invitation to patients on the COPD registers within large GPs practices serving the Ashford, Whitstable and Ramsgate areas

ii. A mailed invitation to patients referred to the East Kent Pulmonary Rehabilitation Service over the previous year

iii. A mailed invitation to members of the British Lung Foundation network of Breathe Easy groups in East Kent

Inclusion criteria i. Severe or very severe COPD as assessed by post-bronchodilator

spirometry at baseline ii. MRC dyspnoea score of at least 3 as assessed at baselinexxiv iii. Physically mobile and able to travel to sessions independently or with the

support of a carer iv. Willing to commit to participating in the project over the course of 18 months

(health permitting) v. Able to speak English and complete questionnaires in English

Exclusion criteria i. Severe dementia or other cognitive or communication disabilities which

renders consent problematic ii. Severe co-morbidities which contra-indicate participation on the advice of

GPs 2.6 Sample size and power The aim of the study is to provide evidence of potential effectiveness and cost-effectiveness prior to committing to a larger randomised controlled trial. Formal hypothesis testing between groups will not be undertaken and as such the study is not powered for hypothesis testing. We estimate 200 participants would be sufficient for the study with a conservative estimate of 50% of these being followed up at 12 months. A minimum of 50 observations in each group provide a sufficient number of subjects to provide estimates of effect sizes within groups and the variability of the standard deviations.


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2.7 The intervention Singing groups will be led by skilled and experienced singing leaders. The facilitators recruited will undergo five days training and will meet regularly throughout the project to ensure a broadly consistent approach. The singing programme will take place in the five groups over three twelve-week blocks. Groups will come together at the end of each block for a choral workshop and performance event. Each session will last 90 minutes, with break for socialising. Sessions will commence with 30 minutes of relaxation, posture, breathing and vocal exercises followed by singing. A wide common repertoire of familiar and new songs will be available in a high quality song book. Participants will also steer the musical direction of their group according to their interests. Keeping the programme fresh, enjoyable, stimulating and stretching is essential for a project planned to run over the course of one year. Songs will be taught by ear and will be sung without accompaniment. Participants will also receive specially prepared CDs of exercises and songs to practice at home at the start of each block of sessions. A partner, friend or family member of the person with COPD recruited into the singing groups may also attend the groups to provide support. 2.8 Methods

i. Spirometry with a qualified health professional, to assess FEV1 , FVC and FEV1 / FVC both before and after bronchodilation

ii. St. George’s Respiratory Questionnaire (SGRQ) – a widely used measure of health impairment employed in research on chronic respiratory illness and COPD.xxv Four scores are produced: symptoms, activity, impacts and total. Different versions of the questionnaire are available covering period of symptom recall over one month, three months and a yearxxvi

iii. MRC Dyspnoea Scale – self-rated breathlessness on a six-point scalexxvii iv. York SF-12 – a 12-item questionnaire which assesses physical and mental

health and can provide health utility scores v. EQ-5D – a 5 item health status questionnaire which provides health utility

scores, very widely used in health economic assessments of health interventions

vi. A COPD-specific health services utilisation questionnaire enquiring about health services accessed during the previous year (including GPs visits, other health professional consultations, medication used, oxygen used, and hospital admissions with exacerbations).

vii. A patient satisfaction questionnaire developed specifically to measure patients’ overall satisfaction with the care they receive.

SGRQ, SF-12 and EQ-5D have been used in a study of quality of life in patients with severe COPD hospitalised for exacerbations.xxviii In studies measuring quality of life of patients with COPD it is recommended that both the clinically specific SGRQ and more generic measures are used.xxix At baseline both groups will complete the questionnaires and have spirometry measures taken. Questionnaires will be completed by post for both groups at 4, 8 and 12 months and spirometry will be undertaken by both groups immediately after the end of the intervention. A patient satisfaction questionnaire will be completed by both groups at 12 months. Interviews will also be conducted with selected members of the singing groups to document personal experiences of the intervention. 2.9 Statistical analysis The major objective of this pilot study is to provide evidence on the feasibility and


