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Shared Reading as Mental Health Promotion Among Newly Retired Men: Design of a feasibility study

Director, The Danish Reader Association
Humanitarian Consultant, DaneAge Association
Postdoc., Department of the Study of Culture, University of Southern Denmark
PhD Student, National Institute of Public Health, University of Southern Denmark
Research Assistant, National Institute of Public Health, University of Southern Denmark
Professor, Department of the Study of Culture, University of Southern Denmark
Head of Research, National Institute of Public Health, University of Southern Denmark

Purpose: The transition from the labor market to retirement is a critical phase of life. Men, especially, are at risk of negative health effects. Shared Reading may be a promising way to engage older men in health promoting interventions. However, no previous studies have investigated its effects on this group. This study aims to investigate the feasibility of a randomized controlled trial (RCT) of a Shared Reading intervention. This article presents the design of the study.

Methodology: The study will be carried out using an exploratory mixed-methods design, investigating collective dimensions of Shared Reading and participants’ experiences and identifying and pilot-testing effect measures in a before-and-after design. Five Shared Reading groups will be carried out and evaluated, with a total of 50 participants.

Findings: The results of the feasibility study will inform a large scale RCT of a Shared Reading intervention for retired men measuring health, social and literary effects and will provide analytical groundwork for an investigation of participants’ experience of reading literary texts.

Originality/Value: The study is the first investigation of the effects of Shared Reading on newly retired men. It invites methodological transparency and reflection on the design, implementation and evaluation of arts and health interventions.

Keywords: Mental health, arts & health, Shared Reading, intervention design, feasibility study

Background

Studies indicate that retirement is one of the most significant life transitions and that it is associated with an increased risk of various mental health problems (Dave, Rashad & Spasojevic, 2008; Heaven et al., 2013; Mosca & Barrett, 2014; Vo et al., 2015). While the immediate effects of retirement can be characterized positively through the possibility to withdraw from a stressful work environment to a more relaxed and leisure-oriented lifestyle, the transition may ultimately lead to diminished wellbeing as individuals lose their occupational attachment and thereby also a source of meaning and identity (Kim & Moen, 2002). Hence, studies into the effects of retirement on mental health show both negative and positive outcomes (Jokela et al., 2010; Wang, 2007).

Some studies have found that men, in particular, are at risk of negative health effects such as loneliness, depressive symptoms, reduced quality of life and self-rated health as a result of retirement (Heaven et al., 2013; Johannesen, Davidsen & Christensen, 2019; Noh, Kwon, Lee, Oh & Kim, 2019; Vo et al., 2015). As retirement progresses, men report a significant increase in depressive symptoms, suggesting that retirement is a potential contributor to men’s depression in later life. All the while, no significant changes in mental health and psychological wellbeing have been found among newly retired women (Kim & Moen, 2002). Other studies have shown that men find it harder than women to adapt to changes in their environment, including life transitions that involve new social and health-related contexts and practices (Hajdu, Mckee & Bojan, 1995; White et al., 2011).

These findings demonstrate the need to address men’s life transitions in health-promoting interventions (Noh et al., 2019) and to explore how to introduce positive changes to retired men’s mental health and wellbeing (Robertson & Williamson, 2005). So far, only a few studies have examined how to promote mental health among this specific social group. Given the pluralism and heterogeneity of retired men, there is a need for interventions that go beyond traditional health promoting activities, such as interventions focusing on healthy eating, physical exercise, and outdoor activities (Evans, Frank, Oliffe & Gregory, 2011; Robertson & Williamson, 2005).

Literature as mental health promotion

Recent research suggests that creativity and the arts can be central mechanisms in the adaptation to old age and that the arts may have a positive impact on the mental health of older adults (Cantu & Fleuriet, 2018; Fraser et al., 2015). A review found that engaging with the arts could potentially improve mental health, quality of life, and meaning in life among older adults (Vella-Burrows, 2016). Further, several studies have shown that creative group activities may provide forums for social engagement that help reduce or alleviate loneliness and social isolation among older adults (Fancourt & Finn, 2019; Greaves & Farbus, 2006; Wikström, 2002).

