Cultivating Cultivating Health Health

The Cultivating Health Project was a joint study with the Institute for Health A study of health and Research (IHR), Lancaster University, NHS Carlisle & District PCT (formerly mental well-being NHS North Cumbria Health Authority), Age Concern, Carlisle and Carlisle City Council. The following people were involved:

amongst older people in Northern England

Professor Tony Gatrell Dr Christine Milligan, Dr Amanda Bingley, Dr Rebecca Wagstaff, Mrs Jessica Riddle, Mrs Elizabeth Allnutt, Mrs Jane Barker University

IHR, Lancaster University IHR, Lancaster University IHR, Lancaster University Director, Eden Valley PCT Director, Age Concern, Carlisle Allotments Officer, Carlisle City Council Gardener/Club Organiser, IHR, Lancaster

End of Project Research Report

The project was funded by the former NHS Executive-Northern and Yorkshire as part of the Government Healthy Ageing initiative.

Institute for Health Research Lancaster University O t b 2003

This Research Report is co-authored by Christine Milligan, Amanda Bingley, and Tony Gatrell.

Cultivating Health
The Cultivating Health Project was a joint study between the Institute for Health Research (IHR) at Lancaster University; Carlisle and district PCT (formerly North Cumbria Health Authority); Age Concern, Carlisle; and Carlisle City Council. The project was funded by the former NHS Executive Northern and Yorkshire Region as part of its Healthy Aging R&D Programme.

The following people were involved in the project:

Prof. A. Gatrell Dr C.Milligan Dr A. Bingley Dr R. Wagstaff Ms J. Riddle Ms E. Allnutt Ms J. Barker

IHR Lancaster University IHR Lancaster University IHR Lancaster University Director of Public Health, Eden Valley PCT Age Concern, Carlisle Allotments Officer, Carlisle City Council Gardener/Club Organiser, IHR Lancaster University

This research report is co-authored by Christine Milligan, Amanda Bingley and Anthony Gatrell.

Details and downloadable versions of reports can also be found on the IHR website: http://www.lancs.ac.uk/depts/ihr/research/mental/cultivatinghealth.htm For further details about the study please contact: Dr Christine Milligan, Institute for Health Research, Lancaster University, Bailrigg, Lancaster, LA1 4YT. Tel: 01524 592127 e-mail: c.milligan@lancaster,ac,uk

Acknowledgements

We would like to thank the following organisations and people who supported the project: The NHS Executive (Northern and Yorkshire Region) for their generous funding NHS staff who supported us from Carlisle & District PCT (formerly North Cumbria Health Authority) Carlisle City Council Department of Leisure and Community Development who offered free use of Longsowerby and Lingmoor Way allotment sites during the study for the project gardening club Age Concern, Carlisle who provided support for the project social club The many people who offered their time as part of project club activities giving talks, demonstrations and hosting visits and outings.

We would, particularly, like to thank all the people who volunteered to participate in this study and without whom the project would have been impossible. Their willingness and commitment has demonstrated that older people in Carlisle have a great deal to offer each other and the community. With adequate support they can create new opportunities for social and gardening activities that positively promote health and mental well-being. We hope that the ideas and experiences of those older people participating in this project will provide inspiration for continuing improvements in community health for older people both within Carlisle and beyond.

Content

Acknowledgements Introduction Summary of key points Ideas and recommendations Section 1: Aims of the study Section2: Methods of collecting information Section 3: Setting up and running the groups Section 4: Dilemmas of recruitment and research design Section 5: Analysis of quantitative data Data analysis and results Concluding comments Section 6: Analysis of qualitative data Gardening activity Gardening in a Club Social Clubs Section 7: Discussion Section 8: Conclusion Section 9: Dissemination Bibliography

3 6 7 8 9 11 17

19 22 24 27 29 30 37 41 46 55 57 60

Tables and Figures

Table 1: Table 2: Table 3: Table 4: Table 5: Table 6: Table 7: Table 8: Table 9: Table 10:

Summary of Research Design Distribution of respondents - 1st SF-36 Living circumstances by group Housing tenure by group Age distribution by group Survey responses by group Number of diary participants by group Health comparison: 1st and 2nd survey responses Change in health score at 5th week Change in health score at final week

12 22 22 23 23 23 24 24 26 26

Figure 1: Figure 2: Figure 3: Figure 4: Figure 5: Figure 6:

Figure 7:

Age range (%) Carlisle over 65s population compared with CHP over 65s Age range in groups (%) Gender balance in groups compared with Carlisle over 65s population Numbers active in Clubs at start (blue) and finish of study (red) Comparison of family and adult history/ experience in gardening in three groups Comparison of age-related restriction to garden, expertise and interest in gardens in three groups Comparison of activities with members of the Social Club

13 14 14 21 31

34 42

Introduction

In early 2002 ninety-three older people in Carlisle volunteered to take part in the Cultivating Health Project (CHP), which ran from January to November 2002. The project, funded by the NHS Executive (former Northern and Yorkshire Region), was set up as part of the Healthy Ageing R & D programme. The aim was to study the effects of different activities on the health and mental well-being of people over 65 years of age. In particular, the study was designed to compare the relative health benefits of gardening versus social activity. We set up three groups, a gardening club, a social club and a reference group. People were invited to join one of these groups over the nine months of the study where they could take part in regular activities, or, for those in the reference group, continue to go about their everyday lives. Participants health and well-being was assessed throughout by a combination of self-assessment and researcher-led observation. The gardening and social clubs proved successful interventions and both have continued to run following the end of the study. In this report we present the main findings and key recommendations arising from the study. In the first section we outline the aims of the project and the methodology used. We discuss recruitment issues, the setting up and everyday running of the project interventions. We also discuss, in detail, ideas and recommendations for future initiatives that, we suggest, may help to promote health and well-being amongst older people in the community. In the second section we explore the quantitative and qualitative findings in relation to each of the two clubs set up as part of the project, referring also to the reference group. We conclude with a detailed discussion of several key issues that emerged from the study. The Cultivating Health Project proved to be an enriching process for many of the people who took part as well as for us, as researchers. The study has deepened our understanding of the needs of older people and points to a number of ways, very often simple and people-led, in which health and well-being can be more effectively promoted and maintained in older age.

Summary of Key Points

Evidence from this study suggests that gardening and social activities have profound and positive effects on a persons sense of worth and mental well-being. These effects support older people to cope better with chronic or debilitating physical ill health.

Social contact is a vital factor in enhancing the health and well-being of older people, whatever activity they are involved in.

There are positive benefits for the health and mental well-being of older people if they garden communally in a club with regular support.

Gardening as an activity has a number of important qualities that help to sustain older people, not just by encouraging physical fitness, but also by mental stimulation.

Social club activities were can be highly beneficial and sustaining to the health and mental well-being of older people.

It is important that the organisation and choice of activities in clubs is entirely guided by the participants. This was key to the success of both the gardening and social clubs set up by this project,

The ongoing support of a project gardener/club organiser is essential in setting up and sustaining a successful, functioning club.

Ideas and Recommendations

Both the garden club and social club demonstrated that older people-led groups have definite benefits for the health and mental well-being of their members. However, to be successful they require appropriate and adequate support and resources. The health benefits associated with sociable activities when meeting in clubs and societies, whether gardening or with otherwise, are far reaching. Even a single weekly social meeting can add a new dimension to an older persons everyday routine. Developing older people-led activity groups is an important way of reducing social isolation and improving mental well-being. There is potential for local clubs to run schemes, which aim to support people to continue to garden and thereby enjoy the benefits of their own gardens for longer than is currently possible. People-led schemes of this kind could advise each other over designing appropriate adaptations, locating regular help, and offer sociable opportunities to exchange ideas and skills. To be successful, older people-led groups require the support of a community officer(s) to give initial guidance and ongoing support. This will provide the structure around which a group can be recruited and developed. Our research indicates that groups can become largely self-sustaining, requiring only limited (but regular) support, after the first year. Limited, ongoing support can help to maintain membership and recruitment of a people-led group through outreach and other referrals, as well as acting as an independent group mentor for supporting the organisation of the groups activities. Clubs of this kind can also accommodate disabled older people, but would require additional financial resources and support.

The Cultivating Health Project was developed in response to a call from the Healthy Ageing R & D programme to look at more holistic ways of improving and maintaining health in older people by appropriate support of their everyday activities. The project was a two-year in-depth study, which included an intervention over nine months. The aim was to explore the extent to which different kinds of gardening and social activities might help to promote the health and mental wellbeing of people over 65 years of age. In particular we focused on the benefits of communal gardening on allotment sites, and social activity as part of a club. We were especially keen to study the benefits of gardening in comparison to other activities. Largely, this was because a number of previous studies suggested that there were tangible and long-term positive effects to physical health and well-being for people that garden regularly (see Galgali et al, 1998; Lemaitre et al, 1999; Galloway et al, 2000). However, very few of these studies looked, specifically, at an older age group in terms of general health and mental well-being. There are virtually no other studies that we are aware of, which compare gardening with social activities. Yet older people, with or without age-related and/or other health problems, are often seen to rely on a great deal of social activity for their enjoyment and wellbeing, as well as very often being keen gardeners in their own and (less often), allotment gardens (Jerrome, 1990; Milligan et al, 2003). We, therefore, felt that there was a need to better understand the ways in which these different activities promoted (or on occasion did not promote) health and mental wellbeing. It is essential that older people have an opportunity to voice their own ideas, opinions and thoughts about their experience of different activities. We, therefore, set out to offer as many openings as possible for this process during the nine months in which the intervention was conducted. We did this through discussion in the groups, meeting with members of the research team in weekly clubs, individual interviews, focus groups and asking our older participants to complete weekly diaries. Our aim was to discover more about how, when and where gardening, socialising and other activities fitted into the lives of older people, as described by themselves.

Section 1: Aims of the Study

We present this report in the hope that we may inspire future innovative community-based initiatives with older people-led leisure and other activities for those aged over 65. The study was based in Carlisle, north Cumbria, and targeted those electoral wards in the south of the city, that firstly, had been recognised as being deprived by the Health Action Zone (HAZ), and secondly, were located in areas where the population as a whole experienced a comparatively high level of social and economic need.

