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CARE, FARMS AND AGEING: AN EVALUATION OF FUTURE ROOT’S COUNTRYMEN’S CLUB
Final report, January 2017 NPC and University of Essex
NPC – Transforming the charity sector
CONTENTS
Executive summary .................................................................................................................. 4Introduction ........................................................................................................................................................... 4Findings ................................................................................................................................................................ 4
Methodology ............................................................................................................................. 6Challenges ............................................................................................................................................................ 6Approach ............................................................................................................................................................... 6
Context: who the Countrymen’s Club is for .............................................................................. 8The target population ............................................................................................................................................ 8Issues affecting the target population ................................................................................................................... 8
The Countrymen’s Club model ............................................................................................... 11Background to Care farming ............................................................................................................................... 11What is the Countrymen’s Club? ........................................................................................................................ 11How does it work: Defining the ‘core’ of the model ............................................................................................. 12Theory of change ................................................................................................................................................ 16
Literature Review ................................................................................................................... 17Hooks .................................................................................................................................................................. 17Overall summary for literature on hooks ............................................................................................................. 18Change mechanisms .......................................................................................................................................... 19Physical and mental wellbeing ............................................................................................................................ 19Personal, Social, and Personal relationships pathways ..................................................................................... 20Overall summary of literature supporting Countrymen’s Club-related change mechanisms .............................. 21
Evaluation findings ................................................................................................................. 23Monitoring / Output data ..................................................................................................................................... 23Service users’ needs ........................................................................................................................................... 25
What activities do Countrymen engage in? ............................................................................ 27What goes on? .................................................................................................................................................... 27Differences between Rylands and Whitfield ....................................................................................................... 27
How well have users engaged with the service? .................................................................... 28Referrals ............................................................................................................................................................. 28Initial drivers to engage ....................................................................................................................................... 28Positive engagement in activities ........................................................................................................................ 30Longer-term perspective ..................................................................................................................................... 30
Other services accessed ........................................................................................................ 36
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Qualitative data ................................................................................................................................................... 37Activities .............................................................................................................................................................. 37Change mechanisms .......................................................................................................................................... 39Evidence of outcomes ......................................................................................................................................... 41
Views of families / carers ........................................................................................................ 44
Disaggregation of service users’ data .................................................................................... 46
Illustrative Case studies ......................................................................................................... 47
What has been learned? ........................................................................................................ 49
Conclusions and discussion ................................................................................................... 52What does the evidence say about the theory of change? ................................................................................. 52What might have happened without the Countrymen’s Club? ............................................................................ 53How do the results vary for different service user groups? ................................................................................. 53What other explanations are possible? ............................................................................................................... 54What are the costs of the Countrymen’s Club? .................................................................................................. 55
Appendices ............................................................................................................................. 56The Boing Boing resilience framework for adults ................................................................................................ 56“Evidence is confidence” ..................................................................................................................................... 57
References ............................................................................................................................. 59
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Executive summary
Introduction
This report presents the findings from an evaluation of the Future Roots Countrymen’s Club over a six month period (May – November 2016).
Future Roots runs charitable programmes from two sites in the Dorset countryside. It is part of the 'care farming' movement, which aims to harness the therapeutic potential of farming practices. Future Roots uses the care farming approach to build the resilience of vulnerable people who are going through transitions in their lives. This includes supporting people to learn life skills, strengthen relationships, and improve mental and physical health.
The Countrymen’s Club addresses the specific challenges faced by older men from rural communities. While much of Future Roots’ other work targets young people, the Countrymen’s Club aims to help older men become more resilient to the life changes they experience as a result of rural isolation and ageing. The programme is targeted at older men in Dorset who have dementia, depression or a limiting long term illness.
Future Roots commissioned New Philanthropy Capital (NPC) and the University of Essex to evaluate the Countrymen’s Club. The principle research question has been to consider the application of the care farming model to older men from rural communities. While care farming is a reasonably established approach to engaging with vulnerable groups, it has rarely been applied to older people in the UK (although it has been used with this age group in the Netherlands and elsewhere in Europe). Future Roots thinks this might be a missed opportunity because;
• Older people are an increasing population in rural areas;
• They often have difficulties accessing existing services; and
• May have an interest in the natural environment which could be a hook for further engagement.
Findings
NPC began the evaluation process by working with Future Roots to develop a clear theory of change for the Countrymen’s Club. This shows how the Countrymen’s Club uses a series of ‘hooks’ that attract the target group to the service, we then describe how the service is intended to work through four pathways; physical and mental health; personal; social; and relationships to give men a series of capabilities described as ‘resilience’ that helps men and their carers / families to improve aspects of their lives and optimise their wellbeing.
Following the theory of change process, both our literature review and the data collected provide broad, indicative support for the model.
Through our qualitative research we have seen that both Countrymen and carers strongly support the notions that:
• This type of support is particularly relevant to the needs and experiences of the target group of older men with a range of health conditions. Once referred to the service, retention, participation and engagement is very high;
• The Club appears to be very effective at overcoming the barriers and reservations that might prevent some older men from accessing support services (feelings of stigma, feeling in control, not wanting to be seen as a ‘patient’ or ‘dependent’). In this regard there seems to be distinct value in this being a club for men, in a working environment that is traditionally associated with masculine identities; and
• Few, if any, similar services are currently available that have the same appeal.
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Moreover our evidence indicates that positive benefits are being achieved. In particular:
• Many Countrymen talk explicitly about the ‘sense of belonging’ they feel and the social relationships they have established - with both staff and other Countrymen.
• Similarly, all Countrymen and carers talk about the benefit of ‘getting out the house’ and ‘doing something different’ which helps combat the risk of lethargy and other bad habits. The fact that the Club is available routinely, twice a week, also seems to give families a positive structure / routine which they can rely on.
• More than ‘getting out the house’, Countrymen talk about the particular value of the agricultural / farming environment, the fact that is ‘stimulating’ to be outdoors, with animals, doing physical activity, drawing on their skills and experience.
• A minority of Countrymen also talk about the fact that it is a working environment, and that they can do worthwhile things that contribute to the environment and make use of their skills. There are also examples of men feeling a sense of purpose from work, art / craft activities and helping others (e.g. new Countrymen).
• There is good evidence that the Countrymen’s Club is performing a valuable respite function. Carers / family members are very positive about both the free time it gives them, and the sense their men are in a place where they are happy and engaged (so it is “guilt free”). A small number of carers go on to say that they think their relationships have improved as a direct result of the Countrymen’s Club.
Some aspects of the model are less well supported by the evidence we collected. Fewer men talk about the benefits of diet / nutrition, better sleep and reminiscence work. Also, the evaluation has failed to establish robust quantitative evidence of success. We have monitored the number of people using the service over the six months, and in particular the impressive retention rate, but quantitative evidence of benefits and impact is only indicative at this stage (albeit a positive indication).
For this reason, given the scale that the Countrymen’s Club is currently working at, and the limited research methodologies available to us, it is not yet possible to be definitive about impact. But we can assert with confidence that the Countrymen who have engaged and participated during the evaluation do appear to be achieving some / many of the intermediate outcomes articulated in the theory of change. And therefore—if the literature is correct—that sustained impact / outcomes are being achieved.
The main question for the future is how widespread the appeal of such a service could be? The encouraging signs from these findings are that:
• The appeal and benefits do not seem to be limited to men with a farming background (fewer than half the men using the club during the evaluation period worked in agriculture, while the others represented a mix of manual and non-manual occupations).
• The Club has supported men with a wide range of health conditions. Indeed, this might be seen as an asset because the mix of conditions encourages dialogue which is not condition-specific and enables men to help one another.
• There is a high retention rate; once men in the target group try the Countrymen’s Club they tend to keep coming back.
• The majority of referrals to-date have been individuals who have failed to engage with other services, indicating that the Countrymen’s Club is meeting an unmet need.
The unknown factor is how widespread the need is, and therefore the extent to which the Countrymen’s Club model will be a niche or more universal service? As such, when operating on a larger scale, or with more formal referral routes, it will be important to test whether the high levels of engagement and impact continue.
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Methodology
This evaluation covers the operation of the Countrymen’s Club over a six month period from the beginning of May until the end of November 2016.
During that period 36 men used the Countrymen’s Club. Although as noted below (page 21), three of these only visited the Club on one or two occasions.
Challenges
The Countrymen’s Club is hard to evaluate for a number of reasons:
• The scale it is currently operating at means that, in purely statistical terms, there are not enough service users for robust quantitative analysis or comparisons for different user groups.
• There is no single way in which people are referred to the service. This makes it harder to collect consistent data at the point of referral, and then to track outcomes through referral agencies. It also makes it harder to create a control group of people not referred to the service.
• While older people are generally willing to take part in research they do vary on the extent to which they can reflect on their situation and they have been effected by the services they receive. Those with more severe dementia pose a particular challenge.
• The client group all have health conditions that are expected to worsen. As such, intended outcomes cannot be framed as ‘improvements’, but rather the maintenance of current conditions or the offsetting of the effects of declining health. In these circumstances the counterfactual is very difficult—if not impossible—to estimate.
• We have been largely dependent on staff for data collection. While this is the most efficient and unobtrusive approach, it has increased the amount of missing data and given us concerns about objectivity.