In the past decade, the use of literature as a resource for mental health promotion – frequently in the form of reading groups – has gained ground in the UK, the US, Australia and Northern Europe. This development has been fueled by The Reader Organisation, founded in 2008 with the aim of advancing Shared Reading as a method to improve wellbeing and reduce social isolation among community groups in the UK. The impact of Shared Reading on mental health and wellbeing has been investigated in a number of studies among various social groups, e.g. inmates, people with dementia, and socially vulnerable groups – with promising results (Bavishi, Slade & Levy, 2016; Billington, Carroll, Davis, Healey & Kinderman, 2013; Billington, Dowrick, Hamer, Robinson & Williams, 2010; Billington, Longden & Robinson, 2016; Davis, 2009; Dowrick, Billington, Robinson, Hame & Williams, 2012; Mcardle & Byrt, 2001).

In order to understand how literature can potentially facilitate mental health promotion, it is essential to look at readers’ experiences of reading. Currently, investigations into the effects of literary reading take two main approaches: an experimental approach which explores the relations between fiction and social cognition (Mar, 2018), and a phenomenological approach, which focuses on individual reader responses (Kuiken, Miall & Sikora, 2004). Both approaches focus primarily on individual, private experiences of reading and do not reflect in depth on the collective or social dimensions of reading.

A few ethnographic studies have looked into experiences of reading fiction and the impact of literature on the lives of readers. Olave & Angélica (2018) conducted a study among UK women in which they found that reading literature enabled self-understanding, ethical reflection, and self-care among reading group participants. Further, Adam Reed’s ethnographic study of a men’s fiction reading society in the UK (Reed, 2002, 2004) illustrated that reading led to a higher degree of reflection on self-conception among participants, and on the societal expectations that govern norms of ideal masculinity. Reed found that the reading community functioned as a space for personal and collective reflection on existential and social issues, as well as a defined and safe forum for the common pursuit of a shared passion for reading. Reed notes that research on reader experience has often focused on women readers, a tendency that reflects the fact that reading groups tend to attract primarily female participants, making the present study’s focus on reading groups for men particularly pertinent.

Recent ethnographic research into Shared Reading has spurred an interest in the social dimension of reading (Skjerdingstad & Tangerås, 2019; Steenberg, 2016; Steenberg, Bräuner & Wallot, 2014). However, these studies have not looked into the connection between literature and health promotion. Building on these, as well as findings from interventions that have applied Shared Reading as mental health promotion among various target groups, it would seem that the use of Shared Reading among newly retired men holds significant health-promoting potential. The above findings have therefore been important sources of inspiration and information in terms of designing and focusing the present study.

The feasibility study further draws on and contributes to the field of narrative medicine, a branch of medical and health humanities which seeks to both improve understanding and communication between health professionals and patients, and to improve the health of different groups and individuals by actively using literary texts in the context of health education and intervention (Charon, DasGupta, Hermann, Marcus & Spiegel, 2016; Crawford, Brown, Baker, Tischler & Abrams, 2015).

Although a few effect studies of Shared Reading interventions have been carried out (Longden et al., 2015; Steenberg, Christiansen & Ladegaard, 2019), no previous studies have investigated the effect of Shared Reading on newly retired men’s mental health. Further, there is no established tradition for conceptualizing and measuring the effects of Shared Reading interventions. Various authors and organizations have pointed to the need for an increased evidence base for arts & health interventions and emphasize a number of challenges that arise in generating this evidence, such as poor study and evaluation design, insufficient attention to feasibility and implementation studies, lack of consensus on how to demonstrate the value of arts and health, and lack of established criteria for the measurement of effects (Carnwath & Brown, 2014; Daykin, 2019; Daykin, Gray, McCree & Willis, 2017; Hamilton, Buchanan-Hughes, Lim & Eddoweset, 2015; Skingley, Bungay & Clift, 2012). In addition, it is argued that there is a need for the employment of mixed-methods designs within arts & health research in order to take both qualitative and quantitative aspects of impact of arts & health interventions into account (Cameron, Crane, Ings & Taylor, 2013; Caracciolo & Van Duuren, 2015; Clift, 2012; Skingley et al., 2012).