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In the course of the project we gathered a vast amount of information with which to gain a better understanding of the relationship between health and mental well-being and the different kinds of gardening and social activities undertaken by older people. In this section we describe the methods used and the kinds of data collected. After gaining approval from the Local Research Ethics Committee, we collected two sorts of information. The first was quantifiable in the form of a Health Survey Questionnaire and the incorporation of standardised questions in the weekly diaries that gave longitudinal health data that related back to the questionnaire. Here, we chose to use a well-known health profile, the Short Form 36 Health Survey (abbreviated to SF-36), as the instrument with which to collect quantifiable data from our three groups, both before and after the intervention. This was chosen because it is considered relatively straightforward, and not time-consuming (no more than ten minutes) to complete (Jenkinson, 1996). The SF-36 comprises a series of eight domains, covering: physical functioning; social functioning; role limitations due to physical health; role limitations due to emotional health; mental health; energy/vitality; bodily pain; and general health perceptions (Jenkinson et al, 1996). Within each of these domains a number of specific questions are asked, and then scored for analysis. The results from these data were analysed numerically. Due to the numbers of participants involved, however, the data were used largely to generate descriptive statistics, although some statistical tests were performed on the longitudinal data (see section 6). There is a wealth of applications using the SF-36 among older adults, typically in assessing the effects of clinical interventions (such as hip replacement) but also in needs assessment. Some authors (Mallinson, 1998; Hill et al, 1996) have criticised the usefulness of the instrument among groups who are disabled or who are hospital-based or who have serious illness, arguing in particular that it masks patients views and proposing instead a more qualitative perspective. However, in a study of nearly 10,000 adults in Sheffield, Walters and colleagues (2001: 342) found that it is useful as a self-completed instrument in communitybased surveys of older people. Their large sample permits them to report means and medians, and standard deviations, for all domains, by age group and sex. Given that our population was also community-based we were confident that

Section 2: Methods of Data Collection

11

the SF-36 would be a useful instrument, particularly, when complement by a rich body of qualitative material that we report on separately. The second source of information was qualitative and involved asking people to talk and write about their everyday lives. Here, we conducted focus groups and semi-structured interviews with participants from each of the three groups. In addition, each participant was asked to complete a [standardised] diary giving details each week about a) their general health and well-being; b) events that may have affected their health and well-being; c) activities undertaken during the course of the week. The researcher also undertook regular observations of the club activities, recording the data both visually and in a research diary. Analysis of the qualitative data is reported in section 7. Table 1: Summary of Research Design:
Method of Data Collection Health Survey Questionnaire Discussion (Focus) Groups Semistructured Interviews Weekly Diaries Observation Visual data Gardening Club Completed at beginning & end of project Convened: beginning & end of project 10 participants: beginning & end of project All willing participants over 30 weeks Regular visits over 30 weeks Yes photographic records of the sites and gardening Social Club Completed at beginning & end of project Convened: beginning & end of project 10 participants: beginning & end of project All willing participants over 30 weeks Regular visits over 30 weeks Yes photographic records of outings and activities Reference Group Completed at beginning & end of project Convened: beginning & end of project 10 participants: beginning & end of project All willing participants over 30 weeks No No

The main themes and the complex of meanings and ideas that emerged from these qualitative data were then analysed using qualitative software (Atlas/ti) and interpreted thematically. In order to ensure the reliability of the data, the emergent themes were returned to the participants in the form of a project summary, and participants were encouraged to feed back their views on these themes. All participants gave informed (written) consent to the gathering and use of both the visual and spoken data and pseudonyms have been used throughout to preserve confidentiality. The Sample Ninety-three people, over the age of 65, were recruited to the project with the help of General Practitioners. This was mainly by invitation to 1,800 people in

12

south Carlisle, but also through the distribution of general publicity about the study in health centres, libraries and community organisations. The recruitment was conducted with the help of GPs to ensure that people were reasonably fit and able to take part. The only exclusion criteria were that potential participants were aged over 65 not mentally confused and had some physical mobility (to the extent that they were able to walk at least one hundred yards without support). The decision to exclude on the basis of lack of physical mobility was purely a financial one; in that the project did not have sufficient resources to put in place the hardcore pathways and raised beds that would have been necessary to facilitate disabled access. We invited our recruits to join one of three groups set up as part of the project, either the gardening group, the social group or the reference group. Each person had the option to join the group of their preference. We aimed to have roughly equal numbers in each group, though seven recruits withdrew before the start of the club meetings and a further seven withdrew during the first three months of the project. By the end of June 2002 the numbers of active members in each of the three groups had stabilised. All those who subsequently withdrew or stopped attending club meetings and activities did so because they were unable to take any active part in the study (due either to their own, or partners ill-health). In general, the age distribution of participants follows the trend evident in Carlisle as a whole. However, as Figure 1 (below) illustrates, the project did recruit a rather higher proportion of 65-74 year olds and a slightly lower proportion of those aged 85 and over than the Carlisle average. This was not unexpected given the tendency for increased age-related health problems and the pattern in the general population.
Figure 1: Age range (%) - Carlisle over 65s population compared with CHP over 65s
% in Age Group
40 30 20 10 0

Carlisle CHP

65-69

70-74

75-79

80-84

85-89

>90

Age Group (years)

13

The age range between the three groups varied significantly (see Figure 2, below). These variations appeared to be directly related to the amount and kind of activities people anticipated would be involved in joining a particular group and whether they felt physically able to take part. Gardening was perceived as the most physically strenuous and appealed to few people over 80 years of age (although, interestingly, gardening appealed to a higher percentage of people in the 75-79 age group). There was a more even balance in age range within groups where less active input was required (as in the case of the reference group) and which did not appear to intervene in an individuals everyday, regular pursuits. For instance, more people over 80 years of age felt able to take part in what they perceived to be the two less physically demanding groups.

Figure 2: Age range in groups (%)

60 50 40 30 20 10 0

Gardeners Social Reference

65-69

70-74 75-79 Age (yrs)

>80

There were, however, some marked differences in the gender balance between the three groups (see Figure 3) and against that of the population aged over 65 in Carlisle as a whole. Very few men elected to either join or were prepared to attend the social club.
Figure 3: Gender balance in Groups compared with over 65s population in Carlisle (%)
100 80 60
55 45 17 48 52 58 42 86

% Men % Women

%
40 20 0

Garden

Social

Ref Grp

Carlisle

Group / over 65 population

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Conversely more women were prepared to join and regularly attended the gardening club than had been anticipated. The balance of men and women in the reference group was roughly in accordance with the general population, possibly because, unlike the other two groups, this did not require any change in their everyday activities. Clearly, the reference group presented the least challenge to each individuals gender perception and consequent choice of activity. There appeared to be a number of other reasons for the gender differences between the three that emerged as the project progressed. These are considered in more detail in the Discussion section. Method At the start of the project all ninety-three volunteers completed a Health Survey Questionnaire; this was repeated again at the end of the project. The aim, here, was to enable us to numerically assess and compare participants general health and well-being at the start and end of the nine month study. Over the course of the project a total of sixty-six people from the group also took part in in-depth discussions. Following an initial pilot discussion (focus) group we convened three separate focus groups, each with around eight to nine people from each of the three groups. The focus groups were repeated at the end of the intervention. We also conducted semi-structured interviews with thirty people selected equally from each of the three groups at both the beginning and end of the intervention. In the first round of interviews and focus group discussions we asked people about their general pattern of health and well-being and the kinds of activities they participated in over the course of an average week as well as things that affected their everyday lives and health. People spoke about how their health and well-being was affected by their living situations, their neighbourhood, family situations and events and also the effects of local and national events. In the second assessment we were concerned to examine the extent to which participants general pattern of health and well-being had (or had not) changed over the period of the study. We were also interested in peoples experience of being involved in activities, whether in the reference group or as part of the garden or social club. People spoke about the extent to which the club and other similar activities affected their own sense of their health and mental well-being. We also explored, in more depth, the kinds of everyday activities people liked to participate in and how different activities and events in the average week appeared to affect their lives.

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Throughout the nine months of the data collection all participants were asked to complete and return a weekly diary. The first section of the diary involved a numerical score of self-assessed general health and mental well-being that related directly to questions on the SF-36. The second section was an opportunity for people about each weeks activities both outside the project (for those in the reference group) and within the project if they were part of the garden or social club. Participants could write as much or a little as they wished. Participants from all groups also wrote about events in their everyday lives and could include ideas, thoughts and feelings in connection to anything they wrote about in the diary. This gave us (and the diarists) a rich and detailed picture of peoples everyday lives and events over a sustained period of time. In addition to the above methods of data collection, we also undertook regular observations of both the social and gardening club activities. Over the course of the project, the researcher spent one day per fortnight observing and recording gardening activities on the allotments and one day per fortnight observing and recording the social club activities. These observations were supplemented by regular visual photographic data and written and oral reports gathered from the project gardener/club organiser.

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Section 3: Setting up and running the groups.

