A Novel Participant-Empowered Pedagogical Approach to Engage and Retain Control Group Participants in Arts-Based Randomized Controlled Trials

Abstract

The overall purpose of this randomized controlled trial (RCT) was to examine the effect of arts classes (ballroom dance and ukulele) on older adults’ well-being compared with a social conversation control group. This article describes a novel participant-empowered pedagogical approach to enhance control group retention and engagement. Sixty-four participants (M = 71 years) participated twice weekly in a 10-week intervention that included ballroom dancing (n = 23), ukulele playing (n = 17), and social conversation (n = 24). Focus group themes revealed participants felt challenged as they crossed their comfort zones, increased confidence, and enhanced social connections. Community-engaged arts programs for older adults should further examine mechanisms that foster positive social connections during sessions, paying special attention to the design of the control group condition in RCTs where competing arts-based intervention groups may be more desirable to participants.

Keywords

focus groups evidence-based/evidence-informed practice strengths-based practice aging/gerontology

Introduction

The randomized controlled trial (RCT) is an important and rigorous methodological approach to examine the effectiveness of interventions (Frost et al., 2019; Johnson et al., 2019). Although many researchers use RCTs, to our knowledge, there has been no focus on the effects of control group assignment on older adult participant retention rates, particularly in arts-based RCTs. In studies that use a gold-standard RCT design, failure is possible if the control group is not empowered or members do not feel they are a meaningful part of the study. Participants who are dissatisfied with being randomly assigned to a group or condition other than the intervention may experience demoralization (Gemmell & Dunn, 2011), feeling a diminished sense of meaning relative to the study’s purpose. Assignment to a control group may be underappreciated by participants, as participants often want to ensure they have a positive experience and that their time is being used in a worthwhile manner. This becomes a significant challenge in arts-based RCTs, where desire to participate in the competing arts intervention conditions, as opposed to the control condition, could be elevated due to the perceived benefit and desirability in taking an art class.

Indeed, the existing literature offers strong support for the positive impact of arts and arts training on well-being and brain functioning (Alain et al., 2019; Roswiyani et al., 2019). Thus, participants who are randomly assigned to the non-arts control group in arts-based RCTs may recognize the positive impacts, and perhaps gained initial interest in the study because of their desire to participate in an art class. This article will describe an arts-based RCT that utilized a novel participant-empowered pedagogical approach for control group participation that (a) retained randomization, (b) ethically embraced participants’ initial disappointment in condition assignment, and (c) offered an empowering participatory approach that did not involve a competing arts-based curriculum. We hypothesized that this empowerment approach to control group participation would lead to enhanced retention and session engagement.

Literature Review

Engaging in the arts improves well-being across many biopsychosocial outcomes. A scoping review by the World Health Organization (WHO; Fancourt & Finn, 2019) found that engaging in arts activities enhances social cohesion and builds empathy and trust. The arts promote healthy living and increase perceived health, while improving well-being by reducing anxiety and stress and increasing meaning, purpose, and life satisfaction (Fancourt & Finn, 2019). A systematic review of arts-based interventions for older adults found most studies focused on music-related interventions (Dunphy et al., 2019). Of these music studies, most involved passive listening, as opposed to playing or learning a musical instrument in a group setting. In comparison, most dance studies focused on learning steps and typically included only one type of intervention (Dunphy et al., 2019). Studies where participants were involved in the making of art (i.e., dancing) as opposed to observing were considered participatory arts studies (Noice et al., 2014). Participatory arts studies that compared arts interventions often showed improvement in outcomes overall, but did not show significant differences in improvement between arts classes. For example, Pearce et al. (2016) explored the effect of singing classes versus creative writing and crafting classes on older adults’ well-being. Higher collective bonding scores corresponded to improved well-being at the end of the classes, although there were no significant differences by art class. A non-arts-based activity or control group was not included in the study. Interestingly, one RCT that utilized a control group took an empowerment approach for the intervention, allowing participants in the intervention condition to choose their subgroup based on personal interest (Pitkala et al., 2009). The subgroups were “a) Art and inspiring activities, b) exercise and health-related discussions, and c) therapeutic writing and group psychotherapy” (p. 793). Conversely, we took a focused empowerment approach with the control group, allowing subgroups to form based on participant interest. This approach allowed the group members to identify shared interests, generate consensus in session decision-making, and take shared responsibility for progressing toward the identified group outcomes.