In accordance with recommendations provided by the UK Medical Research Council on the importance of conducting feasibility studies of complex interventions (Bowen et al., 2009; Craig et al., 2013), the objective of this article is to present the evaluation design of a feasibility study which aims to lay the groundwork for a randomized controlled trial of a Shared Reading intervention for newly retired men in Denmark. The intervention will be assessed in terms of its health effects (e.g. quality of life, meaning in life, life satisfaction), social effects (e.g. loneliness, social connectedness), and what we call literary effects, that is, the aesthetic and emotional responses to literature that Shared Reading prompts. In doing this, we aim to lay the foundation for a mixed-methods approach to the investigation of literature’s effect on readers.

Methods

The feasibility study will take place over a two-year period. In the following section, we outline the design of the study and describe its various components, i.e. the intervention, recruitment strategy, study design, and the expected results.

The Shared Reading intervention

Shared Reading is a method developed to create and facilitate reading engagement in group settings (Billington et al., 2019; Longden et al., 2015). A reading guide trained in conducting and facilitating Shared Reading sessions chooses and prepares the text material and facilitates a live reading experience by reading aloud, or inviting participants to read aloud, and pausing in order to make room for individual responses and group interactions. The in-situ reading, where participants come unprepared without prior knowledge or specific competences, may provide a basis for participants to contribute freely on the basis of their own immediate reading experience (Billington et al., 2019; Steenberg et al., forthcoming). The reading guide is therefore equally trained in exploring both textual features and individual responses, and in facilitating a transaction between the two (Rosenblatt, 1978). This is done by posing open-ended questions about literary language and form, as well as questions concerning the felt qualities of the subjective reading experience. In the intervention, both male and female reading guides will be used, however, relevant feedback and responses from both reading guides and participants with regards to the role and significance of gender will inform the design of the intervention in the RCT study.

Although all Shared Reading groups are based on these basic principles, literary content and form may vary, given that reading guides are individually responsible for putting together a curriculum. Typically, however, it would be comprised of quality literature as defined by critics and reviewers (Bassnett, 2017). In the present intervention, a work of prose (e.g. a short story or an extract from a longer work) is read aloud, followed by a poem, which is typically read twice followed by reactions. Some texts are selected because they deal with characters and life situations that directly reflect the participants’ situation (elderly males facing retirement), while others are selected because they deal with more general or universal themes. Texts will usually be selected by reading guides in order not to create a hierarchy within the group between those with and those without prior knowledge of the text.

The intervention is structured into individual courses of weekly two-hour sessions that run over a period of eight weeks. The length of the courses in the feasibility study have been determined with regards to the feasibility of the courses within the study’s timeframe. Feedback from participants on the topic of length and frequency of the course, as well as to its general form and content, will be drawn on in order to adjust and refine the design of the intervention in the subsequent RCT study. In total, the feasibility study will include five such intervention courses (see figure 1). Each course will involve six to eight participants.

Recruitment

Participants will be Danish men (aged 65+) who are newly retired or facing retirement within a short timespan (six months). Learnings from the recruitment process will inform the recruitment strategy for the RCT study. Inclusion criteria for the intervention will be qualified and adjusted accordingly. Therefore, participants may include men from various social backgrounds and with different health conditions. The Danish Reader Association and the DaneAge Association are responsible for the recruitment of participants. The Danish Reader Association has previous experience with recruitment of participants for Shared Reading interventions targeting a variety of social groups, including older men. The DaneAge Association has a significant membership base of over 850,000 members spread across Denmark, as well as unique knowledge of the target group. Participants will be recruited through local departments of the DaneAge Association and through notices in local cultural and community centers and libraries.

Design of the feasibility study

An important aim of the study is to explore the critical components of the intervention, in particular recruitment and retainment of participants, compliance, acceptability, context, and the functionality of the intervention components. Hence, the feasibility study will not be carried out as a scale model of the RCT, but will instead focus on ensuring the quality of the development, implementation, and evaluation of the full-scale intervention (Craig et al., 2013; Eldridge et al., 2016).