The Gardening Club The gardening club started out with twenty-nine participants. The club was given two City Council allotment sites in Carlisle to use throughout the course of the project, one site in Longsowerby and the other in Harraby. People were given a choice about which site to garden, though most chose the site nearest to their home. The sites were prepared for use by the City Council under the supervision of the allotments officer. The club was organised and supported by a gardener/club organiser, who was employed by the project, and who brought invaluable experience to the project of working with groups and gardens over many years. The gardener/club organiser was on duty on both sites at specified times during the week in order to offer advice and encouragement to people within the group and to help arbitrate in minor disputes until it began to cohere. Project funds provided for all the gardening equipment including seeds, tools, specialist tools for the less able-bodied, bedding plants, compost, a garden shed and most importantly a polytunnel for each of the two sites along with some chairs and tables. We believed (accurately, as it turned out) that the northern climate would be erratic, generally wet and often cold. In order to encourage people to leave their homes to attend the site, we would have to provide shelter and somewhere to sit, rest and socialise. We also had to ensure that the site was accessible and manageable for the less able-bodied participants. With this in mind, the polytunnels proved essential for sheltering both the club members as well as nurturing the seedlings, growing tomatoes and the more delicate flowers in hanging baskets. The gardeners could meet on their allotment site either on a weekly basis or as often or as little as they wanted (or were able) to. The gardener/club organiser also arranged a monthly meeting in Carlisle Old Town Hall Assembly Rooms for talks and discussions. On two occasions an outing to a local open garden was arranged in place of the indoor session. The Social Club Twenty-nine people initially joined the social club. A regular weekly venue was arranged in the Old Town Hall Assembly Room. This site is conveniently located in the centre of Carlisle and has good disabled access, both of which acted to facilitate and greatly encourage attendance. The club was organised by the project gardener/club organiser, who set up an initial programme of events, talks and activities suggested by club members and with which everyone in the club agreed.

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Project funds covered all costs incurred in running the club and Age Concerns involvement in the project enabled the venue to be booked at a reduced cost. The project also covered the costs of: all equipment and materials required for arts and crafts; engaging speakers; and arranging outings to local (and more distant) places of interest. From the outset, club members were encouraged to take ownership of the club to have a say in the kinds of activities that they wanted to take part in; to make suggestions; and to become involved in the weekly running of the club. This was welcomed by participants who insisted that they wanted to avoid the games style of activities commonly offered in many other local clubs around the city. The Reference Group The reference group, with twenty-seven members, was designed to provide a baseline for the study in terms of understanding the kinds of activities that older people engaged in, generally, on a weekly basis. We were interested in understanding the level of participation in activities as well as the ways in which ill health or disability impinged upon an individuals ability to become involved in different activities. We were keen to ascertain how much and what kinds of everyday activities seemed to generally promote health and mental well-being in a group of older people in the city. This information, we hoped would enable us to compare the ways that the project clubs affected peoples everyday health and mental well-being in comparison to that of people who may or may not be involved in similar activities in the area. Though reference group participants completed the Health Survey Questionnaire (HSQ), and participated in the focus group and interview process, the main means of data collection was via the weekly diaries. A core of twentyone reference group members became regular (and mostly) very keen diarists.

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Section 4: Dilemmas of recruitment and research design

We learned a number of significant lessons in undertaking this research that we suggest could support others involved in designing future projects of this kind. With this in mind, we have attempted to be frank about the dilemmas that we faced and how we resolved them. The original research design was based on a mixed methodology with an emphasis on quantitative data collection using a well-known quality of life questionnaire, the SF-36 (Walters et al, 2001), together with interviews and focus groups. In order to ensure the study was sufficiently powerful, it required the recruitment of up to 300 participants. Recruitment was intended to be via a random stratified sample drawn from GP lists. Within a few weeks of initiating recruitment, however, it became clear that the take up rate would be substantially lower than we had anticipated. We can point to three contributory reasons for this low take up rate: 1) Unforeseen delays occurred in gaining access to the sample. GPs are busy people and giving up time to identify exclusions for a research project is necessarily low on their agenda. Consequently, the turnaround time for the return of these lists was considerably longer than anticipated. As a result, the main recruitment drive fell around the Christmas period. Recruitment in winter time is likely to be more difficult especially as the project involved (amongst other activities) outdoor gardening; 2) Despite clear assurances that we were setting up accessible gardening that did not require any heavy digging, the perceived strenuous nature of the allotment gardening activity appeared to be putting some people off joining the study; 3) The initial publicity was not as effective as we had anticipated. In a bid to increase recruitment, we made conscious efforts to improve publicity. This was achieved through the wider dissemination of leaflets locally through GP surgeries, community groups and other community facilities. We also liased with two of the main Community Nurse teams in the area; and raised the project profile by ensuring appeals and articles were published in local newspapers. A short slot was also broadcast on both the local radio and television. Border TV also interviewed some of the project team on the allotment sites. We also increased the extent to which we emphasised the support that would be offered in the two clubs, especially that gardening activities would be tailored for people of all abilities and skills and extended the recruitment deadlines later into the spring.

19

Even with this change in strategy it became clear that recruitment would not reach those levels anticipated in the original research design. Following discussion amongst the research team we took the decision to modify the research strategy to one that would give us greater depth of data using a smaller number of participants. The focus on the use of quantitative methods was thus reduced, with a concomitant increase in the qualitative element of the study. This shift allowed us to work with smaller numbers of participants, using a variety of in-depth methods (semi-structured interviews, discussion groups, written weekly diaries, regular participant observation, visual data and regular participant feedback), as outlined above. The shift from a quantitative to a qualitative approach also meant that it was no longer necessary to use a stratified random sampling technique. Given the significantly different sampling strategies used in qualitative research design, we were able to employ snowballing techniques to increase our sample size. Clearly, a theoretical or a purposive approach would have strengthened the sampling strategy, but despite this, as Figures 1 to 3 have illustrated, our sample of ninety three older people represented a good range of men and women between the ages of 65 years to 91 years. The, largely, ethnographic study that emerged as a result of the change in research design proved to be a highly effective way of covering the issues explored. The changes also meant that, once identified, we could also address some of the limitations found in using the SF-36 Health Survey Questionnaire (Mallinson, 2002). It became clear that participants frequently found the ticking of boxes to answer questions to be a difficult exercise. At times they found questions and possible responses either irrelevant, inaccurate, or lacking in meaning. In addition, it became clear that participants responses were either highly subjective or relative (for example, one elderly participant consistently marked his health down as being excellent despite evidence from the qualitative data that revealed he had serious heart problems). Because the researcher and the gardener/club organiser were in regular contact with participants, the project team was able to explore quite accurately what was actually happening in the lives of people within the groups. Participants, themselves, had far greater opportunity to share their thoughts and ideas with the research team and to talk about their feelings and reasons for enjoying or avoiding different activities. In contrast to the questionnaire, the ethnographic approach appeared to be a mutually enjoyable and instructive experience for those who remained actively involved in the project.

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Dilemmas of drop out Any longitudinal study of older people is likely to suffer high rates of attrition given that there are inevitably increased age-related health and mobility problems in any group over 65 years of age. Relatively high rates of attrition were not, therefore, unexpected in this study. Over a nine months period, nearly one third of our original participants dropped out (see Figure 4 below).

Figure 4: Numbers active in Club at start (blue) and finish of study (red)
40 Participants 30 20 10 0 Gardeners Social Club/Group Reference 29 16 29 22 27 21

If someone left the group the remaining active members, understandably, often felt disappointed. However, there were always clear reasons, ranging from unexpected commitments, serious or incapacitating health problems (unrelated to the project activities), to illness or bereavement in the family. By July 2002, midway through the project, the numbers stabilised and remained at the levels illustrated above. There were sixteen active members of the gardening club, around twenty-two members regularly attending the social club and twenty-one regular diarists in the reference group. However, there were several club members who, though non-active, were still considered part of the project. These participants were unable, for a variety of reasons, to either attend any, or only occasional, social club meetings or gardening club site activities. For example, two or three of this non-active group were occasionally able to attend a club outing, or in the case of the gardening club, one of the monthly talks or events. This group continued to complete diaries and their contribution was invaluable.

21

In the following sections we discuss the main research findings

Section 5: Analysis of quantitative data

In this section we report on the collection and analysis of the quantitative survey data collected from our respondents. This took two forms; first, data collected using the SF-36 and, second, data from the weekly diaries. Diaries Each group was asked to fill in a weekly diary between 15th March and 2nd November (31 weeks) responding to four general health and well-being questions, together with a comment whether any particular event had affected their lives in each week. The response to this last question is to help interpretation of the scores for the general health and well-being questions.
Sample characteristics

We recruited 93 participants to the study, although 8 withdrew before the study commenced. For the first SF-36 survey the distribution of respondents was as follows:
Table 2: Distribution of respondents 1st SF-36

Group
Gardeners Social Reference

Number (%) 29 (33.7) 29 (33.7) 27 (31.4)

Slightly more men (n=16) than women (n=13) were in the gardening group and the reverse was true for the reference group (12 men, 15 women). However, very few men were in the social group (n=4), compared with women (n=25). Not surprisingly, as table 3 indicates, the living circumstances of the three groups reflected this, with those in the social group tending to live alone compared with the two other groups (percentages in parenthesis):
Table 3: Living circumstances by group

Group Gardeners Social Reference

Living alone 10 (35) 15 (54) 11 (41)

Living with spouse 16 (55) 10 (36) 14 (52)

Living with other family member 3 (10) 3 (11) 2 (7)

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In terms of housing tenure (see table 4), again the gardening and reference groups were broadly similar, but the social group had more participants living in private rented or sheltered accommodation:
Table 4: Housing tenure by group

Group
Gardeners Social Reference

Own home

22 (82) 19 (66) 23 (85)

Local Authority/Housing Association 3 (11) 5 (17) 3 (11)

Private rented 0 3 (10) 1 (4)

Sheltered housing 2 (7) 2 (7) 0

The age distribution was broadly similar across the social and reference group; however, the gardening group tended to have a greater proportion of younger people. While five members of the social and reference groups were in their 80s only one of the gardeners was:
Table 5: Age distribution by group

Group Gardeners Social Reference

65-69 years 15 (52) 10 (35) 10 (37)

70-74 years 7 (24) 10 (35) 8 (30)

75-79 years 6 (210 4 (14) 4 (15)

Over 80 years 1 (3) 5 (17) 5 (19)

While there were data for 85 study participants at the time of the first SF-36 survey, as table 6 indicates, this dropped to only 68 at the time of the second survey. Moreover, while there was little drop-out among the social group the responses from gardeners had dropped by a third and the reference group responses were also fewer, as the table below indicates:
Table 6: Survey responses by group

Group Gardeners Social Reference

Number in first survey (%) 29 (33.7) 29 (33.7) 27 (31.4)

Number in second survey (%) 20 (29.4) 27 (39.7) 21 (30.9)