• The limited time period of the evaluation meant that we were not able to collect ‘before and after’ data (because most Countrymen were already using the service when we started). However the processes introduced through the evaluation should equip Future Roots to collect this data more consistently in future.
Approach
Our overall evaluation approach has been informed by theory of change and contribution analysis.
Theory of change is essentially is a blueprint of how a service is intended to work. It describes the context for a service, how it is intended to work, and the existing evidence that supports it 1. A particularly important aspect of theory of change is articulating the ‘mechanisms’ and ‘intermediate outcomes’ that contribute to longer-term impact. For example, the Countrymen’s Club’s theory of change shows how the intermediate outcome of ‘improved social resources’ can contribute to a longer-term impact of reduced social isolation and loneliness.
Contribution analysis is a recognised process for assessing whether a theory of change has been achieved 2. It involves developing a good theory of change and combining data from as many different sources as possible to construct a narrative about whether (and for whom) the theory of change applied, and whether the project has made a difference. Our conclusions section is therefore organised around the key questions posed by ‘contribution analysis’.
The specific data collection methodologies used were:
• An adapted version of the Quality of Life in Alzheimer’s Disease (QoL-AD) questionnaire 3 used by referrers, staff and carers to rate aspects of Countrymen’s quality of life. This relatively succinct approach was chosen by Future Roots because of its simplicity and perceived relevance to the Countrymen. The
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scale covers areas such as physical health, mood, relationships, and life satisfaction. At this stage the data presented from the QoL-AD for the Countrymen’s Club is indicative and we do not have enough data points for a before and after analysis.
• A referral form, including the QoL-AD and other background information. NPC designed a new form as part of the evaluation design and data was collected using this form for some of the new Countrymen during the evaluation period; for established Countrymen we drew upon ad hoc data that Future Roots held on individuals.
• An ‘engagement’ form completed for each countryman after every session they attended. The form asked staff to rate engagement on a scale of 1 to 4 and provide additional free text information about the activities they engaged in and any issues that arose. A total of 779 ratings were made.
• A ‘monthly’ form, which asked staff to complete the QoL-AD for individual Countrymen and answer a small number of general questions about their engagement in the service. In total, 98 monthly assessments were made:
o 9 men were assessed once
o 8 men were assessed two or three times
o 12 men were assessed more than four times
o 7 men were not assessed
• A ‘carers questionnaire’ was used to get the views of family members on; a) which aspects of the Countrymen’s Club seemed most important; and b) any outcomes observed (both for the men and themselves). A total of 18 questionnaires were completed.
• In-depth qualitative interviews were conducted by the research team with 14 service users.
• One group discussion was conducted with carers and three carers were interviewed individually.
• A group discussion was conducted with Future Roots staff involved in the programme.
• In-depth interviews were conducted with three ‘stakeholders’: People working in local services that had referred people to the Countrymen’s Club.
Collectively, these methods gave us a range of information, and to increase its analytical power we combined all the information about each individual countryman into a single spreadsheet and analysed it with an approach informed by Qualitative Comparative Analysis 4,5.
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Context: who the Countrymen’s Club is for
‘The project is open to all, but is designed to address rural isolation and meet the needs of those with lifelong conditions who find it difficult to socialise & access the countryside or work activity.’
Future Roots6
The target population
The Countrymen’s Club is designed as a specific solution to the challenges faced by older men from rural communities, especially those with life-changing conditions like dementia, depression and Parkinson’s disease.. This section of the report summarises the available research into the needs and challenges of this group.
Issues affecting the target population
Dementia
Dementia is a syndrome that can be caused by a number of progressive disorders. It can affect memory, thinking, behaviour and the ability to perform everyday activities. Alzheimer’s disease is the most common type of dementia. Other types include vascular dementia, dementia with Lewy bodies and frontotemporal dementia 7. Dementia directly affects around 800,000 people and a further 670,000 carers in the UK 8, and the current overall cost of this has recently been estimated at £23 billion - £26.3 billion per year 8,9. The prevalence of dementia in UK adults aged 65+ is 7.1% (based on 2013 population data), which equates to 1 in every 14 people in this age group, and over one in every 79 (1.3%) of the entire UK population 9. These figures are rising, with recent analysis showing that 32% of people born in the UK in 2015 will develop dementia during their lifetime 10. With an ageing population, estimates suggest that the number of people living with dementia number may double in the next 30 years 8 and or even treble by 2040 9.
Support for dementia
NHS support for dementia is disseminated via GP surgery and hospitals and can include services such as community mental health nurses, physiotherapy, speech and language therapy, and mobility specialists. Social services provide social care support such as arranging a place at a day club or support group, help managing money and paying bills, dealing with paperwork and claiming benefits, help in and around the home with tasks including shopping, cooking, cleaning, or washing and dressing, and respite care (temporary replacement care to allow carers to take a break).
Regular day care facilities for dementia patients traditionally have a strong care orientation, with either socially or medically oriented main focus, which is related to the residential or nursing home environment in which they are often housed 11.
Current UK-wide provision of support for people with dementia is frequently perceived to be poor by those who experience it. 49% of people with dementia report that they do not get enough support from government, and 67% of GPs think that their dementia patients do not receive enough support from social services 12.
Carers
The lack of state-funded support for people with dementia is often offset by support from unpaid carers such as family members, friends and neighbours. Seventy-seven percent of GPs think that their dementia patients have to rely on family members as they don't get enough support from health and adult social services, whilst 73% said they have to rely on unpaid carers 12. Indeed, across Europe, 50% of carers of people with late-stage dementia spend more than 10 hours per day caring 13.
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Family members who become carers for individuals with dementia often experience physical, emotional, financial, and social burdens 14, and the burden on the carer becomes more severe as the condition of dementia progresses 15. Behavioural and psychiatric symptoms of dementia such as relentlessness, aggression, shouting, depression and anxiety have important associations with burden and depression in carers of those individuals 16. Dementia caregiving has been associated with increased levels of depression, anxiety, and anger, higher use of psychoactive medications, worse physical health and immune function, and increased mortality rate 17-19; as well as poorer resistance to stressors, physical inactivity and other health parameters that in turn increase the risk of social isolation 20,21. Indeed, for the benefit of both people with dementia, and their carers, there remains a pressing need to deliver dementia-friendly health and care settings 12.
Social isolation, loneliness and dementia
The term ‘social isolation’ refers to a lack of contact with family or friends, community involvement, or access to services 22. The concept of loneliness is related but distinct to that of social isolation. Loneliness can be understood as an individual’s personal, subjective sense of lacking desired affection, closeness, and social interaction with others 22. That is, isolation is being by yourself, loneliness is not liking it 23. People with a high degree of loneliness are twice as likely to develop Alzheimer’s disease (the most common type of dementia) as people with a low degree of loneliness 24. Social isolation is associated with risk of developing dementia, with these conditions thereby forming a two-way relationship 20,25. Within the context of its close relationship with dementia, relevant aspects of social isolation are now outlined.
Elderly populations are particularly at-risk of experiencing social isolation and loneliness. Nearly half (49%) of all people aged 75 and over live alone 26, and only 86% of over 65s say they are satisfied with their personal relationships—a lower percentage than all other age groups 27. 41% of people aged 65 and over in the UK feel out of touch with the pace of modern life and 12% say they feel cut off from society and over 1 million older people say they are always or often feel lonely 22. Social isolation can be contributed to by factors such as marital status; frequency of contact with friends, family, and children; and participation in social activities 28.
Beyond the unpleasantness of experiencing social isolation or loneliness, these experiences, and lack of adequate support for them can significantly influence both psychological and physiological health wellbeing; and unsurprisingly, the costs of these conditions particularly high among retired and elderly populations 29,30. Social isolation is associated with blood pressure and other biological health markers 28, and loneliness can influence the individuals’ self-reported personality ratings and socio-emotional states 31. Loneliness and depression are significantly related 32, and perceived social isolation is a risk factor for poorer overall cognitive performance and faster cognitive decline, poorer executive functioning, increased negativity and depressive cognition, heightened sensitivity to social threats, and heightened self-defeating confirmatory bias in social cognition (seeking out only those sources of information that support pre-existing beliefs or theories and actively neglecting all contrary evidence or sources of information 33,34. Additionally, loneliness and social isolation can affect health indirectly through their effects on health behaviours 28.
Satisfying social relationships are crucial for good mental and physical health, and the alleviation and prevention of social relationship deficits and loneliness merit being a key focus in their own right 35. However they also play a key role as adjuncts to the treatment of other psychological health conditions such as dementia 35.
Issues specific to older men
Many older people are deterred from taking part in an initiatives aimed at ‘lonely people’ because there is still a stigma and shame attached to being lonely. Older men in particular often do not identify with being older, will not admit to being lonely and do not wish to be the passive recipient of a service 23,36.
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Older men are at particular risk of physical or mental ill-health. There are several reasons for this, many of which are rooted in common gender role perceptions. Men tend to avoid discussing health problems, are less likely to participate in preventive health activities and are more likely to refuse support. It is likely that masculinity is an important factor in failing to take notice of or take action about symptoms (Bernardes & Cameron, 1998).. In this way, older men use fewer community-based health services than women (Age UK). Another issue which persists is that current social services tend to be dominated by women and are primarily based indoors and often men are reluctant to attend these services (Ruxton, 2006).