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necessity for a more complex and scientifically rigorously controlled randomised controlled trial. In order to assess effects for clinically specific and generic outcome measures we will conduct an analysis of covariance at 12 months taking account of baseline prognostic factors. The analysis will be conducted within each group rather than a comparison across groups. In addition we will explore the variability observed (standard deviation), to inform further sample size calculations. As this is a group intervention we will assess clustering effects by calculating the intra-class correlation. We will also explore: potential predictors of outcome using linear regression; potential baseline x treatment interactions; preference rates in the eligible population and recruitment and retention rates in both groups. Such data is essential to inform further studies. 2.10 Health economics evaluation A critical element in modelling complex interventions is the estimation of economic benefit to the NHS and wider society. We will assess the intervention from a health and social care perspective using NICE guidelines (NICE 2004)xxx and a wider public sector resource perspective (NICE 2006).xxxi The costs associated with running singing groups will be assessed using actual resource costs for these activities using local service costs including costs for premises and managerial overheads. The participants’ use of health, social care or welfare services will be assessed at baseline, 4, 8 and 12 months using a specifically designed service use questionnaire relevant to COPD patients. Units of resources used will be combined with national sources of unit costs (e.g. Curtis, 2007xxxii; DH reference costs 2007xxxiii). Because the resource use occurs within a 12 month period no discounting will be applied. The EQ-5D will be used with population values and the quality adjusted life year (QALY) change calculated using the area under the curve method. The relative costs and effect, measured in QALY’s, will be combined for each group to provide an indication of any potential economic benefits of the intervention and an indication of whether the intervention is economically viable. 2.11 Clinical governance, research governance and ethical approval Standard clinical and research governance procedures will be followed. Ethical approval will be sought from the Faculty of Health and Social Care Research Ethics Committee of Canterbury Christ Church University and a local NHS Research Ethics Committee. The study will be conducted in accordance with MRC good practice guidelinesxxxiv and the Declaration of Helsinki.xxxv 3 OUTCOMES AND OUTPUTS The study will provide pilot evidence includes whether regular group singing benefits COPD patients’ quality of life and control of breathlessness and evidence on potential cost savings associated with singing groups as an intervention. The study will establish and maintain a network of singing groups for patients with COPD will contribute to the development of a practical guide for establishing, running and evaluating such groups elsewhere. The project will provide a basis for further larger-scale controlled studies on singing and COPD. 4 DISSEMINATION Dissemination will be through a final report completed by Easter 2013, conference presentations and publications in peer-reviewed scientific journals. We will work closely with the British Lung Foundation (BLF) to communicate our findings to health professionals and patients with COPD. Members of the choirs could


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perform at conferences, annual meetings of organisations such as the BLF, and special dissemination events to mark World COPD Day in November 2013.xxxvi 5 RESEARCH TEAM

• Prof. Stephen Clift - overall direction and theoretical and empirical input on singing and health

• Dr. Ian Morrison - day to day management of the project • Dr. David Smithard - clinical governance, research governance, ethics,

expertise in gerontology • Dr. Alasdair Stewart - medical interpretation and implications of findings • Prof. Simon Coulton - design, statistical and health economics expertise • Ms. Sonia Page - musical direction for the project, lead singing groups, train

facilitators • Ms. Pauline Treadwell - recruitment of participants into the study,

supervision of spirometry 6 RESEARCH ENVIRONMENT The Sidney De Haan Centre for Arts and Health is the UK’s leading research centre concerned with music and health. It has completed systematic reviews of research on singing, wellbeing and health,xxxvii conducted a cross-national survey of choral singers in England, Australia and Germany,xxxviii and evaluated singing groups for older people run by the UK charity ‘Sing For Your Life’.xxxix On-going projects include an NIHR-funded randomised controlled trial of singing groups for older people,xl a PCT-funded evaluation of a network of singing groups for people with severe and enduring mental health issues,xli and a pilot study on singing for breathing for people with a wide range of breathing difficulties.xlii The Centre for Health Service Studies (CHSS), University of Kent, is an internationally recognised UK centre of excellence for health service research and evaluation. CHSS is also part of the NIHR RDS network within the South East of England. Strong links are in place with health professionals locally providing care for COPD patients. The project is supported by an Advisory Group, which includes a GP with specialist interest in respiratory medicine, a consultant in respiratory medicine, an expert patient with COPD, a community pharmacist with a specialist interest in COPD, a director of public health, a research specialist in pharmacological interventions in COPD, and the Director of Nurse Training at the British Lung Foundation. 7 COSTS AND JUSTIFICATION Details of costs are given on the application form and this section provides justification for the main items of expenditure. All members of the team will be invited to Steering Group meetings (with costs covered) and will be engaged in report writing. A detailed excel spreadsheet is available. Stephen Clift requires 10 days for overall responsibility for the project, to ensure smooth working within an inter-disciplinary team and chair 8 half-day Steering Group meetings. Simon Coulton requires 44 days to undertake data analysis, the health economics assessment. Ian Morrison requires 264 days for day-to-day management of the project. He will attend all singing groups during the first block approximately half in the 2nd and 3rd blocks. Most of the travel costs relate to this activity. One or more Respiratory Nurse will undertake the spirometric assessments of 200 patients at baseline and 200 at 12 months. We assume 90 minutes are needed per patient. Given practical issues of appointments it is expected that an average of five