We obtained diary data from a total of 62 individuals. The gardening club attendance records show that seven participants never worked on the allotments, while a further four were there a maximum of four times. We focused on the remaining 18 individuals who worked on the allotments at least 5

23

times, but note that while many attended on five consecutive weeks, others came sporadically and, therefore, any health benefits may not be comparable. Two people in the social club never attended club meetings, but wrote diaries (for 26 and 18 weeks respectively); a further four attended the club on no more than four occasions. We focused on the remaining 23 individuals who attended the club at least 5 times. The reference group (apart from two individuals who dropped out from the study) have fairly complete diary records with some missing data. The diary data is therefore summarised in table 7 below:
Table 7: Number of diary participants by group

Group Gardeners Social Reference

Number completing diaries (%) 18 (29.0) 23 (37.1) 21 (33.9)

Diary entries were not completed for some weeks because of holidays. There were a maximum of 28 weeks of diary entries for the reference group (29/3, 3/5,20/7 missing), and a maximum of 30 weeks of diary entries for the social and gardening clubs (20/7 and 29/3 missing respectively). There is considerable missing diary data. In addition to the diary entries information is available about club attendance. Many people completed diaries without attending their clubs; the diary data for these weeks therefore does not relate to club participation. Data analysis and results
SF-36

A preliminary comparison of responses to the question that asked about health now, compared with a year ago, suggested evidence that the gardening group felt better about their health, compared with other groups (see table 8). For example, while in the first survey 14 per cent of the gardeners felt that their health was better than 12 months ago, this proportion had increased to 25 per cent by the time of the second survey; of course, this suggestion is subject to the caveat of the samples being very small.
Table 8: Health comparison: 1st and 2nd survey responses.

First survey Group Gardeners Social Reference worse 6 (21) 7 (25) 5 (19) same 18 (65) 17 (61) 17 (63) better 4 (14) 4 (14) 5 (18) worse 3 (15) 4 (15) 6 (29)

Second survey same 12 (60) 19 (70) 11 (52) better 5 (25) 4 (15) 4 (19)

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However, we also conducted some more rigorous statistical analysis of the data in order to determine what influence, if any, group membership (gardening, social, reference) had on changes in health status during the study period. The method used was analysis of covariance (ANCOVA: see Field, 2000). This is a form of linear modelling in which variation in a response variable (here, one of the changes in the nine domains of the SF-36) is explained in terms of group membership, while controlling for the possible confounding effects of other variables. For example, if we detect between-group differences in changed health status, this could be because the groups differ in terms of age distribution, or living arrangements. We therefore entered into the model the following four variables, before entering group type: age (65-69 years; 70-74 years; over 75 years); sex (female; male); living arrangement (alone; not alone); tenure (owning home; not owning home). We then conducted nine separate ANCOVA analyses, where the dependent variables were, in turn, changes in health status on the SF-36 domains. In six of the domains changes in health status could not be accounted for by any explanatory variables. These domains were: physical function; role limitation due to physical problems; role limitation due to emotional problems; social functioning; energy/vitality; and change in health. There were no significant differences between the three groups, nor were age, sex, tenure or living arrangements associated with changed health status. For the pain domain there was evidence that those aged 65-69 years were significantly more likely to have had improved health (p = .020). For mental health there was weak evidence that those aged 70-74 years had significantly improved health (p = .074) and also that the social group had also registered improved health status (p = .061). Last, considering general health perception there is a suggestion that membership of the social group brought significant improvements along this dimension (p = .015), while adjusting for other factors (owning ones own home was weakly significant: p = .060). Diary data As explained above, the diary entries must be used together with allotment or social club attendance records. As each individual enters the study with a different level of health and well-being, we looked for changes in health and well-being scores (sum of scores for the four questions) between the beginning of the study for each person (some people entered the study late) and later weeks.

25

Each individuals entry score was taken to be the score for the first week of their diary entry. This is to be compared with the scores a few weeks later (see table 7): a) on the fifth week of diary entry (at least four weeks later) for the reference group, the fifth week of allotment attendance (at least four weeks in one case 19 weeks later) for the gardening group and the fifth week of club attendance for the social club group (at least four weeks later) and b) on the last week of diary entry for the reference group, the last week of allotment attendance (or as soon as possible after) for the gardening group and last week of club attendance for the social club group (or as soon as possible after) (see table 8). Rarely, there was a missing value for a question. Then the average of the previous and next weeks score for that question was used, or for the first and last week, a score was imputed from the pattern of scores for that question, e.g. consistent value over several weeks. Of the 62 individuals included (with data at week 5), there were 20 in the social club and 14 in the gardening club who continued with both club activities and with diary entries so as to produce useful data beyond the fifth week. The quantity of useful data was therefore limited.
Table 9: Change in health score at fifth week
change in Q2 score week 5 Standard Error of Mean Minimum Maximum .62 -4.00 11.00 .63 -7.00 5.00 .61 -5.00 4.00

1 reference 2 social 3 gardening

Mean .38 .48 -.67

Valid N N=21 N=23 N=18

Table 10: Change in health score at the final week

change in Q2 score final week Standard Error of Mean Minimum Maximum .64 -4.00 11.00 .62 -6.00 6.00 .71 -5.00 5.00

1 reference 2 social 3 gardening

Mean .33 .70 -.36

Valid N N=21 N=20 N=14

The mean change in health score for each of the social club and gardening club was compared with that of the reference group, using t-tests for the equality of means and analysis of variance. There is no evidence of a difference in the mean

26

change in health scores between groups either after five club attendances (p0.24) or at the end of the study (p>0.48). However, as in the analysis of SF36 data this does not control for other explanatory variables. We, therefore, tested the group effect using normal regression analysis, with change in health score as the response variable and controlling for change in Q3 score (health qualifier coded as 0 for serious illness or grief to 5 for a very happy event) and for measures of involvement in the project. Analysing data after the fifth week of club attendance suggests that after control for the change in the health qualifier (entered either as a continuous or categorical explanatory variable) there was no evidence for a group effect (p0.3). Analysing data after the last week of club attendance was as follows. In addition to the change in health qualifier, two measures of involvement in the project were used: a) the number of social club or allotment attendances, or the number of diary entries for the reference group, expressed as a percentage of the maximum possible for each group b) the number of social club attendances plus diary entries for the social group, the number of allotment and club meeting attendances plus diary entries for the garden group and the number of diary entries for the reference group, expressed as a percentage of the maximum possible for each group. After control for the change in the health qualifier (entered either as a continuous or categorical explanatory variable) and a measure of involvement, there was no evidence for a group effect (p0.4). Last, as an exercise, four nonattendants from the social and gardening clubs were added to the reference group. The mean change in health score for the reference group was then negative, showing the effect of just a few more observations on this small sample. The overall conclusions are unchanged. Concluding comments From the analyses we have conducted we draw the following main conclusion. There is no quantitative evidence that belonging to the gardening group brought significant health improvements across a range of health domains. There was weak evidence that membership of the social group conferred benefits in terms of improved mental health, and stronger evidence that it led to improved general health. From the diary data there was no evidence of a group membership effect on health and well-being.

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We need to interpret these findings with some caution, for several reasons. First, the sample sizes are modest, certainly in comparison with other published studies using the SF-36 (Jenkinson et al, 1996). Second, our study has suffered from considerable drop-out, not least among the very group (gardeners) in which we were interested. We were restricted to only 20 gardening respondents in the second survey and in analysing change from the baseline could never increase our sample size beyond that number. A consequence of this is that random modifications in how the questionnaire was filled in (or how the diaries were completed) could affect the results quite markedly. There is very little quantitative evidence of a group effect and nothing to indicate that our small sample of gardeners were statistically more likely than the other groups to register an improvement to their health.

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Section 7: Cultivating health: analysis of qualitative data

The previous sections have illustrated some of the difficulties we encountered in attempting to analyse the quantitative data and the limited utility of these findings given our small sample size. While we were unable to demonstrate from these quantitative data that participating in social or gardening activity produced any statistically significant changes in the health and well-being of older people, the qualitative data gave us some rich and detailed insights into their experiences during the course of the nine month intervention. We have summarized these findings for both of the two main activity groups, before drawing together the implications of these findings in Section 8. As indicated previously, the qualitative data was analysed thematically, we have therefore chosen to present the main findings under heading that represent the key themes emerging from the data.

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Gardening activity

I love my garden, like. I come away/I stand back and look as I close the gate and say I achieved something today, you know? I love it, aye. (Archie, 70 yrs)

Gardening is a very popular leisure activity amongst the older people in Carlisle. The Carlisle City Forum survey, undertaken in 2003, found that three quarters of the respondents aged over 65 to 75 gardened regularly and over half the respondents aged over 75 were regular gardeners (Wilde, 2003). The vast majority of them gardened in their own homes, and almost all had gardened throughout their adult life. However, very few of those in the 65-75 age group gardened on allotments. Those older people who responded to the survey noted that their main reasons for gardening were enjoyment, exercise and general interest. Inevitably the nature of the with a particular interest in as a whole in Carlisle, the (whichever club/group they almost all well-tended. Cultivating Health Project appealed to those people gardening and in common with the older population majority of those who took part in the project were in) had a garden. Garden sizes varied, but

The past history of gardening and garden ownership between members of the three groups was varied (see Figure 5). About a quarter of all participants (in the gardening and social clubs) to a third (in the reference group) had been brought up with gardening, either in the family garden or on an allotment plot: a history described by one of the gardening club members as gardening in the blood. Where gardening had been a prominent activity for members of their family or themselves as children, participants were more likely to have been garden owners in adult life, and vice versa. Of those people who were able and willing to join the gardening club, and thus take part in allotment gardening, more had experience with their own allotments as adults. In contrast no-one with gardens in either the social club or reference group had been involved with allotment gardening as adults and only some people

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Figure 5: Comparison of family and adult history/experience of gardening in three groups

Garden/Allotment History - Garden Club participants
30 Number of participants 25 20 15 10 5 0 Own garden No garden Allotment now Allotment in past Family gardened