Research also suggests that men find it harder to make friends in later life and are more likely to become isolated and refuse support as they age than older women 23. Over 1.2 million older men reported a moderate to high degree of social isolation, and over 700,000 older men reported feeling a high degree of loneliness 23. Older men also cope less well with health problems because they fear they are losing control, ‘Chronic conditions are characterised by unpredictability… which represents a threat to traditional masculinity, with its emphasis on control and taking charge. Women are often thought able to cope better with chronic ill health, because acceptance and passivity align more with the traditional female gender role.’ (Bernardes & Cameron, 1998) In order to tackle gender variances in health seeking behaviours, use of social services and growing rates of social isolation, specific services targeted at older men are needed (Milligan, et al., 2013).
Issues specific to older people in rural communities
Rural areas are ageing faster than urban ones but receive less government funding for social care (while the cost of delivering services is higher). 9.2 million people, or 17% of the UK population, live in rural areas. Of these, 23% are aged 65+ (years), with a further 30% aged between 45 and 65 37. The average age in rural areas is now five years higher than that in urban areas. In England, the population in rural areas who are aged 65 and over is projected to increase by 62% between 2009 and 2029. In many areas of the South West, 60 to 74 year olds are the largest population group and continue to grow in size (Big Lottery Fund / Leisure Futures Ltd, 2011).
Living in rural areas can contribute further to social isolation. Rural isolation is the feelings of powerlessness and disconnection experienced by individuals or groups as a consequence of living in a rural area 38. Rural isolation can be attributed to by a lack of income and employment, a lack of access to transport and other services, and lack of contact with, and help from relatives, friends and neighbours 39. In 2012 only 49% of households in the most rural areas had a regular bus service, compared with 96% of urban households 37. Rural isolation and poor access to services detrimentally contribute to stress, anxiety and depression, and some rural occupations and stigma around mental illness reduce health seeking behaviour 40.
Socio-economic change has led to a significant section of the farming community in particular becoming both economically disadvantaged and lacking in social contact 38. There is some evidence to suggest that former farmers are also particularly unwilling to seek help due to the stigma of not coping (Commission for Rural Communities, 2006). As they retire and their living circumstances change, older men from farming communities can experience challenges to their sense of self. In a qualitative study of rural older people, two men interviewed expressed “a deep sense of personal identity linked to the farming way of life. In losing that way of life, both men conveyed profound feelings of regret and loss” (Commission for Rural Communities, 2006).
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The Countrymen’s Club model
Background to Care farming
‘Care Farms provide health, social and educational care services through the use of farming-related activities for the benefit of clients from a wide range of vulnerable groups of people.’
Care Faming UK41
Care farming (variously 'social farming', 'green care in agriculture', 'farming for health') can be defined as 'the use of commercial farms and agricultural landscapes as a base for promoting mental and physical health, through normal farming activity' 42. The growth of care farming has been accompanied by emerging interest in ‘social prescribing’, and in particular, ‘green prescriptions’. Care farming is a well-established movement in many European countries such as the Netherlands where there are now over 1,000 care farms working with around 10,000 clients 43,44.
There are now 230 care farms in the UK offering farming-related activities for a wide range of vulnerable people including those with learning disabilities, people with Autism Spectrum Disorders, those with a drug history, or on probation, disaffected young people and elderly people, as well as those suffering from the effects of work-related stress or mental health issues 44.
The recent growth in European political, professional, and scientific interest in care farming is linked to transformations within the agricultural and health and social service sectors (from highly institutionalised to community care) 45. Green care farms may have more health benefits for older people with dementia than regular day care facilities 46. With rural areas ageing and care farming developing, there is an opportunity to reframe older people’s social care in rural England.
Care farming provides important provision of elements of work, structure and responsibility, which are associated with both mental and physical health 47-50. Additionally, socially stimulating group activities function to reduce isolation and loneliness in older people, and to improve wellbeing and cognitive function 51. Care farms can be considered as an innovative example of community-based services that can improve the quality of life of clients 52.
What is the Countrymen’s Club?
Future Roots is part of the care farming movement in the UK and the Countrymen’s Club is grounded in the Care Farming UK Code of Practice. The Countrymen’s Club focuses on providing meaningful activities in a safe, agricultural environment. Activities are based around the needs and preferences of service users but may include work with animals, horticulture, rural crafts, woodwork, art therapy, socialising with others, or just touring the farm and experiencing the agricultural surroundings. Many sessions include an element of reminiscence through involvement in current issues.
It takes place at two sites, Whitfield and Rylands farm. Rylands is the main site. It is a 30 acre high welfare farm with a variety of animals from cows, sheep and pigs to chickens, ducks and goats which is used for outdoor social farming and animal-assisted therapy. Whitfield is a four acre site on the outskirts of Dorchester. It has outbuildings for horticultural and forest skills projects, a catering kitchen, a large fully equipped woodwork room and a pottery and art space plus meeting and break out rooms.
The Countrymen’s Club operates every Tuesday to Friday (1pm until 4pm). There are two sessions per week at each site. It is a paid service; £10 per session. Participants are either referred by medical professionals, carers
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or are self-referred. Some live locally while others travel from nearby town. A minibus is used to take the men to and from the site. This has an additional cost of £5-10 depending on how far they travel.
Typical activities at the Countrymen’s Club (picture credits: Gavin Parsons)
How does it work: Defining the ‘core’ of the model
This section aims to outline what is fundamental to the Countrymen Club model, in other words ‘how it works’. At the end of the first section we bring everything together by presenting a ‘theory of change’. Our description of the theory of change is illustrated with comments from Future Roots staff about how they think the model works.
Outcomes / impact
We start by being clear about the intended positive impact of the Countrymen’s Club (shown to the right). Like most services for older people, the aim is to maintain or optimise health, independence and wellbeing, and the model recognises the key role of reducing isolation and loneliness. As noted above, in evaluating the service it is important to appreciate the challenge that many of the Countrymen have health conditions that will naturally deteriorate so that it may not always be possible to improve their situation, but rather to help them to achieve the best possible outcomes given their circumstances.
Intermediate outcomes: “Resilience”
The Countrymen’s Club works to achieve the impact described above by encouraging its service users to develop a range of capabilities and attributes that help them to achieve impact for themselves. This is reflected in Future Roots’ concept of ‘resilience’, which refers to ‘the successful negotiation of adversity, to counter the life changes experienced as a result of rural isolation and ageing-associated diseases’.
‘The idea of resilience, to bounce back from adversity in a positive way, underpins all of the activities and enables Future Roots to be effective in their goal.’
Future Roots53
There are four broad, mutually supporting domains to the resilience model:
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• Physical and mental wellbeing: Encouraging men to be as active as possible, to be relaxed, to sleep well and eat well.
• Personal: This relates to the mens’ attitudes towards themselves and their lives. In particular positive identities; feeling useful rather than someone who is ailing. Respect for what they have and do achieve.
• Social: A focus on ‘belonging’ through ‘making sense of where the person has come from’ and ‘finding somewhere to belong’. Improved social networks and confidence in social settings.
• Personal relationships: Better relationships between men and their partners / carers, both through the outcomes above, and the ‘time off’ that the Countrymen’s Club gives carers.
“Hooks”
Wellbeing programmes access their target audience via ‘hooks’. Hooks can be any particular feature of interest that resonates with target individuals and thereby encourages a connection to the programme, and acts as a platform through which a range of beneficial activities and outcomes can be achieved. For example, the Celtic FC Foundation runs community-based health, wellbeing and educational programmes, and uses the hooks of football, and their own club brand, to engage target populations 54.
The particular ‘hooks’ for the Country Man’s Club are:
• The opportunity to spend time at the farm and doing farm based activities may be appealing and relevant
to men living in rural areas, and particularly to those men who have previous experience of farms. Staff report that for some this is seen as the key to overcoming initial reluctance to participate.
• The fact that it is only for men creates a distinct appeal. Future Roots arrived at the decision to make it men only after a period of trial and error with mixed gender. The found that women had different needs and interests on the farm, and it was harder to manage these alongside men. More importantly, they found that men were more interested and engaged in attending a programme that was specifically for them.
• Enthusiasm and passion of the team. Staff work ‘energetically’ to create a warm and welcoming environment, and an atmosphere which is safe, sociable, comfortable and where everybody feels part of the farm. Staff are also expected to be passionate about health and safety, the enjoyment of the men, listening to men's views, and about what they want to achieve for the men.
• It is a flexible service that can work with people who have a range of health problems and disorders, late stage and early stage. Similarly, staff emphasise how they work to be ‘person focussed’ rather than ‘condition focused’ and they try to emphasise what the men can do rather than what they can’t. 55
• A ‘real’/non-institutional setting. One stakeholder remarked that she felt this had particular appeal for men, who in her experience don’t seem to respond well to institutional settings. Similarly, the fact that Future Roots is informal, non-clinical may help some men to overcome interventions which they believe may treat them as ‘patients’.
• The farm environment has genuine variety. It is interesting and there are many things to do. Including working with animals, rural crafts, horticulture.
• Sessions are loosely structured and Countrymen are given ownership and control over the activities they do. New activities occur when ideas/opportunities arise (‘organic growth’) driven by interests of the men (e.g. games, singing). This sense of choice / control helps to establish the trust of the men and feelings of being ‘at home’. It may also contribute to feelings of self-respect / efficacy.
‘We don’t push them around here. They can be independent. Be a man’
• A safe and professional environment, which reassures families / carers and others who are referring people to the programme.