Overall, although researchers have examined the effect of arts on older adult outcomes in both quasi-experimental and gold-standard RCTs, little published work exists examining how to successfully engage and retain older adults who are randomly assigned to the non-arts control group. Thus, while the broad purpose of this study was to examine the effect of community-based participatory arts programming on well-being in a sample of healthy community-dwelling older adults—we examined the effects of older adults’ participation in a 10-week ballroom dance, ukulele, or social conversation control group on physical, mental, and social functioning—in this article, we focus specifically on the control group and summarize the overall focus group findings with special emphasis on the novel participatory approach used to engage participants.

Method

This study involved a multidisciplinary research team, which included social work, sports medicine, the College of Visual and Performing Arts, and a performing arts center. The study was approved by our Human Subjects Institutional Review Board. All participants gave written informed consent to participate in the study. In this RCT, we employed a pre-post three-group intervention design with 1-month follow-up. Participants were randomly assigned following simple randomization procedures (computerized random numbers) to one of the three groups. A single investigator who was blinded to the identities of participants before the intervention generated the random allocation sequence. If participants were not able to stay in their first randomized group due to logistics or timing issues, we reassigned them using either re-randomization or consultation. Of the total 64 participants who underwent randomization, we had to reassign four participants. Due to the nature of the interventions, we could not blind the participants or facilitators after allocation. This randomized clinical trial was registered on ClinicalTrials.gov (ID: NCT04281654).

Sixty-four participants (M = 71 years) engaged twice weekly in a 10-week RCT. Interventions included dance (ballroom dance, n = 23), music (ukulele playing, n = 17), and control (social conversation, n = 24). The classes took place in a multipurpose room at a local performing arts center. The room was able to accommodate the activities of the dance, music, and control groups, with 45-min sessions held twice per week, for a total of 10 weeks. We provided all participants two sets of two free tickets each for selected performances at the performing arts center to promote adherence and retention. Participants received one set of two tickets halfway into the intervention (i.e., after Week 5) and one set of two tickets after the post-2 testing.

Three focus groups were conducted at the conclusion of the study to assess participants’ experiences and subjective evaluation of the interventions’ effects, using questions adapted from prior work (Komatsu et al., 2017). Independent focus groups were conducted for the ballroom dance, music, and control group, and all participants were invited to attend. Transcripts of the recorded focus groups were independently coded for comparison.

Group Facilitation

Ballroom dance classes were co-facilitated by two professional dance instructors who taught various styles of dancing (waltz, rumba, bachata) progressing in difficulty over the 10-week intervention. The music class was led by a professional ukulele instructor who taught progressively more difficult ukulele songs as participants’ skills increased during the class. The social conversation control group was supervised by social work investigators and co-facilitated by two graduate social work students with prior experience working with older adults and/or working on research study teams.