The design of the feasibility study draws primarily on methodological experiments from the field of arts & health. The study will be carried out using an exploratory mixed-methods design involving a qualitative and a quantitative strand. This approach allows us to conduct concurrent exploratory and confirmatory investigations that will inform each other at different stages of the research process, while relating to different aspects of the overall research objective (Teddlie & Tashakkori, 2009).

The qualitative strand will focus on participants’ experiences of different aspects of Shared Reading. Particular attention will be paid to the potential of the distinctive mode of reading engagement provided by Shared Reading, allowing readers to explore and share subjective dimensions of human experience in order to promote mental health and well-being (Ladegaard, Steenberg & Christiansen, 2019; Longden et al., 2015). We will also pay particular attention to the various collective dimensions of Shared Reading, including the interaction between readers and the role of the reading guide as a facilitator of collective reader responses (Caracciolo & Van Duuren, 2015; Oatley, 2011). The quantitative strand will focus on identifying and pilot-testing effect measures in a before-and-after design.

The feasibility study will consist of three phases, each one informing the next, so that insights gained in each phase will feed into the following (see figure 1). A process evaluation will be conducted during all three phases with a formative and a summative objective, the former to adjust and inform the intervention, and the latter to assess the extent to which the intervention is implemented as planned, including its ability to reach intended participants (Devaney & Rossi, 1997; Saunders, Evans & Joshi, 2005).

Figure 1

The design of the feasibility study

Phase 1: Preparation and needs assessment

The aim of the preparation phase is to explore the needs and perspectives of the target group and to investigate possible outcome measures. The preparation phase will proceed in three steps. Firstly, the empirical literature will be screened for knowledge of similar interventions, knowledge of the needs and health challenges of the target group, and literature on factors and mechanisms involved in adaptation to retirement as a form of life transition. Secondly, empirical literature on possible outcome measures will be analyzed with a particular focus on positive mental health effects (e.g. quality of life, meaning in life, life satisfaction), social effects (e.g. loneliness, social connectedness), and literary effects (see table 1). Our investigation into the latter category will be based on the theoretical concepts of reader response developed by Rita Felski in her works Uses of literature and Hooked: Art and Attachment (Felski, 2008, 2020). Thirdly, the two previous steps will inform a qualitative exploration of the perspectives and needs of the target group to corroborate and validate the findings from the literature, and to explore user perspectives on the content and frame of the intervention and initial responses to potential outcome measures (see table 1). The suggested outcome measures have been chosen because they have been validated in terms of reliability, validity, sensitivity and specificity in a range of international studies (see references in table 1). The health and social scales have all been translated into Danish and are widely used in Danish population studies. They have well known psychometric properties which are especially relevant for the measurement of the positive dimensions of mental and social wellbeing.

The qualitative exploration will consist of two workshops with representatives from the target group recruited from two ongoing Shared Reading groups hosted by the Danish Reader Association. We will observe one Shared Reading session in each group, followed by a focus group, and interviews with individual members of the group as well as the reading guide of each group session. This will help us gain insight into the target group’s thoughts and reflections on different aspects of the intervention. Fieldnotes and interviews will be transcribed, coded, and thematically analyzed in the qualitative data analysis program NVivo. A template analysis approach will be applied in order to identify interlaced themes and structures and summarize the interview data (Crabtree & Miller, 1999; King, 2012). Findings will inform the planning and framing of phase 2.

Table 1. Potential primary and secondary outcome measures

OutcomesOutcome indicatorsMeasures/scales
Health outcomesQuality of life
Meaning in life
Life Satisfaction
Stress
Self-rated health
WHO-51
MLQ2
SWLS3
PSS4
General Health scale from SF-365
Social outcomesLoneliness
Social Connectedness
UCLA Loneliness Scale6
Social connectedness Scale7
Literary outcomesRecognition
Enchantment
Knowledge
Shock
Attunement
Aesthetic Emotions Scale8
Operationalization of theoretical concepts about reader responses9

Phase 2: Development and formative evaluation

The aim of the development phase is to develop the intervention and to identify outcome measures to be used in the survey in the third phase of the study. Building on data from the needs assessment, two development courses will be carried out. As part of the qualitative strand of the study, a formative evaluation will be conducted in order to investigate if the intervention should be adjusted and to test if the chosen literary material is well received.