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• Providing transport to make access as convenient and cheap as possible (currently men travel from up to 28 miles away)
• Regular and dependable (throughout the year) - means it can fit in with people’s lives.
• Two sessions per week - means the men have a lot of contact with staff and other Countrymen to strengthen their ties to the service.
Change mechanisms
With engagement established, various aspects of the Countrymen’s Club work to create ‘resilience’ amongst the service users. These arguments are set out below under the four headings:
Physical and mental wellbeing
• Being outdoors, experiencing the changing seasons and engaging in physical activity is often different to anything else in their lives and is thought to lead to a positive impact on positivity, wellbeing and other elements of ‘resilience’.
‘Sometimes you see real joy.’
• Both staff and stakeholders felt that connection to animals was crucial for both the engagement of some of the men and contributed to the resilience outcomes they had seen. For example, animal contact may help men to do something else, and in a simpler way. It may evoke memories from past farm experiences.
‘Connection with animals has a massive effect.’
Personal
• The Countrymen’s Club enables service users to rediscover and apply past skills and knowledge within the farm setting. This gives the men a sense of purpose: using their skills and experience to make a contribution to the welfare of animals, to young people and to each other; therefore supporting feelings of self-worth and pride.
• Working on the farm and specific reminiscence work may facilitate positive memories of the past. However Future Roots is keen to emphasise that the Countrymen’s Club is distinct from other reminiscence work that takes place with older people. Rather than focussing on the past for its own sake, staff aim to get men to apply knowledge, skills and experience to the present day (making a contribution). Hence reconnecting and with identities rather than pure nostalgia.
• Spending time at the farm helps people to reconnect with their former selves and recover positive identities (including traditional masculine identities)—such as ‘worker’, ‘farmer’, ‘contributor to society’ (rather than ‘patient’, ‘sufferer’ etc.).
Social
• According to staff, the Countrymen’s Club is focused on building a community and a sense of togetherness amongst the men, a shared identity and camaraderie. For example, serving food is mainly intended to get the men sitting and talking together (as well as providing nutrition).
• Through the Countrymen’s Club service users meet new people that they can connect with, and develop positive relationships with staff and volunteers. The range of people who attend, coming from different ages and abilities, may give Countrymen the chance to interact with a wider spectrum of community. Coming to the Countrymen’s Club gives men something in their lives to talk about, including with people outside the club and may improve openness to engagement in wider community life. All which may help to enhance peoples’ social lives, improve social skills and confidence - which might in turn lead to reduced social isolation.
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‘The farm becomes part of their life in a way I don’t think a day centre or more institutional support group would.’
Personal relationships
• The Countrymen’s Club gives carers periods of respite from their responsibilities and helps them to feel more confident that their loved ones’ needs are being met and not feeling guilty themselves. This leads to positive benefits for carers themselves, as well as potentially improving the relationship between service users and their carers.
• Attending the Countrymen’s Club, twice-weekly provides an element of routine to people’s weeks (both carer and service user), and in some respects mirrors the atmosphere of going to work and doing something which had a purpose and was meaningful.
NPC – Transforming the charity sector
Theory of change The theory of change described is summarised in the diagram below:
COUNTRYMEN’S CLUB: SUMMARY OF THE THEORY OF CHANGE
Reduce social isolation / loneliness
Maximise wellbeing
Slowed cognitive decline
Prevent health conditions from
becoming chronic
Have better / maintain
relationships with carers
Better / maintain sense of belonging
/ inclusion
Improved ‘social resources’, skills,
networks
Better / maintain self-knowledge / worth/esteem, pride, sense of
purpose
Remain independent for
longer
Supportive interactions with staff
Older men feel listened to / understood
Meeting-up and working with peers
on the farm
Carers reduceemotional stress / worry & improved
wellbeing
Maximise physical health
Activities Change mechanism
Outcomes (resilience) Impact
Increased engagement in
community
Maintain/ reconnect with positive identities
More positive about life
Respite for carers
Use and maintain their practical skills /
knowledge
Develop positive relationships with
staff & one another
Sense of controlChoice about which activities they do
Carers meet and helped to support
each other
Something different / out of the house
Calmer, less agitated / anxious
More physically active
Improved diet and nutritionHealthy meals
Physically active in outdoor environment
Enjoyment / senses stimulated / uplifted
Assisted animal therapies
Calming environment
Better sleep
Secure / safe / welcoming
environment
Rural landscape
Reminiscence activies
Physical & mental wellbeing
Personal
Social
Personal relationships
NPC – Transforming the charity sector
Literature Review
This section looks at how well the intended outcomes and impacts of the Future Roots Countrymen’s Club are supported by the existing literature.
It is structured around the headings introduced in the previous section.
Hooks
There is some literature that attests to why of the Countrymen’s Club’s hooks might be successful in engaging with older men in rural areas. Some of these are outlined now.
Appealing and relevant to men living in rural areas
The most frequently cited reason for difficulty in attracting men to attend social programmes is the activities generally on offer (Johal, Shelupanov, & Normam, 2012); thus there is a need for more activities that actually resonate with and appeal to the target cohorts. A report by Age Concern UK found that part of the appeal of pub-clubs was that these enable men to reconnect with important aspects of their former lifestyle (Age Concern, 2007), indicating that the opportunity to spend time at a farm, and doing farm based activities may be appealing and relevant to men living in rural areas - and particularly to those men who have previous experience of farms. Indeed, the suggestion that activities relevant to older men’s identities are most effective for promoting engagement is evermore frequent and consistent within grey literature, as a cited learning from programme implementation56,57. However, no rigorous academic research has yet been conducted on this topic; for example, whereby engagement and adherence are measured as outcomes of a comparative trial of different activity relevancies. This omission means that neither causality nor comparative efficacy can currently be inferred.
Only for men
Regarding the hook of the Countrymen’s Club being for men only, research from other domains suggests that the decision to admit both sexes rather than only one might be expected to influence the appeal of attending; an important function of female-only health clubs is to allow attendees to avoid unwanted exposure to sex-related social experiences and stigmas58. When programmes are mixed-sex, men often feel out of place, that they were likely to be tolerated rather than welcomed, and sensitive to how they should behave to be acceptable to the women attendees59. A survey in Florida (USA) found that nearly 78% of programme coordinators and instructors agreed that the perception of exercise programs as feminine was a barrier to engagement for men60. Indeed, although men-only groups are not attractive to all men, for some men they provide vital encouragement, support and friendship in a safe environment61. In a report comprising a brief literature review and a review of their own programme for older men, Age Concern concluded that ‘in practice, the success of a particular activity for older men depends on factors such as how it is presented to men, how it is run, whether other men also attend, and crucially, on whether it is regarded by men as an appropriate ‘masculine’ activity’59. Indeed, image is an important aspect; programme attendance can be perceived by older men as synonymous with ‘the last stop’ on the way to the grave whereby they are “yielding up” their individuality, or admitting some sort of “defeat” by attending62. Although these findings relate to older men per se, it is likely that they are even more clearly applicable to older men in rural areas, as links between occupation, identity and place values can be particularly strong for men involved in rural occupations such as forestry and agriculture63-65. The strength of the findings relating to the ‘men-only’ hook, is that they come from focus group discussions with older men, and face-to-face and telephone interviews with staff working for Age Concern and other organisations who work with men specifically; that is, findings accurately reflect real experiences of implementing and participating in wellbeing projects. However, like for the previously discussed
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hook, this evidence comes very predominantly from the grey literature, and is lacking in terms of more classical academic research.
‘Real’/non-institutional setting
Research suggests that older people want both to be involved in projects that make a difference66, and to be necessary and utilised, not just ‘tokens’67,68. An important lesson from the findings on green care farming to date is that individuals’ preferences and remaining capacities to behave in accordance with those preferences should serve as a start point for care services69. Arber and Davidson summarised that older men have preference for social activities and organisations involving ‘doing for others’ rather than being ‘done to by others’70. Here, the Countrymen’s Club hook of a ‘real’, non-institutional setting, might be successful in gaining and maintaining engagement, as the farming and horticultural tasks offered by the Countrymen’s Club are meaningful activities that appear to serve a functional purpose, rather than mere entertainment, unlike many activities provided in traditional care home settings.
Genuine variety / ownership and control
Age Concern’s 2007 report (Age Concern, 2007), suggests that traditional notions of gender emphasise the importance for men of independence, self-reliance and strength, and that roles in the workplace can become central to men’s identity. Therefore, autonomy to initiate their own activities is crucially important for some older men. This finding was synthesised by practitioners and researchers at a ‘research into practice seminar’, whereby contributory research comprised qualitative interview data only. To the point of this finding, the aim of the Countrymen’s Club to give attendees ownership and control over the activities they do, should work positively as a hook to maintained attendance. A more robust systematic review by Mulligan et al.71 concluded that opportunities provided by men-only projects, for older men to exercise autonomy, experience personal growth and re-create a sense of purpose in life, appear to have a positive effect on older men’s sense of wellbeing. Other research has shown routine to have positive benefits for older women and to be linked to their ability to meet obligations, maintain activity level, maintain health, anticipate or look forward to things, maintain control, balance work, rest and play, accomplish and achieve, feel good about self, and provide continuity (Ludwig, 1997); it is not unreasonable to assume that older men may gain some of the same benefits. It is notable that like for other suggested engagement hooks, evidence for the efficacy of variety and ownership / control is only found in the form of reported learning from implementation of projects, and there is a lack of rigorous research.