Garden History - Social Club

20 18 16 14 12 10 8 6 4 2 0 Own garden No garden Allotment Garden in past Family gardened

Number of participants

Garden history - Reference Group

25 20 15 10 5 0 Own garden No garden Allotment now Allotment in past Family gardened

Number of participants

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had childhood memories of fathers, uncles, or in one or two cases mothers, who had gardened allotments. This pattern would suggest that childhood experience in gardens tends to encourage more confidence and interest in later life. However, we found that not everyone enjoyed gardening in spite of his or her childhood experiences and that a love of gardening appeared to be more of an innate enjoyment. One participant noted that despite having two sisters (with exactly the same upbringing), she was the only one who had developed a lifelong love of gardening. Very often people described either themselves, or others, as having a natural gift for gardening. Most of those participating in the project had enough garden space in which they could at least keep some tubs and hanging baskets. There were a surprising number of very enterprising gardeners who, despite only having a tiny backyard, grew carrots, potatoes, fruit bushes and, in one case, even a cherry tree using old buckets and variety of containers. Although many participants described enjoying their garden, for others, keeping the garden tidy and looking good had become a burden as their age-related health problems many gardening tasks exhausting or impossible. People had found various ways of overcoming these problems. About a quarter of our participants, for example, had paved or grassed over existing garden areas. This was viewed as a positive action in the face of increasing limitations as it eased the chore of tidying. Other adaptations ranged from gardening almost entirely in easily managed pots and tubs or putting down shillies (shingle or gravel) with pots or tubs set within the areas. Planting that did not require annual replacement (such as small trees, shrubs etc.) was also popular. Only two of those participating in the project had paved or grassed over areas because they actively disliked or had absolutely no interest in gardening. Some participants had found help in maintaining their own gardens, but only two were able to pay for this service. More often relatives or neighbours helped to keep the grass cut and the garden weeded and tidy.

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Several people had been keen gardeners in the past, but age-related disabilities and changing circumstances had forced them to move to apartments or sheltered housing which had either no garden or small, communal gardens which were managed by the city council or housing association. One or two people in this situation noted that, if they wanted, they could still have a hanging basket or share some small area that was gardened for residents. Those without gardens often had a long-held interest in gardening generally, and most enjoyed visiting garden centres or open gardens, an activity that was also popular with garden owners (see Figure 6). Many people without gardens felt, that to some extent, this made up for the loss of their garden or the fact they only had a small yard or shared resident garden. Gardening, for those who do enjoy it, has certain particular qualities that are distinct from other activities. There is a strong sensory pleasure associated with being in a garden. Many people said that they enjoyed just sitting or gardening amongst the colours, scents and different types of flowers. Others described a sense of wonder in the process of nature: the magic of seeds germinating, plants growing and ripening.
the magic of planting something and seeing that it grows, you know, is still a source of wonder. (Hugh, 70 yrs)

Some gained particular enjoyment from the task of nurturing young seedlings and plants, which they likened to the kind of tending involved in caring for a child. While tending young plants always has an edge of uncertainty, those participants who gardened, especially the more experienced, were very philosophical about the likelihood of certain plants failing in some years, and saw such events as a challenge to be overcome. As one man said: theres a challenge every day - you learn summat every day (Archie, 70 yrs). For many people the challenge was to successfully grow fresh vegetables that could then be eaten. This added to the overall sense of achievement, satisfaction and wonder reported by the majority of those that gardened.

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Figure 6: Comparison of age-related restriction to garden, expertise and interest in gardens in three groups
Ability and interest in garden - Gardening Club
10 9 8 7 6 5 4 3 2 1 0 Does minimum Has help Garden adapted Unable to do Keen/able Like it/less able

Number of participants

Ability and interest in garden -- Social Club

6 Number of participants 5 4 3 2 1 0 Does minimum Has help Garden adapted Unable to do Keen/able Like it/less able

Ability and interest in garden - Reference Group

12 10 8 6 4 2 0 Does minimum Has help Garden adapted Unable to do Keen/able Like it/less able

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People described gardening as creative: it provided mental as well as physical stimulation. Gardening is often assumed to be largely about physical activity. This view was re-iterated, mostly, by those who were either unable to garden due to physical disability or who had little gardening experience. However, the more experienced gardeners in our study noted that gardening is creative in many ways, both physically and mentally, in that people have to plan and think about the design, learn about the needs of different plants and glean new ideas from other gardeners. Others had very little gardening knowledge, but as one woman commented, this had made the gardening club more interesting for her as you are learning all the time (Amy, 72 yrs). This mental stimulation was an aspect of gardening that some participants felt was often overlooked; yet it is an important feature of the activity. One individual noted that gardening encouraged him to go and look up information and gather gardening books, where previously he had very little call to acquire knowledge through books.
Its a bit of a challenge the garden like, in any sense, and as I say Im still learning. Ive got a lot of books on gardening. (Stuart, 66 yrs)

Another described how he enjoyed lying in bed at night thinking out his gardening plans and designs for the season and attempting to work out how to solve problems in the garden. Gardening is perceived to provide a therapeutic' space, which enhances or improves mental well-being. Gardening and gardens can offer many opportunities for engendering positive feelings of well-being, for example through the sense of achievement in successfully nurturing and tending plants, to the pleasure of being surrounded by the colours, scents and variety of flowers and shrubs (Milligan et al, forthcoming). Gardening activity differs from many other popular activities in that it can also provide solitary space and time, which is beneficial to the individual rather than leaving them feeling lonely or isolated.

35

As described by Barbara, below, not only can gardening be less stressful than forcing oneself to socialise and do things that perhaps may not be enjoyed, but the garden, itself, can also provide a setting in which it is possible for an individual to sort out difficult feelings on their own:
I was a bit of wary wondering what the Social Club was going to involve you in, if you were sitting, you know, four walls to a group of people that you maybe didnt gel with and doing things that you werent very happy with. Where in the garden you can just dig your way out of your misery. (Barbara, 67 yrs)

While the positive and therapeutic aspect of gardening is well-documented in studies, largely arising from research in horticultural therapy (see Wells, 1997; Sempik et al., 2003), there is also a negative aspect to gardening that has, to our knowledge, not been addressed in other studies to date, and which we found to be especially prevalent in this older age group. Participants noted, that at some point, due to reduced physical health and energy, a garden or allotment plot can become too difficult to manage and consequently becomes uncared for and overgrown. Its presence, then, can be a source of worry, anxiety and depression - a constant reminder of the individuals increasing disability and loss of strength. This aspect of gardening activity may be particularly relevant to those older people who are not associated with any particular therapeutic or community gardening project and who thus remain unsupported in their gardening activities. As we discuss in the following section communal gardening can go some way to mitigating this perceived burden. These findings are examined in more detail in the Discussion Section.

36

Gardening in a Club
Sharing tasks is a vital and very supportive way of gardening. Communal gardening activity on an allotment site offers the opportunity to share the responsibility for the upkeep and maintenance of the garden plot with others. This can reduce the burden of a garden site, which has become too large for one individual to manage, and increase the enjoyment gained from the gardening activity. In our project, gardening in a club appeared to counteract this problem very well, particularly for those participants who had been forced to abandon their gardening activity after a period of illness, or because they felt generally less energetic and able to manage an allotment site or their own garden. Even those gardening club participants who were still able to manage their own plots or gardens found communal gardening on allotment sites to be better than gardening alone. For six participants who had never before considered an allotment, being in the club opened up a new dimension to gardening:
.. because there was quite a bit of enthusiasm, people were quite keen to learn and, you know, put effort into it. And it did, it went well, and when they saw things growing of course/ I mean some of them hadnt gardened before, you know. And when they saw things growing/ took more interest in it. It was good. (Ben, 65 yrs)

A key reason for the success of the club approach to gardening was the opportunity it offered to share tasks in a sociable environment and, as Barbara says below, as part of a communal effort:
[Its] ..a communal effort. So when youre digging out or weeding and that, instead of having a tired/well you know its weary when youre doing a section on your own, you dont seem to get anywhere. We do it in little groups and you have a bit [of a] laugh and talk and stop and get a chair out.. (Barbara, 67 yrs)

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Group support offered people an opportunity to garden as much or as little as they were able to without feeling guilty or pressured. Those who were frail or unwell were particularly appreciative of this. Despite feeling unwell, some group members would come to the allotment site simply to sit down, watch the activities and enjoy the company. Though the gardening activity still continued, other members of the group would express their concern and care for the individual, facilitating their ability to still feel included as part of the group. This was viewed as an extremely supportive function of the club, combining the therapeutic benefits of both social contact and gardening. As Ben commented:
There was a lot of people who werent really physically fit enough to do the work. So then it was just a matter of helping them, so everybody just ended up piling into the plot, and that seemed to work. It was communal, everyone helped each other. (Ben, 65 yrs)

Group support offered the potential for everyone could go away from a gardening session with a sense of achievement. Communal gardening can, thus, fulfil several different functions: from the therapeutic effects of gardening activity; to the beneficial effects of social contact between the members of the group. The social space and opportunity for social contact provided by the gardening club was an aspect of the activity that was seen to be of equal importance to the gardening, itself:
.. when I come home, and Im thankful Ive been and happy Ive been, you know. Cos like you say, youve got that feel good, youve been in the fresh air, youve been talking to people and discussing the gardening and this, that and other. .. Its gave you that pleasure to know that youve been and enjoyed it.. You feel so different. (Alice, 66 yrs)

As Alma explains below, whether able to do the heavy digging or only able to be involved in less strenuous activities such as potting up or planting seeds, participants could still enjoy the social interaction.