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patients will be seen per day = 80 days work. Pauline Treadwell requires 44 days to manage recruitment of participants via GP practices, pulmonary rehabilitation service and Breathe Easy groups, and monitor assessments to ensure the gathering of robust data. Costs for mail shots are based on estimates provided by a local general practice. Sonia Page requires 88 days to develop the musical programme, create CDs for participants, train additional facilitators and lead a group herself. Community musicians are required to lead singing groups (4 groups x 40 sessions = 160 half-days). Group leaders will also be given time to complete regular reports on their observations of the group and feedback from participants. Administration: 20 days of administrative support are needed during the field phase of the project to ensure accurate personal records of attendance, follow up absences from groups and filing of data from assessments and questionnaires. Alistair Stewart and David Smithard require 5 days each to provide on-going guidance, support the ethical application and clinical governance processes, and help to interpret findings from the study. Materials and equipment: funds are required to produce high quality musical materials - song books and CDs of the exercises and songs. Estimates are based on De Haan Centre experience of similar projects. Audio recording, transcription and DVD resource: costs for professional recordings of the groups singing, interviews from the research team, group facilitators and participants based on the De Haan Centre’s experience of completed projects. The filmed material will be of particular value in disseminating information about the process of the project and its outcomes. Dissemination: costs to support the production of a final report and for dissemination events based on our experience of previous projects. Given the role of performance in the project we envisage that members of the singing groups could form a choir for performance at COPD conferences and related events (e.g. the annual general meeting of the British Lung Foundation). The performance of the choir and personal testimonies would make a more substantial impact on an audience than a standard academic presentation. Travel costs based on previous experience of such events. 8 INDICATIVE TIMETABLE 2011 Activities Steering Group Key milestones January Preparatory work Meeting 1 February Ethical approval

submitted

March Preparatory work April Preparatory work Research governance

and ethical approval obtained

May Recruitment Meeting 2 June Recruitment Target numbers for the

study achieved July Baseline assessment -

spirometry

August Baseline assessment - spirometry

Baseline completed

September Singing Meeting 3 Start of intervention October Singing November Singing, Workshop, First follow up


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Performance December 2012 January Singing Meeting 4 February Singing March Singing, Workshop,

Performance Second follow up

April May Singing Meeting 5 June Singing July Singing, Final

performance Third follow-up

August Final assessment – spirometry, interviews

September Final assessment – spirometry, interviews

Meeting 6 Final assessment completed

October Data analysis November Data analysis December Data analysis Meeting 7 Data analysis completed 2013 January Report writing February Report writing March Report writing April Final report Meeting 8 Final report and DVD

delivered May Preparation of papers June Preparation of papers July Preparation of papers August September Dissemination events Press release, media

coverage Local dissemination event to NHS professionals, GP Practice-based commissioners, COPD patients

October Dissemination events Choir at a national COPD conference

November Dissemination events World COPD Day 2013 December Dissemination events Local Christmas carols