Overall summary for literature on hooks
Findings regarding the efficacy of the stated hooks for engaging older men are found predominantly in the form of grey literature that reports learning from programme implementations. There is clear evidence from these sources, that points favourably towards expected success of the suggested Countrymen’s Club hooks, intended to engage the target cohort or older men in rural areas who might be experiencing social isolation or another life-limiting condition. However, this expectation can largely only be assumed, as the findings tend to be synthesised from research regarding older men per se, rather than more specifically older men in rural areas. Further, across each of the suggested hooks, rigorous research studies evidencing either change or causality are currently lacking.
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Change mechanisms
Literature relating to the change mechanisms, outcomes and impacts described by the theory of change, is now outlined. Many but not all elements of the theory of change are addressed, and in many cases, length of discussion per element is indicative of the quantity of literature available in relation to it.
Physical and mental wellbeing
Via engagement with the natural environment, and being calmer, less agitated and less anxious
The ecological dynamics approach explains that characteristics of the individual and the environmental setting can both act as boundaries and create ‘affordances’ (behaviours available to individuals), which function to shape behaviours72. A balanced interpretation of this approach suggests that the farm setting and activities of the Countrymen’s Club afford opportunities for experiences that benefit individuals’ health and wellbeing. Benefits of engagement with the natural environment include improved emotional state (reduced stress, agitation, anger, apathy and depression), physical health (skin health, fitness, sleeping patterns, eating patterns), verbal expression, memory and attention, awareness, sense of wellbeing, independence, self-esteem and control, social interaction and sense of belonging8.
Evidence from carers featured by Natural England’s ‘Is it nice outside?’ report highlighted the therapeutic influence of time outdoors for dealing with dementia patients’ experiences of anxiety8. Spending time in nature-based environments has been shown to acutely improve emotional state, and aid psychological recovery from stressful or frightening stimuli73-76. Nature functions to promote psychological restoration, and humans seem to be innately aware of this; individuals who report high negative mood are more likely to at that time also select a natural place, rather than other places, as their favourite place77.
Individuals’ desire for contact with nature is not just the result of a romanticised view of nature, but is an important adaptive process, which appears to aid optimum functioning78. A multi-study analysis found that engagement in any of ten different physical activities (such as horse riding, walking, fishing) in UK countryside had notable benefits for individuals mood and self-esteem79,80. A further review by Bowler et al. summarised that research findings indicate that being physically active in natural compared to man-made environments is associated with lower negative emotions such as anger and anxiety81. Attesting to the power of environment, both short-term recovery from stress, and long-term overall improvement of health and mental wellbeing, are among the most frequently identified health-related influences of simply viewing nature82. Indeed, engagement with the natural environment can positively benefit the wellbeing of people living with dementia by improving emotional state, and senses of wellbeing and self-esteem, and by reducing stress, agitation, anger and depression8,83. That is, farm environments, such as that provided by Future Roots, positively affect the health and wellbeing of individuals with limiting long-term illnesses such as dementia84.
Via animal-assisted therapies
An important aspect of care farming per se, and of the Countrymen’s Club specifically, is that of animal-assisted therapy (often termed ‘animal-assisted activity’), which has been suggested as a useful facet of interventions that should be available for individuals with all types and severities of dementia, who are experiencing comorbid agitation, depression and / or anxiety85. Animal-assisted therapy has been found to have positive effects on both physical, mental and social health and well-being parameters, across different client groups, including myocardial infarction patients, elderly schizophrenics and older adults in long-term care86-88 and with different animal species, such as cats, dogs, horses and donkeys88-90. Animals introduced in a therapeutic context may serve as a buffer and divert attention from an anxiety-generating stimulus that the patient faces91,92; spending time interacting with animals has been shown to reduce individuals blood pressure, and increased
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neurochemicals associated with relaxing and bonding93,94. Compared to non-animal-assisted equivalent therapy, animal-assisted therapy promotes more frequent and longer social interaction in geriatric care patients87. That is, these activities offer a calming experience that can reduce agitation and anxiety and thus contribute positively to attendees’ wellbeing directly as well as through the animals serving as a vehicle to promote social interaction and other behaviours.
Via improved diet and nutrition, being more physically active and more restive sleep
The Countrymen’s Club promotes healthy eating among its attendees. Attending a care farm can have a significant impact on prevention of dementia-associated dehydration, undesirable weight loss and under eating55. The research of de Bruin reveals that older dementia patients who participate in day care on a care farm have a higher intake of energy, carbohydrates and fluid than their peers in regular day care11, thus helping to maintain or improve nutritional status and health associations with this.
The Boing Boing resilience framework indicates the importance of ‘exercise and fresh air’ for the maintenance or improvement of resilience (Appendix 2) Farm environments represent a recognizable and meaningful non-medical context, which can stimulate activity11. Regular physical activity can improve cognitive functioning in adults age 65+ who either do or do not have impaired cognitive functioning95. Exercise increases levels of brain-derived neurotropic factors and other growth factors, which are important for creation and maintenance of neural circuitry, and thereby improve learning and mental performance96. Physical activity can have significant long-term benefits in terms of slowed cognitive decline, dementia risk, and perhaps dementia progression, by attenuating brain ageing and resilience to dementing neurodegenerative mechanisms97,98. Resonating strongly with the content of Countrymen’s Club project, interventions which offer language enriched physical activity and socialisation can function to slow cognitive decline of individuals with Alzheimer’s disease99. It is expected then, that attendance to the Countrymen’s Club might function to slow the decline in cognitive performance that is associated with ageing per se, and dementia more specifically.
The resilience framework suggests an importance of individuals getting ‘enough sleep’ for the maintenance or improvement of resilience. 'Let Nature Feed Your Senses'—a care farm project run in partnership between LEAF and Sensory Trust reported that following a visit of elderly persons to a care farm, these individuals sleep better at night100. Stemming both from the attending men enjoying the range of activities open to them and from the supported social interaction with staff, attendance to structured social intervention and light physical activity can significantly enhance deep, restorative parts of the sleep cycle in older adults, as well as improving their memory performance101. Additionally, the environment in which individuals are physically active can enhance this outcome. Compared to equivalent activity in built urban environments, being physically active in a nature-based environment can enhance physiological markers of restorative sleep102.
Personal, Social, and Personal relationships pathways
Via reminiscence activities
Amongst those suffering from dementia, loss of memory serves to compromise wellbeing primarily because it is associated with loss of identity103. Future Roots’ care farming approach uses reminiscence - a common approach within the UK that is characterised by use of memory triggers, prompting discussion of remote memories, which may be individual or group based104. The Countrymen’s Club provides a range of meaningful activities that can evoke feelings and memories; this leads to service users’ feelings of reconnection with their identity, self-worth, self-esteem and pride, each of which contribute to wellbeing105. Indeed this feature of the Countrymen’s Club also resonates with the Boing Boing resilience model’s subcomponent of ‘help the person to know her / himself’, within the element of ‘core self’; care plans should always seek to include retaining a familiar environment104.
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Via improved social resources, skills and networks for older men
Community factors such as family, social support and social participation facilitate resilience; and at the societal level, culture and service provision are seen as important in the research literature106. Activity theory outlines that quality of life and life satisfaction in older years is enhanced by remaining socially active and maintaining personal relationships and endeavours107,108. Care farms offer opportunities for social interaction, often through working with others as a team on the farm, which brings mental health benefits for vulnerable client groups109. The buildings and outdoor areas of a farm represent a recognisable and meaningful non-medical context, which can stimulate memory and conversations11. The activities of meeting-up and working with peers on the farm, supported conversations and interactions with staff / volunteers, and regular phone calls from staff / volunteers function to increase individuals’ contact with people from the local area and promote an increased social network55. Despite these identifications from practice, de Bruin’s11 research was comparative and did not find that these characteristics of care farms led to differences in cognitive or emotional outcomes over time, compared to equivalent traditional care settings; notably however, this research was not that of a randomised controlled trial, so causation cannot be inferred.
As many older people with dementia leave the house less frequently, their number of social contacts decreases55. 60% of people with dementia stop doing the things that they used to because of a loss of mobility110. As social isolation within rural contexts can be further compounded by loss of a driver’s license and inability to drive, the ability for individuals to leave their home via Future Roots’ coordinated community transport facilitates their participation in activities that combat social isolation111. Green care farms such as that of Future Roots make people with dementia feel part of society112. This in turn promotes each of the outcomes that that theory of change describes to reduce social isolation and loneliness. Ecotherapies such as care farming can replace a pathological sense of alienation from self, others, and the world, with a rekindling of relatedness to each of these facets113. Whereas the effectiveness of home visiting and befriending schemes is less clear, educational and social activity group interventions that target specific groups can alleviate social isolation and loneliness among older people114, and research has consistently demonstrated the importance of social relationships in the definition of a ‘good quality of life’115. Finally, as discussed within a previous subsection; animal –assisted therapy is a key component of many activities at the Countrymen’s Club, as it functions to stimulate conversation by the presence and unscripted behaviour of the animals91,116,117.