38

I dont know what else I can do except set seeds in the polytunnel and do little jobs, sit around or maybe have a chat with them. ..We are all a lively group, you know, we are/really, have some fun, you know laugh and that. So I quite enjoy that. (Alma, 80 yrs)

In addition to the weekly gardening on the allotment sites, all the club members from both the Lingmoor Way and Longsowerby allotment sites met every month in a central indoor venue. The meeting would involve both a talk on gardening given by an invited expert speaker and a general get together. On two occasions members went on visits to local open gardens. On one further occasion there was a demonstration of the use of coppice products in the garden. These outings and talks were very successful and universally enjoyed, mainly because the events encouraged discussion and ideas on gardening. The events also provided an opportunity for those who were unable do the gardening as a result of ill health to participate in some club activities, so gaining a degree of social benefit from sharing their enjoyment of gardens and gardening. The sharing of gardening knowledge and ideas is an important element of communal gardening. People noted that they found the club a safe, sociable place in which to learn new techniques or to pass on their skills to others. As noted above, this was found to been an especially compelling aspect of gardening:
the thing I like about it is we all seem to have gelled you know, the people that go there.. Theres different characters, weve all sort of gelled, and talk to each other a lot, and ask, you know, not be frightened to ask anybody something, you know. Shouldnt be ashamed to ask anybody anything if you are not sure. (Ben, 65 yrs)

For some, the opportunity to grow vegetables was an aspect of gardening activity that they had not experienced before. Participants not only gained knowledge and a sense of achievement, but also benefited from harvesting fresh produce to eat.

39

Oh Ive done a bit of digging .. and a bit of weeding and a little bit of planting. I did potatoes and lettuce and things like that. I put potatoes in early on. Well Id never done that before. Aye its very rewarding I think like. .. its nice when youve grown them and youve eaten them. You know its lovely. (Amy, 72 yrs)

For many participants, sharing and gaining knowledge promoted a sense of worth, re-affirming their place as a valued and experienced member of the community. Our observations indicated this was not only an important element in the communal approach to gardening, but also in the running and dynamics of the social club and in other group activities undertaken by members of the reference group. We discuss this in more detail in the following section. Towards the end of the active fieldwork, participants were encouraged to discuss how they might go about continuing the club by themselves. The aim was to demonstrate how a gardening club, of this kind, might become self-sustaining or at least manage with limited support. At the time of writing (October 2003) a small group are still successfully maintaining allotment plots at Longsowerby. This was the larger of the two sites with a greater core of able-bodied members. However, our findings indicate that for a club to work, successfully, for its less able members, older people need to be offered regular and sustained support. This need not be the intensive levels of support offered during the first year of the project, but should be offered on a regular weekly basis. The recommendation is discussed in more detail in the later section.

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Social Clubs
The Social Club added a new dimension to the lives of many of those who regularly took part. Although the club was only convened once a week, many participants reported that attending it had made a significant change in their weekly life. It was an event to look forward to, one which was especially enjoyable for those who lived alone, felt isolated or restricted in their activities.

Makes another afternoon out, if youre on your own, you know, you enjoy an afternoon out. (Connie, 71 yrs)

For others the club provided an opportunity to meet with other people, where previously they had felt increasingly anxious about going out as a result of age-related disabilities or frail health.

..as somebody whos sort of housebound because of physical disability, getting out, at first I couldnt stop talking. Now I just talk as much as everybody else does, and I thoroughly enjoyed it, and the company [and] the speakers because its something different to think about. Ive thoroughly enjoyed it. (Angela, 68 yrs)

For some, the contact and opportunity to share each others stories and experiences was particularly valued as it helped them to see their own lives in a different perspective:
Well, I find thats the best bit about it. It does get you out. You meet other people and you make friends. Instead of sitting at home feeling sorry for yourself or depressed it gets you out and about. And you realise that other people have illnesses and things, you know and that. (Esther, 68 yrs)

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The social club opened up the opportunity to make new social contacts. Participants particularly appreciated being able to start afresh in a club where everyone was on an equal footing in a new venture. This aspect of the club was interesting given the findings of Jerromes (1989) earlier study, in which the ritual of attending an established club with regular, well-practised activities was found to be of prime importance. In contrast, in our study, although eighteen (out of the total of twenty-nine) participants in our social group were regular attendees of other clubs or activities, many had previously (and in some cases studiously) avoided some of the more traditional clubs. Participants maintained that they often found people in well-established clubs to be set in their ways and that the activities on offer were often boring and routine. Some, further, noted that when they had attempted to join a wellestablished club they had experienced unfriendliness, even hostility, from the long-term members, who appeared to find a newcomer rather threatening to the status quo. Figure 7 illustrates the extent of social club participants involvement in additional activities such as clubs, societies, or adult education.
Fig.7 Comparison of Social Club members outside activities

14 12 10 8 6 4 2 0

13 10

Numbers involved

4 1

3 1

Social Club

Class

Society

Sport Club

Games

Church

MU/WI

Club/Society etc

We found sporting activities to be the most common additional activity that people participated in on a regular basis. Indoor (and outdoor) bowling, keep fit and gym, swimming and golf were particularly popular. Only one third of our social club members attended other clubs. In the main, (with the exception of sporting activities) this group was involved in far fewer outside clubs or societies than those who participated in the gardening club or reference group.

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This finding reflects the more isolated nature of the lives of the majority of social club members. The social club was, therefore, felt by some participants to have provided an unusual and welcome opportunity to join a club where previously they might never have considered such a move. For those put off by what they perceived to be the negative aspects of existing social clubs, the project offered an opportunity to create a club with a different agenda. Club members had a wide choice and say in the kinds of activities they would like to participate in. Some also felt that this provided an opportunity to develop a different and more inclusive ethos within the club. Without exception, participants asked for arts and crafts, talks, and outings rather than games. These activities, particularly the local outings, proved very popular. Only four members already attended clubs where they could take part in arts, music, adult education, or cookery (two of which were organised by Age Concern). The other members had either been unaware of possible educational activities or societies, or felt unable to get out to a music or art class or club. Within the social club, several arts and crafts sessions were organised ranging from silk painting, card making to pot decoration. The arts and crafts sessions were greatly enjoyed. Some participants noted that they would never have imagined being able to do any arts and crafts before, and were surprised how much fun and pleasure they gained from taking part. As Meryl commented:
Ive thoroughly enjoyed it. Oh, its really tickled me pink. Like last week sitting painting plant pots. I thought if anybody, any of my colleagues, knew and they could see me now they wouldnt believe it. And yet you get something out of things you never think of doing, you know the painting and that sort of thing. It never entered my head I would paint, cos Im not a person for my hands. But Ive enjoyed doing different things. (Meryl, 71 yrs)

Some participants noted that they had consciously avoided the traditional games style of club. They had no interest in playing Scrabble, board games or cards. Within the project social club, everyone, it seemed, was looking for some different or new ideas.

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Organised outings were felt by social club participants to be very important. In many cases it was an opportunity to get out and about, with company, in a way that was otherwise no longer possible:
I like getting out to Tullie House very much, I enjoy that. You see any change of scene is a joy to me now, and going somewhere different. Going to the llama farm, we had a bit of a laugh on the bus going. I enjoyed seeing the animals. I havent seen them before. Ive enjoyed the activities and the lectures.

While local activities in the immediate vicinity, or the city centre, were popular the outings further afield were less well-attended in spite of significant interest, initially, in the suggestion. The longer trips were, mostly, attended by the more able members of the group. This suggests that, for less-able members, the reality of longer excursions may be too arduous, hence they opted to stay home. At the regular venue people enjoyed the way the sessions were structured, with the planned activity at the start of the session followed by some social time with refreshments. This facilitated the opportunity for participants to chat together, encouraging a social atmosphere:
this clubs different from the other Clubs that I go to because the other Clubs are more competitive and this is you know a social atmosphere. (Monica, 73 yrs)

Participants felt the emphasis placed on developing the social atmosphere meant that the club was very relaxed. As one person said: Theres no stress attached to this club. (Esther, 68 yrs). This highlights the general feeling amongst participants that because the club was a new venture, they had a sense of empowerment and common ownership. It is worth noting that the preferred activities of this group were markedly secular with only three people professing to be strong churchgoers involved in their local church activities. This, contrasts sharply with the findings of Jerromes study (see above) in which she had found that older peoples clubs often retained a strongly religious ethos that determined the structure and running of a club.

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An important function of the social club was to provide a focus of conversation for people to share with family or friends.
Its a shared experience, you know. You chat about it the next

week and Ive been able to share it with friends and family, that sort of thing. (Meryl, 72 yrs)

Being involved in activities outside the home was seen by participants as empowering, enabling them to renew their sense of selves as valued, valid and active member of the community as well as gaining a sense of well-being from taking part in their chosen activities. The key to the success of the social club proved to be the way members chose to organise it. As a people-led venture decisions about the organisation and activities within the club were made by consensus (supported by the organiser). The club organiser ensured all participants had an opportunity to discuss their choice of activities with both her and each other. As a consequence, all participants were able to have an equal say in the running of the club. Towards the end of the Project members were encouraged to discuss continuing the Club by themselves. At the time of writing the Clubs success has been maintained by a continuing, strong group commitment and limited but ongoing support from Age Concern.