As part of the formative evaluation, baseline interviews with participants in the two development courses will be carried out with the aim of identifying motivations for participation in the intervention, participants’ perspectives on the form and content of the courses, as well as responses to and conceptualizations of the outcome measures identified in the first phase of the study. Participant observation will be conducted throughout the two development courses and focus group interviews will be carried out at the conclusion of the courses. Particular attention will be paid to the need to adjust or narrow the inclusion criteria for the intervention. In addition, reading guides will be asked to keep a logbook throughout the intervention in which they reflect on their expectations towards the participants’ reactions to different texts, followed by a final reflection on what they have experienced during individual reading sessions.

Further, insights from the baseline interviews will be used in the final survey design, which will test the outcomes of the Shared Reading intervention. At the end of the second phase, participants from the development courses will pilot-test the survey. As in phase 1, fieldnotes and interviews will be transcribed, coded, and thematically analyzed. Findings will inform the planning and framing of phase 3.

Phase 3: Testing – summative and outcome evaluation

The aim of the final phase is to test the adjusted Shared Reading intervention and to pilot-test its outcomes in three test courses. According to the recommendations of the Aesop framework for developing and researching arts in health programs (Fancourt & Joss, 2015), the outcome evaluation will equally test health effects, social effects and literary effects (see Table 1). Participants will be asked to fill in a survey at baseline prior to the initiation of the course, at the conclusion of the course, and at a follow-up two months later. Further, participants will be interviewed at baseline and at two-month follow-up with the aim of qualifying the outcome measures and to collect data on the implementation and potential reach of the intervention.

The literary effects of the evaluation will mainly be investigated via qualitative interviews due to the more explorative nature of this focus. Literary theory on the outcomes of Shared Reading will be tested empirically through in-depth exploration of the mechanisms at play when readers collectively interact with literature. Analysis of the qualitative data collected in the third phase will build on themes and findings from the previous phases. Survey data will be analyzed concurrently, so that analyses and results of the qualitative and the quantitative strands supplement each other.

Further, this phase will include a parallel exploration of the scalability of the intervention as well as an investigation into the potential application of a digital component to the intervention through citizen science-inspired methods that engage representatives of the target group in the exploration of these aspects through three workshops. Drawing on citizen science, a methodological approach aiming to involve citizens in all aspects of the research process, our aim is to strengthen and qualify the empirical knowledge base of the feasibility study further, as well as to ensure that the study design reflects the needs of the target groups (Den Broeder, Devilee, Van Oers, Schuit & Wagemakers, 2018).

Results

The results of the feasibility study will inform a large-scale RCT to be conducted over the course of two years. The aim of the RCT will be to evaluate the effect of a Shared Reading intervention for newly retired men with the primary outcomes targeting effect on mental health promotion and secondary outcomes targeting social and literary effects. We expect that the results of the feasibility study will inform the RCT on the following parameters:

  • Recruitment and retention of participants

  • Compliance, acceptability and fidelity of the intervention

  • Functionality of intervention components and delivery

  • Identification of relevant outcome measures for the measurement of health, social, and literary effects

  • Appropriate large-scale evaluation design for the evaluation of outcomes and implementation

  • How to ensure maximum impact of the intervention

We expect to conduct the RCT as a randomized wait-list controlled effectiveness study. The number of participants involved will depend on the exact power calculation (Desveaux et al., 2016; Kinser & Robins, 2013). The ultimate choice of RCT design, including pilot study, choice of statistical procedures to assess statistical significance, effect sizes, and clustering effects will be based on the results of the feasibility study.

Discussion

The current feasibility study differs from previous research in several respects. It involves the development of a Shared Reading intervention, co-designed with newly retired men using participatory methods. It explores the collective dimensions of Shared Reading, including the interaction between readers and the role of the reading guide as a facilitator of collective reader responses. It draws on qualitative and quantitative approaches to the measurement of effect, jointly acknowledging the need for documentation of health, social and literary outcomes. It develops and investigates the critical components of the intervention in a mixed-methods design as a basis for the conduction of a large-scale RCT. And finally, it invites methodological transparency and open reflection on methodological issues in the design, evaluation, and implementation of arts & health interventions.