Via carers reduce emotional stress / worry and improve wellbeing
Outlined by Winterton and Warburton118, not only is there is a strong association between being a carer and being socially isolated in later life119, but social isolation can increase perceived caregiver burden120, and this can be detrimental to the carer-recipient relationship and indeed the care given121. As described previously, care farming can serve to increase social networks, and to this point, Future Roots incorporates social sessions for carers. Evidence suggests that increasing carers’ social networks can alleviate the stresses of caring122 and provide emotional comfort, release and understanding118,123. These findings represent evidence from practice, and learning from qualitative reflection of participants and carers, rather than rigorous research design and measures.
Overall summary of literature supporting Countrymen’s Club-related
change mechanisms
There is strong research evidence supporting many of the change mechanisms, outcomes and impacts outlined within the current theory of change. Much of the research evidence comes from robust crossover or randomised research designs that are comparative and infer causation. Importantly, findings from scientific research sources are consistently complimented by qualitative findings and evidence from practice.
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Evaluation findings
The previous sections have outlined the Countrymen’s Club model and reviewed the evidence that supports it. We now turn to the empirical data collected during the evaluation period to help us assess the extent to which the model was achieved.
Monitoring / Output data
Who has used the Countrymen’s Club?
During the evaluation period (May to November 2016) there were 106 Countrymen’s Club sessions (roughly two each week per site):
• There were 56 individual sessions of the Country Club at Rylands and 55 at Whitfield.
• At Whitfield the average number of men attending per session was 5. The fewest number of attendees at a session was 2 (although this was atypical) and the highest was 8.
• At Rylands the average number of men per session was 9. The fewest number of attendees was 7 and the highest was 12.
• Per individual, a total of 779 sessions were delivered; 498 at Rylands and 281 at Whitfield
A total of 36 men came to the Countrymen’s Club:
• 20 men came to Rylands, 15 men to Whitfield (and one man came to both).
• However, 3 of these men only came to one or two sessions. So it is probably more accurate to say that there were 33 full Countrymen over the six months (20 at Rylands, 12 at Whitfield and one at both).
• 16 men were new to the Countrymen’s Club in 2016, 17 were existing Countrymen.
• During the six month period 10 men stopped coming (see discussion below on page 27).
• So, by the end of November 2016 there were 26 active Countrymen (of whom 9 were new to the Club and 17 who had visited the club throughout the six month period).
• Roughly speaking this is regarded as ‘capacity’ for the two sites. According to Future Roots, more than this number of Countrymen would be too busy and exceed staff’s capacity to manage.
The average frequency of visit was one in every 2.2 sessions at both sites, but varied between the men:
• 8 men visited every session (or nearly every session).
• 13 men visited roughly every other session.
• 9 men visited roughly once every three sessions.
• 3 men came less often than this.
24
In the chart below we have summarised this data by segmenting the 36 Countrymen according to their contact with the programme during the evaluation period. It suggests that over a six month period around one in three Countrymen could be considered to be the main service users – at the heart of the programme – augmented by a smaller number of a less frequent but still regular service users. Alongside these longstanding users there are both new Countrymen and those who are withdrawing from the programme.
The age of Countrymen ranged from 61 to 90, with roughly equal numbers of men above and below 80.
In terms of relationship status for the 34 Countrymen who engaged with the programme:
• 23 were living at home with a partner or other carer
• 5 were living alone
• 8 are missing data
The following chart shows the working background of the Countrymen engaged in the programme during the evaluation period. It shows that the largest group have a background in farming / agriculture but by no means all of them, indicating that the Countrymen’s Club has a broader appeal.
.
X AXIS
LOWER LIMIT
UPPER LIMIT
CHART TOP
Y AXIS Y AXIS LIMIT
1
PROFILE OF COUNTRYMEN (MAY – NOV 2016)
4
3
6
6
5
12
0 2 4 6 8 10 12 14
Dropped out after a small number ofsessions
New joiners not yet coming often
Regulars who have stopped coming
New joiners coming often
Regular but less frequent (one sessionin three or less)
Regular very frequent
Base: 36 Countrymen (May – November 2016)
X AXIS
LOWER LIMIT
UPPER LIMIT
CHART TOP
Y AXIS Y AXIS LIMIT
4
BACKGROUND OF COUNTRYMEN (MAY – NOV 2016)
12
1
1
1
1
1
2
3
5
9
0 2 4 6 8 10 12 14
Missing
Builder
Delivery Driver
Pilot
Senior manager in industry
Salesman
Engineer
Carpenter
Services / police
Farming / agriculture
36 men engaged with Countryman programme May – Dec 16
25
Service users’ needs
Health conditions
The health conditions experienced by Countrymen are shown in the next slide. Slightly under a third were suffering from Alzheimer’s / Dementia, while others had a range of conditions. We have looked for any relationships between health condition and frequency of visit but non are apparent. With more data this might be a useful area for analysis.
As part of the evaluation design we developed a new referral form which asked staff to record both the nature and severity of conditions. However, this form has not yet been completed for enough Countrymen for us to report on this data. Nevertheless, we know from observation that the severity of conditions varies significantly amongst the Countrymen, for instance amongst the Alzheimer’s / dementia group are those with both mild and serious forms of the condition.
Qol-AD data
As part of the evaluation, an adapted version of the QoL Ad was agreed as the best off-the-shelf tool for assessing Countrymen’s needs and potential impact. The following chart shows the profile of 30 Countrymen for / with whom this was completed, at the earliest point possible in the evaluation period. The data was completed either by referrers or family members, whilst for longer standing countrymen the data was completed by Future Root’s Staff.
X AXIS
LOWER LIMIT
UPPER LIMIT
CHART TOP
Y AXIS Y AXIS LIMIT
2
HEALTH PROFILE OF COUNTRYMEN (MAY – NOV 2016)
6
2
2
2
3
3
3
3
3
4
4
5
5
6
13
0 2 4 6 8 10 12 14
Missing data
Arthritis
Learning disabilities
Cancer
Lung conditions
Schizophrenia
Depression / bipolar disorder
Hearing loss
Sight loss
Parkinson's Disease
Heart problems / hypertension
Diabetes
Mobility problems
Stroke
Alzheimer's disease / Dementia
26
The chart shows that the main problems experienced by countrymen were around energy, memory and level of physical activity, while diet and nutrition, living situation and calmness are generally rated higher. As Future Roots collects more data it should be aiming to compare results for individuals over time and from different sources (individuals, carers, and staff) to measure whether the service can be associated with any improvements or other changes.
X AXIS
LOWER LIMIT
UPPER LIMIT
CHART TOP
Y AXIS Y AXIS LIMIT
5
SERVICE USERS’ NEEDS, AS MEASURED AT THE EARLIEST POINT IN THE EVALUATION PERIOD
30 men for whom a QoL_AD was completed
5
1
4
9
8
5
4
2
2
3
4
10
9
5
7
8
9
7
7
2
9
9
13
13
13
13
15
10
13
2
3
4
5
5
6
6
10
10
Energy
Memory
Physical activity level
Physical health
Mood
Family
Calmness
Living situation
Diet and nutrition
Missing Poor Fair Good Excellent
27
What activities do Countrymen engage in?
What goes on?
Firstly, in terms of the structure of the sessions:
• All Countrymen’s Club sessions begin with a lunch from 1:00 – 1:45
• Between 1:45 – 15:00 the men are invited to choose an activity to engage in. As described above, choice is seen as an important part of creating engagement and ownership.
• Nearly all Countrymen’s Club sessions end with tea, cake, reminiscence and singing from 15:00 – 16:00
Based on analysis of the session plans there seem to be five main areas of activity:
• Arts and crafts, inc. woodwork, drawing, typography.
• Animal based – eg feeding animals, grooming, tagging pigs, rounding-up chickens
• Farm based – walking around the site, gardening, clearing ivy, filling bird feeders
• Games – boule / horseshoe
• Socialising – including eating, singing and poetry reading
Looking across all the activity and engagement forms sent, a rough segmentation of what engages different service users could be:
• Some men appear to be particularly engaged by animal work, and others by farm based activities more generally.
• A number of men seem particularly focussed on craft activities, in particular woodwork.
• The social aspect of the Club seems to be more important for some than others. At either extreme are; those for whom socialising, singing, playing games appears to be the main / only thing they do; and others who seem mainly to get on with activities by themselves. This can be seen as evidence that the model is working because men seem free to choose what they do, on the other hand the social aspect of the theory of change might not be realised if men are not really engaging with others. This is probably a dilemma that is best managed by staff. People cannot be forced to be sociable against their will; indeed we did hear from one man who didn’t like being encouraged to join in with the singing.
One stakeholder questioned whether the winter offering was a strong as the summer, because of the natural variation in seasonal activities on a farm, and whether there was any further potential to diversify the amount of activities available. Future Roots has recently been looking at this issue and has extended the winter offer through more craft, art and social activities.
Differences between Rylands and Whitfield
There is some evidence of a difference in activities between the two sites.
• In terms of activities, Rylands has animals, better facilities and a wider range of activities available. Whitfield is primarily a horticulture site, with no animals.
• Although not the result of any deliberate strategy, it was felt that service users at Whitfield generally have later stage dementia compared with Rylands .
• Moreover, according to staff there is a slightly different atmosphere between the two sites. In particular it was felt that Whitfield may be missing something of the sense of community/ homeliness, possibly because it is not a working farm and no-one lives there.
28
• However, it was also noted that activities might be more tailored to the men’s needs at Whitfield and that it operates at a ‘gentler pace’).