Participant-Empowered Approach: Control Group

The social conversation control group employed a participant-empowered pedagogical approach. This approach, over time, decreased the initial resistance and disappointment that many participants felt when they found out they were randomly assigned to a control group for which they had hoped for an arts-class assignment. Control group members were invited to engage in weekly discussions on the broad topic of “living well in our changing world.” The topics were generated by the interests of group members. After a democratic voting process and facilitation by research team members, three subgroups emerged. Members elected to work in smaller units, focusing on (a) technology needs and interests for older adults, (b) active retirement, and (c) lifetime wellness. Each of these subgroups tailored their weekly conversations to their shared interests. Members spent time engaging with one another twice a week for 45 minutes. During the second session each week, the subgroups briefly gathered with one another to share highlights from the week. Co-facilitators of the sessions provided current research articles and resources to spark conversations or provide further information requested by subgroups. Participants were interested in hosting guest speakers on participant-identified age-related topics, and the co-facilitators coordinated with guest speakers to meet each subgroup’s requests. Speakers included a representative from American Association of Retired Persons (AARP), a local Area Agency on Aging (AAA) nutritionist, and an expert on happiness and well-being. During each of these sessions, members learned about cutting-edge technology and its potential impact on older adults, nutrition tips relevant across the life course, and behaviors and practices that characterize a happy life. Each subgroup also worked toward various goals determined by the members. For example, the active retirement members organized tips for staying active in their local communities. The wellness group enjoyed exploring a variety of physical and mental health topics related to aging. The technology group compiled a robust document, created with significant outside research, to address a resource gap they identified in their community.

Results

In the final analysis, 53 of the 64 participants initially enrolled were retained at completion of the study. This equated to a retention rate of 82.8% (dance = 18, music = 17, and control = 18). Attrition for dance and the control group was about equal (five discontinued dance and six discontinued the control group), whereas attrition for the ukulele class was 0. Overall attendance = 87.8% + 2.7%.

Focus Groups

At the conclusion of the study, all participants were offered the opportunity to discuss their experiences in a focus group according to their study condition. Of the 64 participants included in the study, 22 (dance = 8, ukulele = 6, social conversations = 8) took part in these focus groups. Transcripts of the recorded focus groups were transcribed verbatim and independently coded for comparison by two researchers. The researchers defined the codes, compared them, and decided together on emerging themes. Specifically, two independent research team members conducted line-by-line coding, with codes shared and themes agreed upon by consensus. Once the themes were agreed upon, the researchers analyzed the themes across groups. Focus group data analyses revealed positive outcomes for participants in all three groups. Members across all intervention groups felt challenged as they crossed their comfort zones, experienced increased confidence and a sense of accomplishment as they learned new skills, and noted their enhanced social connections. Members of the control group most frequently expressed frustration with the process. The specific construct of “frustration” was not further unpacked in the interview data, but it is not uncommon to experience frustration as part of a collective participatory group process that strives to work toward consensus and goal attainment, using this empowerment approach that charged the group members themselves with the responsibility for moving an agenda forward. Even when resources were available (e.g., the speakers, facilitators, group space, and materials), perhaps participants’ frustration arose out of the challenges experienced engaging with these processes.

Feeling challenged and frustrated

As might be expected when participating in a new activity, participants were challenged by learning the steps to a dance, the different notes on the ukelele, and how to navigate a social conversation group. Although participants expressed frustration with different aspects of this process, they also felt a sense of accomplishment after the initial resistance to crossing their comfort zones. A participant summed it up well by saying, “The strumming, the beat, putting your fingers in the right place. It’s like three parts of your brain are functioning at once” (Music group, Line 38).

Frustration was also expressed in all classes. In the dancing group, some members had difficulty following the instructor’s directions due to hearing limitations. In the ukulele group, members mostly referred to personal frustration as they were working to build their skills in sessions. In the control group, ambiguity surrounding the group purpose was at times (i.e., mostly in the beginning sessions) a barrier to full engagement. Williams et al. (2019) found that strength or skill building assists with the development of social identity. As skill building was not the explicit focus of the social conversation control group, perhaps this accounted for some of the experienced frustration:

Yeah, I found a lack of instruction at the very beginning was disconcerting. We had no way to go. It was just scattered. (Control group, Line 101)

So, when we came into the social group in general, not separated into the three groups, the whole idea was, “Well, what’s expected of us?” We knew that we were the control group, so to speak. But beyond that, what was the expectation? (Control group, Line 51)