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Section 7: Discussion
Health: physical fitness and mental stimulation The health benefits of different activities for older people often tends to focus around promoting or improving physical health and fitness. In terms of gardening, for instance, this is reflected in previous studies that emphasise physical activity as the major health factor in gardening (see for example Caspersen et al., 1991; Cowper et al., 1991; Crespo et al., 1996; Galgali et al., 1998). Mental health and well-being in relation to gardening activity for older people has been less well-documented (for exceptions see Houseman, 1986; Armstrong, 2000). Importantly, as noted in the gardening section of this report, mental stimulation was considered by many of our participants to be a key element of gardening activity. In this study we were primarily concerned to explore the benefits to mental health and well-being of different activities, although we did note those changes in physical health and fitness that participants observed in their selfassessment both during and at the end of the project. It is interesting to note that, for those older people participating in the project, the physical benefits arising from an activity were of less concern than whether or not they felt better in themselves. The exception to this general view focused around those activities specifically designed to improve physical fitness, such as yoga, keepfit classes, prescription fitness gym sessions, walking, cycling and so on. Whilst a varying degree of age-related illness and disability is inevitable with increasing age, participants demonstrated a variety of strategies that they employed to maintain their physical and mental abilities for as long as possible. These included keeping themselves disciplined by making a positive effort to go out to do things whenever and wherever possible and keeping their minds active with topics that interested them. This might include either joining a club, society, or an adult education class, keeping physically active, gardening, and making a positive effort to ignore their chronological age. As Ted (69) and Natalie (69) commented respectively, my age is no excuse ; I dont want to be saying ooh Im seventy and I cant do this. Most significantly, participants noted that they made a positive choice to avoid watching much television. This activity was considered by most of the participants as a death knell, particularly daytime television. As Archie (70) put it, In fact you get worse as you/sitting watching television is/youre deteriorating all the time. Conversely, crossword puzzles were seen as a particularly useful means of keeping the mind active. For some participants this

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kind of mental activity was viewed as a preventative measure against illnesses such as Alzheimers or other memory loss problems. The intensity with which some people engaged in activities suggested they were distracting themselves from concerns about possible, and in some cases increasingly real, age-related disability. Mental impairment was by far the most troubling aspect of ageing for our participants and finding sufficient mental stimulation in their activities was a priority for many. These strategies could (and some felt should) be used to minimise age-related physical restrictions to getting out of the home, thus maximising older peoples enjoyment of everyday life. Several participants noted that the highly creative and mentally stimulating qualities of gardening are also to found in other skilled activities. This was particularly true of those activities that require manual dexterity and creativity, such as upholstery, flower arranging, art, DIY or woodwork. In part, as suggested by the quote below, there is great value in any activity that is mentally stimulating and which provides a sense of achievement:
I get the same feeling with the DIY work I do as well. Yeah, I agree entirely with everything said there, maybe, about the gardening. Brilliant. You know the achievement. Ah, I just think being active is mentally stimulating really.(Ronald, 67 yrs)

Health and gardening Participants noted that although, on occasion, they found that gardening helped their fitness and stamina, its key benefit was in improving their sense of mental well-being. These positive aspects to gardening activity occurred despite, in some cases considerable, age-related health problems and disabilities that placed limits on their ability to bend or kneel, or to undertake any gardening that demanded physical exertion. In particular, people gained pleasure in being able to get out and feel occupied, even if this was limited to a little pottering about:
You get out in the garden and it keeps you going, summat to occupy. Whether you can bodily or physically do it or not its get out there and get summat done. Thats what I say! (Archie, 70yrs)

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The health benefits of gardening were, thus, felt by many participants to be a direct result of being out in the fresh air, and in contact with nature via the earth and the plants. For our participants, the on-going challenge of gardening and the need to look and plan ahead were key factors in helping to maintain mental well-being.
The great joy of gardening is .. its always making you look ahead isnt it? You know, although youre regretting the end of the Summer .. you are planting bulbs and looking forward to the snowdrops that you planted last year and so on, coming through.

In addition to the pleasure and anticipation of planning and designing the garden and the new tasks to be undertaken each season, gardening offered the potential to learn new ideas and refine existing skills. Participants maintained that the mental stimulation engendered by their gardening activities enabled them to cope more effectively with their existing physical health problems, as well as making them feel less prone to low moods or depression. As Barbara commented:
Oh everybody should garden! Because its so healthy. Its so calming. Its, you know its just/you forget the world somehow. ( Barbara, 67 yrs)

Gardening provided the space for participants to distance themselves from the wider world for a little while and people found they could forget some of their worries and troubles, including anxieties about physical health or actual physical discomfort. Avril, in particular, felt that without the communal gardening to look forward to, and the pleasure of being able to still get out in her own garden, her increasing physical disabilities would have been much harder to deal with:
Oh its been great! I think if I hadnt had that [gardening] to look forward to Id have been much more depressed and weary than Ive been. Its been my main activity since Ive had to give things up through being limited. (Avril, 73 yrs)

One of the key aspects of the gardening activity was that it offered people the opportunity to garden communally on an allotment site. The communal gardening proved to be a significant factor in maintaining mental health and well-being,

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combining the enjoyment of the gardening activity with the substantial health benefits of social contact. Health and social activity Social contact is critical to maintaining and promoting health and mental wellbeing. The majority of people recruited onto the project, with a few exceptions, described having very active lives with regular social contact either with their family, friends or as part of a club or society. This social contact was crucially important for everyone involved, regardless of the different activities they engaged in. The most successful activities were those that offered good social opportunities. Even when illness and disability prevented peoples active involvement in social activities, participants noted that they felt better for having some social contact either by going to a club, society meeting or other activity and just being in the company of other people. Generally, peoples enthusiasm for activity occurred regardless of their age (active people aged over 80 years were as busy as those in the 65-69 yrs age group). If people were unable to be physically active then, as often as possible, they did some mental activity. In the initial interviews participants commented on the extent to which an active or fulfilling social life helped to maintain their health and mental wellbeing. This was viewed as particularly important in helping to prevent loneliness and isolation. For some, families, especially grandchildren (and great grandchildren) provided the major social contact in the week. For others, this was met through strong and enriching friendship networks that had been maintained or developed over many years. Many people gained supportive and sustaining social contact by attending clubs, societies, church activities or taking part in voluntary work in schools, hospitals, charities or community projects. A few of our participants were still in parttime paid work, which also provided them with social contact. However, in spite of a multitude of activities undertaken every week, a significant number of people noted that they had to make a conscious effort to go out and get involved in some form of activity in order to ward off feelings of isolation and loneliness. We also found a close relationship between physical health problems and an overall decline in well-being. This might arise either as a result of loneliness or following some personal upset or family event, often after bereavement. At

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these times participants found that if they made a conscious effort to maintain some social contact with other people, this would also help to reduce or ease the ill-effects on their general health. Strategies to maintain social contact were particularly important where an individual had lost a partner, lived alone, where they lived at some distance from their family, or were estranged. Social isolation was also more likely where a person suffered illness or disabilities that made it difficult to get out. Overcoming these problems could be particularly difficult where transport was scarce and/or it meant waiting, alone, in streets that were perceived to be dangerous, and during winter months when dark, cold nights discouraged people from going out of the house. Keeping active and feeling valued Older peoples need to feel valued in society is highly vulnerable to ageism and ageist attitudes (Bytheway, 1995). Sharing knowledge in a group or club was supportive to different individuals in often quite subtle ways, boosting their self-confidence and sense of self-worth. Some participants had only recently retired and one or two still undertook some part-time paid work. Although some participants clearly relished retirement, finding it gave them the freedom and opportunity to undertake voluntary work, or to pursue [sometimes new] hobbies and activities, for others the transition had been difficult. These individuals talked quite frankly about how hard the transition to retirement had been for them. This was especially relevant to those aged between 65 70 years of age, where the experience, itself, was still vivid as were the strategies adopted to overcome the problems of this transition. As Robert (68) commented:
When you retire, I dont know if any of the rest have told you, its a bit of a shock to the system. Its like driving a car and crashing it and writing it off. And when you get out of that car your mind tells you its not all - youre alright, the cars bent.

Robert sought to overcome the shock of retirement by involving himself in a significant amount of activities, some of which involved physical activity and others that he found mentally stimulating. He belonged to a regular, formally organised, social club and an informal coffee club consisting of friends (all retired men) that put the world to rights every week. He was also a keen member of the golf club and he and his wife socialised regularly with groups of friends. This range of activities presents a typical picture of range and extent of activities undertaken by a significant number of those participating in the project.

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As Robert noted, however, numbers in the informal club had fallen recently as the obituary columns have thrust their knife into it. As Sarah further commented:
I dont have as many friends, as you get older they seem to fall by the wayside Theyve all died, thats me, Ive none left. (Sarah, 89)

The increased likelihood of ill-health and mortality amongst older people can thus result in a significant shrinking of those social networks that older people have formerly drawn on for support. Furthermore, the loss or long-term illness of a partner can result in older people having to re-think their identity within their existing social networks. The provision of social spaces in which older people can meet and share experiences while participating in mutually enjoyable activities, can, we suggest, facilitate the re-forging of new social identities within new social networks. Strategies to determinedly pursue social and other activity following retirement were also viewed as important by some participants as it gave them a sense of value and worth. Older people can often find themselves combating the feeling of being of less worth to the community. Their knowledge and experience is no longer valued or called upon by younger, fitter, working members of the community. Yet many older people have gained significant knowledge and expertise in the course of their lives. An important aspect of the activities engaged in within this project was that they offered a forum for the skills and expertise of these older people to be acknowledged and shared amongst their peers. This was particularly true of the gardening activities, but was also evident in other skilled activities in which our participants engaged, such as DIY, crafts, volunteer teaching and organisational skills. As Roger commented:
I often think retired people, theyve all done something throughout their working life, whatever, and theyve all been experts in their field. It doesnt matter what it is. Theyve all done their - theyve an awful lot to offer, you know, plumbers, joiners, electricians. All these people, all this knowledge and its just gonna disappear when they go. You know, if there was some means where they could pass this on, I dont mean to people my age, but to younger people. (Roger, 72 yrs)

There were several people who were very active in the community working as volunteers in schools or in church-led and secular social and sport projects with younger people. These sorts of activities provided the kind of outlet for sharing skills that Roger alludes to. Equally, for those who participated in the clubs set 51

up by the project, there was a clear sense of value in sharing knowledge amongst their peers. People noted that they found the social club settings and communal gardening especially helpful in this respect. Health and issues of gender Gender issues emerged throughout the project, not least because, as noted earlier, there were some wide (though predictable) differences in the balance of men and women in the three groups. Although, we often found that gender stereotypes were affirmed, there were many occasions when gender issues confounded both our own perceptions, and surprised those of our participants. These issues were seen to be an important factor for participants in terms of their willingness to either engage with the project in the first place or, once part of the project, the choice of activities in which they were prepared to engage. Both women and men agreed that a social club where there was little structure leaving much opportunity to talk together was going to reflect what they perceived of as the needs of women. In general, participants considered that women were happy to chat together over a cup of tea during the daytime in an informal, homely setting, whilst men preferred to go down to the pub for a drink, or to a structured, often highly organised and usually well-established, male-dominated club. Predictably, then, the most blatant stereotypes were apparent in the social club. This was considered by two or three of the men to be just another womens chat club. While, originally the allocation of participants to the club was intended to reflect a relatively mixed gender balance, drop out and new [early] recruitment meant that, once club numbers stabilized, it was dominated by women (twenty-three women to six men). Of the six men that did join the club, only three were still regularly attending by the end of the project. Two men withdrew following the first social club meeting - one commenting that, for him, it was just another WI meeting (Bruno, 75 yrs). Another simply found it boring (Huw, 79 yrs). Three of the male participants said they would have preferred something more structured, with some structured purpose. Exceptions to this view were found in two of the men who liked the company of women, were happy to take part in the less formal meetings and enjoyed the variety of talks and crafts. One of the men who continued to attend commented that, in his view, he was untypical of most men in that he was a loner and positively disliked the sort of stereotyped clubs dominated by men and alcohol.