This will be the first study of a Shared Reading intervention designed to improve positive mental health among newly retired men. Clift (2012) argues that the objective of scaling up arts interventions in order to achieve public health-level impacts can only be reached through robust controlled studies with measurable outcomes, but that the value of qualitative research in understanding these impacts as well as assessing the value of arts & health must be recognized if a nuanced account of the potential value of arts as a public health resource is to be gained. Therefore, as is argued elsewhere (Billington et al., 2019; Cameron et al., 2013; Caracciolo & Van Duuren, 2015; Clift, 2012; Skingley et al., 2012), it is essential to use a mixed-methods approach in a feasibility study to provide an adequate knowledge base for defining and testing the research focus for an empirical study on literature’s effect on readers. With this study, we aim to lay the foundation for such an approach.

Another novel feature of this study relates to methodological issues within the field of arts & health. As stated in the introduction, there is a need for an increased evidence base for arts & health interventions (Carnwath & Brown, 2014; Daykin et al., 2017; Fancourt & Joss, 2015; Hamilton et al., 2015; Skingley et al., 2012). We wish to contribute to a strengthened evidence base in the field of arts & health as well as to address the current lack of studies that investigate relations between literary engagement and mental health. The role of arts as a public health resource is beginning to be more widely understood (Clift, 2012; Fancourt & Finn, 2019), but although the evidence base of arts & health research is growing, there is still a lack of consensus on how to demonstrate its value and how to define the role of literature, in particular, in arts & health interventions.

Efforts have been made to establish evaluation frameworks for arts & health interventions (Daykin et al., 2017; Daykin & Joss, 2016; Fancourt & Joss, 2015). However, to date there is still no clear picture of how to approach and assess complex arts interventions. Further, there is a need for transparent reflection regarding methodological approaches to research within the field (Fraser & al Sayah, 2011; Moula, Karkou & Powell, 2019). Such measures are vital to further the advancement and establishment of the field and in order to strengthen the theoretical basis for a discussion on how good evidence is generated. In conducting this feasibility study and through the present article, we aim to contribute to this discussion as well as to promote an open reflection on the methodological challenges and potentials related to intervention development and design processes within the field of arts & health.

Limitations

The feasibility study may have limitations in terms of recruitment, adherence and attrition levels. It may turn out to be difficult to recruit newly retired men for a Shared Reading intervention. To ensure relevance and adequacy of the intervention, recruitment methods will be adjusted according to feedback from the target group and the Shared Reading guide in the first phase of the study. In order to enhance adherence and reduce attrition, the intervention will be monitored closely. Absence will be followed up on by reading guides. Further, the reading guides in the individual courses will be available for questions and ongoing dialogue with the participants between reading sessions throughout the courses.

This study attempts to reach the broad population of retired men aged 65 plus. Although some level of representativeness will be pursued through organization-based recruitment, it is not guaranteed. In analyzing the data, we will pay attention to the need to adjust or to narrow the inclusion criteria for the intervention.

Ethical considerations

This study has gained ethical approval by the Committee on Health Research Ethics of the Region of Southern Denmark. It has also been approved by the Danish Data Protection Agency (the University of Southern Denmark did not have an Institutional Review Board (IRB) at the time of the initiation of the study). All procedures performed in the study will be in accordance with the ethical standards of the 1964 Helsinki declaration and its later amendments. Informed consent will be obtained from all individual participants included in the study.

Statement of interest

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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1Bech, 2012; Topp, Østergaard, Søndergaard & Bech, 2015
2Steger, Frazier, Oishi & Kaler, 2006
3Diener, Emmons, Larsen & Griffin, 1985
4Cohen, Kamarck & Mermelstein, 1983
5Bjorner, Damsgaard, Watt & Groenvold, 1998; Bjorner, Thunedborg, Kristensen, Modvig & Bech, 1998
6Russell, Peplau & Ferguson, 1978
7Lee & Robbins, 1995
8Schindler et al., 2017
9Felski, 2008

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