This comparison is potentially significant in that they might tell us how well the model could be applied in different circumstances. In the following sections we will consider whether the differences in the sites appear to have had any effect on engagement and outcomes.
How well have users engaged with the service?
A key part of the theory of change is the ‘hooks’ that work to overcome the know barriers to older men’s engagement in services. To test this the evaluation has focussed on assessing how well the Countrymen’s Club engages men in the target group and this section describes the relevant we have collected.
Referrals
Firstly looking at the data on initial referral we can see that around half of the Countrymen for whom we have data are either self-referrals or referrals by family members:
• Self-referral: 10
• Carer / family: 6
• Social services: 6
• NHS: 2
• Other Charity: 2
• ‘Memory nurse’: 1
• ‘Wayfinder’: 1
• Missing data: 8
This is a rather disparate range of referral routes which reflects the active marketing that Future Roots has engaged in (including a range of outreach and media)
Initial drivers to engage
From the data we have available (10 referral forms completed) it appears that the two main drivers for coming to the Countrymen’s Club initially are; wanting to meet people / improve social live; and to maintain a connection with farming.
From the stories that the men tell about how they first got engaged it seems that word-of-mouth plays an important role in many cases.
At the Dorchester site (Whitfield), they have a men’s shed. They referred an old man to FR whose daughter had contacted social services due to the fact her father was deteriorating. Her father used to be a farm manager and didn’t want to be looked after. Attended the men’s shed and consequently went to the gentleman’s club and really took to it.
Stakeholder interview
There was somebody else here and then I got a welcome, because I did gardening for a hobby, I worked on a farm and they said ‘we could do with you’ so after that I came up Monday and I do carpentry in the joining shop.
29
Staff discussed how once someone comes for a visit they aim to do everything they can to secure continuing engagement. In practice this means making them feel welcome and introducing them to other men, it also means trying to understand what they will be most interested in doing and how the service might need to be adapted for their needs.
Despite this, during the evaluation period 10 men stopped coming, or came only once or twice:
• Two men died.
• Two men could not come anymore because they entered a nursing home.
• Two men stopped coming because of ill health.
• Two men stopped coming because they had activities with Society for the Blind on the same day.
• One man became reluctant to leave his wife
• One man stopped coming because of the cost.
Staff did acknowledge that the service wasn’t right for everyone, and that a number of people had not continued with the service. They offered some general reflections on why new users might withdraw:
• Staff felt that all men needed significant encouragement to attend and engage in the first few weeks of coming to the club (sometimes the men need ‘forcing to go out’)
• In this respect it always seemed important to have wife/carer support in the first few weeks to encourage the men to keep going
• A key sign of success was: wanting to be at the Farm and engaging/participating without encouragement.
It feels like the focus is on the person when things working; but on the condition if things don’t
Staff had observed two slightly opposing reasons why the Countrymen’s Club might not work for someone.
• Firstly, some men can feel that it is a too early stage in their condition. That they did not feel ready for this kind of service and that they were generally healthier, younger and more able than other men.
To tell you the truth, I’m still in limbo, not sure whether I’m going to carry it on or not... It’s just me with, it’s not work... Everybody else here, I mean they’re quite a bit older. I don’t know how old, but they are
• Secondly some men come with challenging behaviour and high dependency on their carer that it is too difficult to move away from.
In the final analysis, of the 19 Countrymen who signed-up to the service in 2016, 15 were still using the service by the end of November - suggesting a take-up rate of roughly 80%. In our view this represents a good rate of engagement for any service, particularly a paid service.
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Positive engagement in activities
At the early stage of the evaluation process we worked with Future Roots to develop an evaluation scale that could be used to measure service users’ ongoing engagement with the programme (shown below).
This was used consistently throughout the evaluation period and the figure in the third column shows how staff rated service user’s engagement at each of sessions they attended (i.e. 774 total sessions for individuals).
Level of engagement Service user might say: % of all
sessions rated
in this way
1) Isolated &
unwilling/unable to
participate
• The activities here aren’t for me • I’ve been made to come, I don’t want to be
here
1 only (less than
1%)
2) Beginning to take
part
• I don’t mind some of the activities here • I still prefer to keep to myself 19 sessions (3%)
3) Raised self-
esteem & social
connections
• I enjoy some of the activities here • I get on with people I meet at the farm 80 sessions (10%)
4) Fully participating • I am able to take part and do what I want to • I look forward to meeting new people • I feel content today
674 sessions (87%)
The table shows that the overwhelming majority of sessions were rated as a maximum ‘4’, which is a very positive result. Moreover there is also no evidence that a lack of engagement is related to not using the service: All those who stopped using the service were rated by staff at 3 / 4 on their last visit to the Countrymen’s Club. There is also no relationship between engagement in sessions and frequency of visits: Those who come every session show the same level of engagement as those who visit every one in three.
The positive side of this is that all the Countrymen in our sample continued to engage positively throughout the evaluation period; there is no evidence of anyone getting bored, or leaving from disinterest. But on the negative side, the evaluation forms might need to be reviewed because they have not picked up the natural variation we might expect - or enabled us to measure how engagement progresses over time. Indeed, the majority of new joiners were rated at ‘4’ from their first session onwards.
Longer-term perspective
As well as rating engagement for each session, staff were also asked to reflect on each countryman’s engagement and progress on a monthly basis. During the evaluation period 98 individual assessments were made and an aggregate analysis of these is shown in the chart below.
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It provides a slightly more nuanced picture than the weekly / session based assessments above - which are almost unremittingly positive. It shows that in the most part, staff believe that Countrymen are calm, have a sense of belonging and are well fed. Meanwhile ‘Engagement in activities’, ‘social skills’ and ‘physical activities’ provide slightly more mixed results (although still positive overall). The lower scores given to self-esteem and social networks may in part be driven by staff not feeling that they know enough to comment (which might prompt us to look again at the value of the questions used).
This data can also be analysed over time to see if any change is associated with spending longer at the Countrymen’s Club. This analysis is shown in the charts below, but first it is important to point out the limitations:
• Data is based on staff perceptions of how Countrymen are doing, so it is subjective and impressionistic.
• Sample sizes are generally very low (arguably too low for this sort of analysis).
• Sample sizes are lower still for later data points, bringing the risk of a ‘false positive’ impression because the sample at later points consists only of those who stayed with / engaged more in the programme.
• For older people with deteriorating health we might not expect to see ‘improvement’ over time, but rather maintenance or slowed decline (as per discussion on page 6)
• There may even be a seasonal effect (earlier data points collected in May / June, later data points in October / November)
For these reasons, our view is that this quantitative data is less useful than the qualitative data in the following section. However, we present it here for; completeness; because it highlights one or two useful things; and as indicator of the kind of analysis Future Roots ought to be able to do as the Countrymen’s Club grows in size.
To produce the first two charts we calculated a composite score across all 8 items that staff rated Countrymen against, which gave us a simple way to observe any change over time. Hence in the chart below, the X axis shows the increasing time points and the Y axis the composite score. Each line in the graph is an individual countryman.
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The first chart shows the change in composite scores over time for 9 ‘longstanding’ Countrymen i.e. those using the service from 2015 or earlier. It shows that the scores for most Countrymen fluctuated but did not change in a meaningful way over the evaluation period. The exceptions are;
• a) and b), for whom we only had two or three data points but whose scores did seem to improve; and
• c) Whose scores worsened. This Countryman suffered from declining health and stopped using the service during the evaluation period – which explains this score.
X AXIS
LOWER LIMIT
UPPER LIMIT
CHART TOP
Y AXIS Y AXIS LIMIT
8
CHANGE OVER TIME FOR LONGSTANDING COUNTRYMEN (COMPOSITE SCORES)
Base: 9 ‘longstanding’ Countrymen (for whom we had more than one data point)
Points in time
1.5
2.0
2.5
3.0
3.5
4.0
1 2 3 4 5 6
Com
posi
te s
core
acr
oss
8 m
easu
res
(a)
(b)(c)
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The following chart repeats this analysis for the potentially more interesting group of new countrymen. As above it is difficult to discern any pattern from the regular fluctuation. There are three Countrymen (a) whose composite score appear to improve between points one and two/ three. But this offset by three Countrymen (b) whose scores moved in the opposite direction (although it should be noted that these men were continuing to use the service by the end of the evaluation period).
X AXIS
LOWER LIMIT
UPPER LIMIT
CHART TOP
Y AXIS Y AXIS LIMIT
2.0
2.5
3.0
3.5
4.0
1 2 3 4 5 6
9
CHANGE OVER TIME FOR NEW COUNTRYMEN (COMPOSITE SCORES)
Base: 11 ‘new’ Countrymen (for whom we had more than one data point)
Points in time
Com
posi
te s
core
acr
oss
8 m
easu
res
(b)
(a)
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The next chart summarises the composite change seen over the evaluation period (from the first data point to the last data point for each countryman for whom we have data). It shows that slightly more Countrymen had declining scores than improving scores (11 vs 9), but that increases were generally larger in scale than decreases (average improvement = 0.8 points vs average decline = -0.5). Across the cohort as a whole the average change was +0.1 percentage points.
On composite scores, there does not appear to be any difference between ‘continuing’ and ‘new’ Countrymen.