Yeah, they made clear that a lot of the goals, a lot of the things to be done, were our choices, which is not always the best way to approach it because people retire. They don’t want to work at it. (Control group, Line 57)

Gaining confidence and sense of accomplishment

One participant shared that the social confidence developed in the social conversation control group transferred to other contexts outside the group:

And I also noticed that just after the first few meetings, I attended a town hall and the way the town hall worked, and I’d never done this before, everyone was split into small groups. And the facilitators went from group to group. So we stayed in our small groups and worked on different questions. And I was really enjoying this, whereas before, I don’t think I would have sat there and been too afraid to say anything. (Control group, Line 162)

One control group participant shared the importance of providing tangible structure to mitigate some of the ambiguity, particularly early in group formation:

So, you went online, you found something, you print it out, and you pass it out . . . .Now they had something tangible. (Control group, Line 171)

Over time, social conversation control group members began to experience a sense of purpose, engagement, and accomplishment as the participant-directed subgroups emerged:

And I’m going to continue to challenge myself. This group, not having any instructions, I’m talking about our technology group, not having any instructions, was a challenge. I think we met the challenge. We might have made up what the challenge was. But we met it and it’s like, I have a sense of accomplishment, I think.

I learned a lot of things, and just by watching other people inside and outside of my group react. (Control group, Line 117)

It stretched my mind after having been in retirement for a number of years and me thinking every day, “I don’t have to do anything.” It made me think. It made me think critically. It made me think how are we going to put all of this stuff together. It increased my desire for more social interaction. (Control group, Line 126)

And I’m going to get out more. And this is wonderful. And I don’t have to get out more with the people that I know. I can get out more in groups that I don’t know and say, “Hey, I’m here.” (Control group, Line 130)

Enhancing social connections

Participants from all groups reported being able to meet new people as a positive aspect of their experience and was a frequent theme in the control group:

I also learned from each other. I got some nice references, things to read that I can do on my own. We did do a lot of visiting, and even covered a couple of topics that I’m flabbergasted that would have come up in a mixed group when you really don’t know these people very well. (Control group, Line 34)

I think that my main thing to come out of this is being more comfortable with people that I don’t know. (Control group, Line 357)

Because one of my objectives is that I had worked for what seems like a hundred years, and so then you get away from the business world and the social contacts became very small. So, I was also looking at this as an opportunity to meet more people. (Control group, Line 4)

Continued learning occurred across conditions as participants described not only learning new skills but also learning from each other:

Yeah, definitely a positive experience. Meeting new people, new experiences, learning something new that I never thought I would learn. (Music group, Line 153)

And we were trying to talk about things that, in effect, made us happy, or secure, or things that brought us down, because we had a handful of sessions where we talked about the positive things of life. And then a couple of things that really pulled us down. And getting along with other people and the way that we could change some of our behavior in order to get along better with people. But I found one of the things helpful, as a whole, is that it’s not easy for me to jump out of my box, and I felt very comfortable with the people that were in my little group. (Control group, Line 38)

Discussion

In this article, we described a novel participatory approach to engage the social control group, when many control group participants would have preferred the luck of assignment to one of the arts conditions. Although initially the control group participants were disappointed to have been assigned to the non-arts control group and felt the unstructured format was not helpful, the participants grew into an organized group where subgroups emerged, meaningful social connections developed, and tangible products were outcomes of using a participant-driven and facilitator-guided approach.

Overall Findings

Overall, these community-dwelling older adults reported improved health-related outcomes after taking part in both the participatory arts and social conversation control group classes. By taking a participant-empowered pedagogical approach to control group participation post-random assignment to study conditions, we found participants actively engaged in the design and development of subgroups based on common interest. Three such subgroups were formed allowing participants’ smaller groups within which to share and learn from each other, around participant-defined meaningful themes. Facilitating opportunities for older adults to come together, share interests, and engage in meaningful social experiences holds value just as participatory skill-based arts classes demonstrate for its participants.