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9 REFERENCES iTheBrightonBreatheasySingingGroupwasestablishedin2008forpeoplewithbreathingdifficultiesincludingCOPDwithfundingfromBrightonandHovePCT.ThegroupisledbymusicianandsingingteacherUditaEveritt.See:http://www.uditamusic.co.uk/voice_coaching.htmliiNationalInstituteforHealthandClinicalExcellence(2010)QuickReferenceGuide:ChronicObstructivePulmonaryDisease,London:NIHCE.iiiGlobalInitiativeforChronicObstructiveLungDisease,see:http://www.goldcopd.com/ivDiagnosingCOPD,Thorax2004,59,i27‐i38,accessedfromwww.thorax.bmj,comvBritishThoracicSociety/BritishLungFoundation(2002)PulmonaryRehabilitationSurvey,London:BTS/BLFviFletcher,M.,vanderMolen,T.,Salapatas,M.andWalsh,J.(2010)COPDUncovered,London:EducationforHealth.http://www.educationforhealth.org/data/files/news/copd_report.pdfviiJones,P.W.(2009)Healthstatusandthespiralofdecline,COPD,6,59‐63.viiiDepartmentofHealth(2010a)ConsultationonaStrategyforServicesforChronicObstructivePulmonaryDisease(COPD)inEngland,London:DoH.ixBritishThoracicSociety/BritishLungFoundation(2002)ibidxBritishLungFoundation(2007)Invisiblelives:ChronicObstructiveLungDisease(COPD)findingthemissingmillions,London:BLF.xiDepartmentofHealth(2010a),ibidxiiBritishThoracicSociety/BritishLungFoundation(2002)ibidxiiiDepartmentofHealth(2010a)ibidxivDepartmentofHealth(2010b)Equityandexcellence:LiberatingtheNHS,London:TheStationaryOffice.xvClift,S.andHancox,G.(2001)ThePerceivedbenefitsofsinging:findingsfrompreliminarysurveyswithauniversitycollegechoralsociety.JournaloftheRoyalSocietyforthePromotionofHealth,121,4,248‐256.Clift,S.,Hancox,G.,Morrison,I.,Hess,B.,Kreutz,G.andStewart,D.(2009)Whatdosingerssayabouttheeffectsofchoralsingingonphysicalhealth?FindingsfromasurveyofchoristersinAustralia,EnglandandGermany,EuropeanSocietyfortheCognitiveSciencesofMusic(ESCOM)Conference,Jyvaskyla,Finland,12‐16August,2009.xviClift,S.,Hancox,G.,Staricoff,R.andWhitmore,C.(2008)Asystematicmappingandreviewofnon‐clinicalresearchonsingingandhealth.SidneyDeHaanResearchCentreforArtsandHealth,CanterburyChristChurchUniversity.Availablefrom:http://www.canterbury.ac.uk/centres/sidney‐de‐haan‐research/xviiEngen,R.(2005)Thesinger’sbreath:Implicationsfortreatmentofpersonswithemphysema.JournalofMusicTherapy,42,20‐48.xviiiBonilha,A.G.,Onofre,F.,Vieira,L.M.etal.(2008)EffectsofsingingclassesonpulmonaryfunctionandqualityoflifeofCOPDpatientsInternationalJournalofCOPD,4,1,1‐8.xixLordV.M.,Cave,P.,Hume,V.etal.(2010)Singingteachingasatherapyforchronicrespiratorydisease–randomisedcontrolledtrialandqualitativeevaluation,BMCPulmonaryMedicine,10,41,ArticleURLhttp://www.biomedcentral.com/1471‐2466/10/41.ForaBBCreportonthisproject,withCOPDpatientssinging:http://news.bbc.co.uk/1/hi/england/8189957.stmxxArecentreportfromAustraliashowsthatadesireforperformanceemergedspontaneouslyinasinginggroupforolderpeople‘withphysicalandmentalfrailties’:Davidson,J.W.andFaulkner,R.(2010)Meetinginmusic:Theroleofsingingtoharmonisecarerandcaredfor,Arts&Health:AnInternationalJournalforResearch,PolicyandPractice,2,2,164‐170;Performanceisincreasinglyseenashavingavaluableroleincommunitymusictherapyinterventions:Pavlicevic,M.andAnsdell,G.(2004)CommunityMusicTherapy,London:JessicaKingsley.Thecapacityofelderlypeopletoperformmusicallyisclearlydemonstratedbyhigh‐profileprojectssuchas‘Young@Heartchorus’,see:http://www.youngatheartchorus.com/and‘TheZimmers’,see:http://www.thezimmersonline.com/Welcome.htmlxxiMRC(2008)DevelopingandEvaluatingComplexInterventions:NewGuidance.London:MedicalResearchCouncil