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Gender issues, however, were more complex in the gardening group. The garden offered a much freer space for women and men to share tasks that they had previously associated with the opposite gender, and thus helped to create a social space based on a greater equality and respect than is often found in traditional settings. We would argue that this in part was due to the fact that both in the UK and in many other cultures around the world, women have traditionally occupied a niche in the garden (Wells, 1997; Buckingham Hatfield, 2000). Although, within this niche, women are seen to have specific roles in nurturing (food production), healing (the growing of herbs) and aesthetics (tending flowers), they have, nevertheless, maintained a respected place in the garden in general. Conversely, men are often regarded as having more technical knowledge in gardening activity (e.g. agricultural food production) or specific expertise (e.g. as horticultural specialists). On allotment site where the gardening activity was shared, however, both men and women discovered much common ground. Whilst one woman initially referred to the men as the diggers (Alice, 66 yrs), she, along with other participants, later noted that, in fact, men and women shared all the tasks. The major factor determining the tasks each person undertook, was their physical ability. Major changes occurring in peoples lives, such as bereavement, retirement, illness or family difficulties also focused attention on some of the gendered and ageist attitudes experienced by older people. Most evidently, men were able to maintain their status in a crisis by avoiding making any significant adjustment to their lives. In cases of bereavement or illness, for example, men were more likely than women to be supported by a female friend or relative, thus enabling them to continue their lifestyle with only limited change. In contrast, women were more likely to find themselves having to adjust to greater changes in their lives. This occurred not solely as a consequence of their increased likelihood of being bereaved, but because they were more frequently called upon to support other family members in crisis. This support was frequently demanded of them regardless of their own disabilities. Women who were left alone often found themselves having to forge a new life for themselves through engaging in new forms of social or physical activity if they wanted to avoid suffering from extreme isolation. This reflects the increased willingness of older women to participate in the project, particularly the social club, seeing it as an opportunity for a supportive social network.

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The reference group had a relatively even balance of men and women, but in terms of willingness to join the project, gender issues were not seen as a factor, since the status quo of either male or female would not be challenged.

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Section 8: Conclusion
Two major conclusions arise from this study. The first specifically concerns the benefits of gardening communally and/or alone; the second concerns health benefits associated with social activities in clubs or other settings. Gardening offers a valuable tool for maintaining older peoples health and mental well-being, and in some cases supporting fitness and stamina. However, there is a need for sensitivity and flexibility in the approach taken. Communal gardening will not appeal to, or suit, everyone; hence gardening interventions for older people need to be tailored to individual needs and, in particular, communal projects need to be adequately and skilfully supported. Other communal projects report similar findings. Though not an evaluated project, the Marsh Age Link (Community Project) in Lancaster, NW England, also found that the presence of a skilled support worker on a site dedicated to communal gardening was crucial in encouraging older people to get involved in the gardening activities. Within this framework the worker was able to offer individual, but often, unobtrusive support for each person who showed interest (Drew, 2003). This kind of approach is supported by evidence from other projects around the country that have been supported by the horticultural therapy charity, Thrive (see Sempik et al., 2003). Our findings also indicate that gardening activities can be encouraged if the allotment site or domestic garden is adapted to accommodate people with a variety of abilities and needs. The allotment site needs to be close to peoples homes and specialist tools are helpful for those people with more limited physical ability. In the course of the study we provided some support for some people within the gardening group to tend a plant in their homes. While only a few individuals took up this option, a large number of participants, across all groups, spoke about the ways in which they had adapted their gardens to enable them to keep gardening as long as possible. This leads us to suggest that the health benefits of gardening might be best promoted by a combination of schemes, from allotment sites with supportive clubs to the introduction of flexible supported gardening schemes where people can garden in their own homes with support. There is also a case for the provision of small domestic plots in sheltered housing with gardens (Milligan et al., in press).

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Finally, we conclude that there is a need for the development of social spaces within which older people, particularly those who feel socially isolated, can meet and share experiences. Social contact was unanimously and overwhelmingly found to be the crucial factor in maintaining the health and well-being of older people. Whether as a club, a society, through voluntary work, or an informal meeting of friends or family, the development of spaces in which older people can make these social contacts is of prime importance. They can facilitate not only the reforging of new social identities within new social networks, but they can also act to cushion the effects of stress and anxiety. During the course of our study, it became clear that the garden and social clubs acted as sites within which older people were able to develop friendships, express caring and discuss issues around family life, struggle and coping mechanisms in their daily lives. Activity within such clubs can bring a range of benefits, e.g. the opportunity for self-expression; a context for working out new social identities; a sense of security; supportive networks; and a chance to confront some of the ambiguities and losses of ageing. The importance of these clubs, we would argue, is that they can open up spaces for some older people that offer greater opportunities for their emotional expression that those existing in their everyday lives.

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Section 9: Dissemination
The project team have made a considerable effort to ensure that the findings from this project have been disseminated both orally and in written format to a range of different audiences as detailed below. Papers have been delivered at regional, national and international conferences and presentations have been given in less formal seminars. Professor Gatrell has also been an advisor to a project supported by the Community Fund (joint Thrive and Lougborough University) on assessing the evidence base for horticultural therapy. Published journal articles on issues arising from this study are detailed below. We have also produced a summary report aimed at older people particularly those who participated in the project - alongside this more detailed report for voluntary/community organisations and other groups who may be interested in the project and who may wish to develop similar clubs or gardening schemes. Both of these reports are available electronically as Word and .pdf documents on our Cultivating Health website at: http://www.lancs.ac.uk/users/ihr/research/mental/cultivatinghealth.htm A limited number of hard copies will be made available to those interested in the findings of the research. Please contact Dr Christine Milligan (for contact address see page 2 of this report). Our overall aim has been to disseminate the findings of this study to a wide variety of audiences including academics, health and social care professionals, the voluntary and community sector as well as older people themselves. Current and Submitted Publications: Allnutt, E. (2003) Cultivating Health, Allotment and Leisure Gardener, The Journal of the National Society of Allotment and Leisure Gardeners, Issue 1 p.6. Allnutt, E (2003) Cultivating Health Carlisle Focus Issue 7 p.6. Milligan, C., Gatrell, A. and Bingley, A. (in press) Cultivating health: therapeutic landscapes and older people in northern England, Social Science and Medicine, (corrected proofs online).

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Milligan, C., Bingley, A. and Gatrell, A. (submitted) Healing and Feeling: the place of emotions in later life, in Davidson, J., Bondi, L. and Smith, M. (eds) Emotional Geographies, Blackwell Pubs, London.

Planned and Forthcoming publications: Bingley, A., Milligan, C. and Gatrell, A. (forthcoming) In the garden and beyond: observations on gender and ageing, Gender, Place and Culture. Gatrell, A. and Wagstaff, R. (planned) Cultivating Health and well-being amongst older people in Northern England, Health Services Journal. Gatrell, A., Milligan, C., and Bingley, A. (planned) The Plot Thickens: methodological issues in cultivating health amongst older people in Northern England, Aging and Society. Milligan, C., Bingley, A. and Gatrell, A. (planned) Diaries and dilemmas: exploring health and activity amongst older people through narrative approaches, International Journal of Qualitative Health Research. Reports: Bingley, A., Milligan, C., Gatrell, A., Allnutt, E., and Wagstaff, E. (2003)

Cultivating Health: a study of the health and well-being of older people in Carlisle, end of project summary, June 2003. Institute for Health Research,
Lancaster University.

Milligan, C., Bingley, A. and Gatrell, A., (2003) Cultivating Health: a study of health and mental well-being amongst older people in Northern England, Final Research Report, October 2003. Institute for Health Research, Lancaster University. Conference Papers and Presentations: 2001 IHR Seminar, Lancaster University: Cultivating Health - A. Gatrell. 2002 University of Liverpool Seminar Department of Primary Care: Cultivating Health A. Gatrell.

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2002 North Cumbria NHS: International Older Persons Awareness Day: Healthy Living Conference: Cultivating Health amongst Older People in Northern England - C. Milligan, A. Bingley & J. Barker. 2002 Emotional Geographies Conference, Lancaster University: Digging and Dreaming: therapeutic landscapes and older people in Northern England, Lancaster - C. Milligan and A. Bingley. 2002 IHR Seminar, Lancaster University: Digging and Dreaming: therapeutic landscapes and older people in Carlisle: C. Milligan and A. Bingley. 2002 North Cumbria Healthcare Research and Development Conference, Westlakes: Cultivating Health and Well-Being among Older People in Northern England A. Bingley 2003 International Medical Geography Symposium, Manchester: The plot thickens: methodological dilemmas in cultivating health amongst older people in Northern England - C. Milligan. 2003 Association of American Geographers, New Orleans, USA: Cultivating Health: therapeutic landscapes and older people in Northern England - C. Milligan. 2003 GRAIN, Reading: Growing Together Seminar - C. Milligan. 2003 Institute of British Geographers Annual Conference (RGS-IBG): In the garden and beyond: observations on gender and ageing - A. Bingley.

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complementary roles of nature, exercise and diet physical and emotional wellbeing and impications for public health policy CES Occasional Paper March 2003:

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