Control Group Findings

Participants felt challenged as they crossed their comfort zones, increased confidence, enhanced social connections, and developed a sense of accomplishment when learning new skills. These themes are similar to other studies that found common mechanisms of change of creative arts interventions with older adults to include social, cognitive, and cultural domains (see review Dunphy et al., 2019). In this study, we also found the high retention rates, which were equal to the dance group, compelling and promising for community-dwelling older adults as they (a) have multiple options for how to spend their time and (b) were aware of each other’s intervention groups because of preexisting social ties. Although the control group reorganized into subgroups, none of the subgroups engaged in arts-based activities, retaining methodological integrity of the control group experience.

Limitations and Future Recommendations

A limitation to our study was the inability to offer the arts-based classes to the control group after the initial 10-week session. The anticipation of eventually receiving a dance or music class may have been more satisfying or motivating for control group participants. Future studies should examine motivators that attract participants to participatory arts programming, mechanisms that encourage social connections during sessions, and the utility of a participant-empowered pedagogical approach for control group members and the influence of this approach on control group retention, receptivity, and outcomes.

Practical Implications

Our study revealed that providing some structure and guidance in the early sessions can reduce ambiguity of purpose and lead to a control group more open to take responsibility in moving their collective agenda forward. Careful thought for the design of the control group condition in RCTs may maximize the positive experience for participants. Other arts-based RCTs might employ our novel approach to increase control group retention and engagement without compromising the study design’s methodological integrity. Practitioners may be inspired by the social connections formed during these groups and by the particular interest these healthy community-dwelling older adults had in technology as a subgroup theme. During this global pandemic when virtual connections have become important in reducing social isolation among older adult populations, innovations in utilizing a participatory empowerment approach that engages older adults via virtual technologies that allow for meaningful social connections around the arts (e.g., virtual group-based museum tours, arts or cultural activities offered via Zoom) should be further explored. Our study found that such technological innovations may be acceptable, desired, and empowering when initiated by and for community-residing older adults.

Other studies found autonomy in decision-making is important to older adults and is related to perceived quality of life, and meaningful social engagement and community participation are significant contributors to successful aging (Tiilikainen et al., 2019). Individual and group empowerment can be enhanced through community group engagement (Fisher & Gosselink, 2008). In this RCT, an empowerment-based approach was used to draw on the collective wisdom of individual control group participants to identify and attain agreed-upon action outcomes. The group members self-organized and communicated with one other and with the facilitators and other staff about their collective interests and group goals. They were able to successfully translate these identified goals into outcomes, advocating for their interests throughout the group sessions.

The interdisciplinary research team included graduate students and faculty, university-based cultural arts programming staff, and community-dwelling older adults. The study demonstrated feasibility in bringing together a diverse team in a community-engaged arts, health, and aging initiative that focused on healthy community aging, suggesting value in continuation of these efforts. Such projects that recognize community member input and advocacy, alongside promoting community-engaged research skill training for graduate students, offer an important contribution to gerontological social work in fluidly advancing both research-informed practice and practice-informed research.

Conclusion

Themes that emerged across the intervention groups included participants feeling challenged as they crossed their comfort zones, increased confidence, enhanced social connections, and gained a sense of accomplishment when learning new skills. Community-dwelling older adults reported improved health-related outcomes after taking part in participatory arts and social conversation sessions. Implementation of community-engaged arts programs for older adults in the future should examine motivators that attract participants, mechanisms that foster positive social connections during sessions, and best practices in implementing a participant-empowered approach to increase retention and encourage active engagement in the control group. We believe a participant-empowered approach may be an important way of engaging control group participants when other more desirable skills-based arts classes are the “competing” programming for RCT study participants.

Footnotes

Disposition editor: Sondra J. Fogel

Declaration of Conflicting Interests

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

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Endowment for the Arts (NEA) Research Grants in the Arts program: Grant# 1856113-38-19.

ORCID iDs

Holly C. Matto

Emily S. Ihara

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