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xxiiNationalInstituteforHealthandClinicalExcellence(2010)ibidxxiiiWhitmore,C.andLimentani,S.(2009)EastKentCOPDNeedsAssessment,PublicHealthDirectorate,NHSEasternandCoastalKentPrimaryCareTrust.xxivTheMRCscaleisadaptedfrom:Fletcher,C.M.,Elmes,P.C.,Fairbairn,M.B.etal.(1959)Thesignificanceofrespiratorysymptomsandthediagnosisofchronicbronchitisinaworkingpopulation.BritishMedicalJournal,2,257–66.ThescaleisasimpleandvalidmeasureofdisabilityforusewithCOPDpatients.See:Bestall,Paul,Garrodetal.(1999)UsefulnessoftheMedicalResearchCouncil(MRC)dyspnoeascaleasameasureofdisabilityinpatientswithchronicobstructivepulmonarydisease,Thorax,54,581‐586.Stenton,M.(2008)TheMRCbreathlessnessscale,OccupationalMedicine,58,226‐227.xxvThestandardSGRQwillbeusedinpreferencetotherecentlydevelopedSGRQ‐CquestionnaireforusewithCOPDforseveralreasons:1.TheSGRQiswidelyusedinclinicalpractice,includingacrossEastKent,2.ThereisaconsiderablebodyofresearchevidenceavailableusingtheSGRQandasfewstudieshaveemployedtheSGRQ‐C.3.TheevidencefromthevalidationoftheSGRQ‐Csuggeststhatthescoresproducedareverysimilartothosefromtheoriginalquestionnaire.TheSGRQissupplementedwiththreeadditionalmeasurestoensureabroadassessmentofhealthstatus,wellbeingandqualityoflife.xxviStGeorge’sRespiratoryQuestionnaireManual,Version2.2,March2008,availablefrom:http://www.healthstatus.sgul.ac.uk/xxviiSeeendnotexxiabovexxviiiMenn,P.,Weber,N.andHolle,R.(2010)Health‐relatedqualityoflifeinpatientswithsevereCOPDhospitalisedforexacerbations–comparingEQ‐5D,SF‐12andSGRQ,HealthandQualityofLifeOutcomes,8,39,doi:10.1186/1477‐7525‐8‐39xxixDaudey,L.,Peters,J.B.,Molema,J.etal.,(2010)HealthstatusinCOPDcannotbemeasuredbytheStGeorge’sRespiratoryQuestionnairealone:anevaluationoftheunderlyingconceptsofthisquestionnaire,RespiratoryResearch,11,98,doi:10.1186/1465‐9921‐11‐98xxxDetailssee:http://www.nice.org.uk/xxxiDetailssee:http://www.nice.org.uk/xxxiiCurtis,L(2007)UnitCostsofHealthandSocialCare,Canterbury:PSSRU,UniversityofKent.Themostrecentlyavailablecostestimateswillbeemployed.xxxiiiFordetails:http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_098945Themostrecentlyavailablecostestimateswillbeemployed.xxxivMRC(2005)GoodResearchPractice,London:MedicalResearchCouncil.Availablefrom:http://www.mrc.ac.uk/Utilities/Documentrecord/index.htm?d=MRC002415xxxvDeclarationofHelsinki(1964)Availablefrom:http://www.who.int/bulletin/archives/79(4)373.pdfxxxviWorldCOPDDay,see:http://www.goldcopd.com/wcdindex.asp#xxxviiClift,S.,Hancox,G.,Staricoff,Retal.(2008)Asystematicmappingandreviewofresearchonsingingandhealth,Canterbury:CanterburyChristChurchUniversity.Availablefrom:http://www.canterbury.ac.uk/centres/sidney‐de‐haan‐research/arts‐health.aspClift,S.,Nichol,J.,Raisbeck,M.andMorrison,I.(inpress)Groupsinging,wellbeingandhealth:Asystematicreview,UNESCOObservatoryJournalxxxviiiCliftS.andHancox,G.(2010a)Thesignificanceofchoralsingingforsustainingpsychologicalwellbeing,MusicPerformanceResearch,3,1,79‐96.Clift,S.,Hancox,G.,Morrison,I.etal.(2010)Choralsingingandpsychologicalwellbeing,JournalofAppliedArtsandHealth,1,1,19‐34.xxxixSkingley,A.andBungay,H.(2010)TheSilverSongClubProject:singingtopromotethehealthofolderpeople,BritishJournalofCommunityNursing,15,3,135‐140.Bungay,H.,Clift,S.andSkingley,A.(2010)TheSilverSongClubProject:asenseofwellbeingthroughparticipatorysinging,JournalofAppliedArtsandHealth,1,2,165‐178.xlTheSilverSongClubResearchProjectinvolvespeopleaged60+randomisedtofivecommunitysinginggroupsorwaitingcontrolgroups.Theeffectsofweeklysingingover12weeksisbeingassessedusingtheSF12,HADS,EQ‐5Dandahealthandsocialcareutilisationquestionnaire.xliClift,S.,Morrison,I.andHancox,G.(2010)FindingsfromtheEastKent‘SingingforHealth’NetworkProject,paperpresentedatthe20thIUHPHEWorldConferenceonHealthPromotion,Geneva,11‐15July2010.ForaBBCWorldService‘HealthCheck’filmonthisprojectsee:http://www.bbc.co.uk/news/health‐10732106xliiSeetheBritishLungFoundationmagazinereport:Tuneyourlungs:Issingingreallygoodforyou?ApilotprojectinFolkestoneishopingtofindout,BreathingSpace,2010,Issue20,4‐5.

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