X AXIS
LOWER LIMIT
UPPER LIMIT
CHART TOP
Y AXIS Y AXIS LIMIT
10
AVERAGE OVERALL CHANGE DURING THE EVALUATION PERIOD (FOR INDIVIDUAL COUNTRYMEN)
Base: 20 Countrymen (for whom we had more than one data point)
-1 -0.5 0 0.5 1 1.5 2
Percentage point change in composite scores during evaluation period
= ‘Continuing’ countrymen
= ‘New’ countrymen
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The final chart looks at change over time at the level of the specific measures asked about. It only covers the first three available time points because beyond this the sample size would be too low. It shows increases in scores for ‘sense of belonging’, ‘social skills’, ‘self esteem’ and ‘calmness’, which can be interpreted as a positive resulti.
In all, we would have to concede that the analysis presented above is not particularly compelling at this stage because of the small number of service users, (and in particular new service users) - and the relatively short window for evaluation. It does serve to highlight that the ‘progress’ of Countrymen is not a neat picture; there is natural fluctuation because of the nature of their age, condition and mood, and that in some cases positive change can be observed. However, there is not enough here to merit an accreditation of level 2 in the Nesta standards of evidence - and we think the qualitative research presented below offers a more accurate picture.
Nevertheless we recommend that Future Roots continues to collect this data because in time more powerful analysis will be possible.
i There is a disparity between the disaggregated findings, which show slightly higher numbers of countrymen with a declining trend, and aggregated findings, which appear to show improvement, is that we generally have more data points for countrymen that have shown improvement, hence they contribute more to the statistic. For this reason the disaggregated findings might be seen as more accurate.
X AXIS
LOWER LIMIT
UPPER LIMIT
CHART TOP
Y AXIS Y AXIS LIMIT
11
CHANGE IN SPECIFIC MEASURES OVER TIME
Base: 20 Countrymen (for whom we had more than one data point)
2.5
2.7
2.9
3.1
3.3
3.5
3.7
3.9
Time point 1 Time point 2 Time point 3
a) Engagement inacitivites
b) Relationship with carer
c) Sense of belonging
d) Social skills
e) Social networks
f) Self-esteem
g) Calmness
h) Physical activity level
i) Diet and nutrition
(a)
(b)
(c)
(d)
(f)
(f)
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Other services accessed
An important contention of the theory of change is that no other similar services are available and that Countrymen’s Club is therefore addressing unmet need. To this end the updated referral form we designed as part of the evaluation includes questions on which – if any – other services the Countrymen were accessing. By the end of the evaluation period we had collected this data from 21 out of the 33 countrymen and it showed that nearly half (9) were not accessing any other services at all. Of those who were accessing other services, this was by and large care-based services such as care visitors, day centres or lunch clubs. One or two country men were attending condition specific services such as Parkinson’s gyms or memory clubs. None appeared to be visiting services that were similar to the Countrymen’s Club.
Carers were also asked about alternative provision, both in the interviews and questionnaires. They all expressed the view that the Countrymen’s Club was distinct in its offer:
My husband wouldn’t have gone to anything else but this
It is the only suitable provision available
They were also asked to compare the Countrymen’s Club to other similar services and, as above, the unanimous view was that Future Root’s offered a more appealing service for their husbands / partners.
Much better. Very friendly, welcoming, accepting
This is better. At the other group they play games, pass the parcel, sing carols etc. But Future Roots is outdoors, fresh air. No carers. Which is good for both me and my husband. It’s more physically stimulating.
Future roots is different. It is more active and he is less concerned with what he can no longer do. He has never been able to accept the limitations that the stroke has imposed on him
FR is a million times better. Ticks the boxes in every way.
Further evidence comes from the small number of ‘stakeholders’ we spoke to that commented on the lack of similar services in the Dorset area.
There’s very little else which is work/environment based in Dorset, there is some nursery-based interventions but the value is that FR provides a more small holding, agricultural feel.
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Qualitative data
The strongest data we have comes from qualitative interviews conducted with service users and carers. Interviews were conducted using a guide developed to test people’s perception of the service in a fairly unprompted way: They were asked how they found out about the Club, why they came and what they liked / disliked about it? We have then loaded transcripts of the interviews into NVivo 11 software to help us structure the data around the key themes of the Theory of Change. The results are outlined in the tables grouped in line with the Theory of Change, by Activities, Change mechanisms, and resilience-related Outcomes.
In addition to provide a full quantification of the results we also looked across our other data sources to check for mentions of aspects of the theory of change by staff or carers and reported in the table below. However it is important to stress that this quantitative data is both subjective and indicative - as it was based on our judgement about what was said. Moreover, it should also be noted that just because something was not reported frequently, it does not mean it is not important; rather it may not be top-of-mind, or people could find it difficult to articulate. The value of the quantification is just to give a broad sense of which features of the programme are important to people and what the outcomes might be, while the quotations are included for illustrative purposes.
Activities
All but two of the ‘activities’—described in the Countrymen’s Club theory of change—were cited as important by a substantial number of countrymen and carers we interviewed. The positive things about the Club that men and carers mentioned most often were; the opportunity to meet with others on the farm; followed closely by freedom / choice; the opportunity to use practical skills / knowledge and the supportive staff.
The evidence from carers is particularly persuasive of the benefits of the club. All but one of the carers interviewed spoke highly about the time off it gave them, and that they were confident they were leaving their loved ones in an environment that was safe and enjoyable.
The ‘activities’ found less often in the data was ‘healthy meals’, which nobody mentioned to us as specifically important (although some did mention that they liked the food). Similarly, in the third table below the outcome of healthier diet and nutrition were not widely evidenced in the attendee and carer interviews. This might be an example of a feature which is important but not front of mind, nor the most appealing thing about the service. Based on this it might be better regarded as a ‘hook’ for engagement, and a way to encourage socialisation, than a core / essential part of the model.
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The other exception was carers meeting one another to support one another, which was only mentioned positively by one carer. Part of this might be that the carer group had only just been established at the start of the evaluation periodii so we cannot determine how much this adds to the overall model.
Theme
Total number of
references to
theme across all
data from 33
service users
Example(s)
Secure, safe and welcoming
environment
17 (52%) Totally relaxed atmosphere; They are just nice; Its informal, other things can be formal and this is informal.
It was a nice friendly welcome and, yes the chap’s not here today, or two of them are not here, but we had similar interests. There’s a beekeeper.
Oh yes I think I am losing a bit in one of my legs, you know, but I thought they would chuck, kick me out because of that, but they have supplied me with this one to go around in.
Animal assisted therapies 12 (36%) Communication with people, activities, animals. I know being a farmer, animals are a great balance for the type of illness
Yes, it’s sort of hands on and meeting the cattle and things. Never bothered me because I’m quite happy to stroke them if they want to be, or anything like that, yes.
My husband’s not a farmer, but he loves animals… he relates to animals.
Rural Landscape 10 (30%) When you go out on days out you see them out on the fields and that. It was full of cows, oh what a sight! And I will see the tractors. Like we had to go to back via Weymouth and my boy took me round and I was seeing hay being harvest!
Healthy meals 0 / 0 NOTE: Some Country men and carers mentioned the food, but not that they liked the fact it was healthy
Choice about which activities
they do
18 (54%) So anybody who’s interested in carpentry can do that. I was doing that
And if they don't want to join in, they can, if they are able wander about on their own
Use and maintain their
practical skills / knowledge
17 (52%) Chris wanted, tried to shoo the bull out the way. He run like hell. I shut the gate on his way out. That sort of thing, he never asked me to do it…That is where I can come in.
‘I think, you know when he’s put into that moment, it suddenly comes back. He says ‘yes, I’ve done it before’
The tunnels that were all falling to bits and that, I helped that and did a bit of landscape gardening, digging out all the stuff and everything.
ii Only between 5 and 7 carers currently attend
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Theme
Total number of
references to
theme across all
data from 33
service users
Example(s)
Meeting up and working with
peers on the farm
21 (64%) He's going to ask you why you like coming to the Countrymen’s Club. Have you got an answer for that?)… Well just to meet people, that's all.
To me, that’s nice if you’ve got somebody that doesn’t communicate, if you can communicate in enjoying a game together
Yes we all stick together… the chaps with the hoes getting the weeds out and I do with the fork and spades and every time they come with the rake and rake it all over. It is all teamwork.
Supportive interactions with
staff
16 (48%) I come here and I am doing something and I, you know and the staff treat me and talk to me and the other, you know there are some very intelligent clients here which we talk and everything and yes, yes it does bring out the best.
‘My husband feels he has got other people to talk to; That’s the main thing isn’t it? It’s just doing something completely different.’
Respite for carers
17 (95% of carers) It gives the wife a chance to get out. I know that she comes at a set hour… she normally goes shopping in Sherborne then.
Yes, I have to say, I never thought I'd say it but it is a relief. When I leave him here I can go put, although my husband is not that bad yet, otherwise yes it is 24 hours.
I think for me it gives me a break from you know. And knowing he's in a safe environment so it's working two ways. It's given me three hours in an afternoon, you know. I'm meaning it in a nice way, away from him…But I know he's in a safe environment. He enjoys what he does here.
Carers meet and helped to
support each other
1 (6% of carers) Well we have started a ladies group… yes and the last one was cancelled, but we will be having more and that’s just for the women to come while the men are here.
Change mechanisms
In looking at the ‘change mechanisms’ we are getting to what it is about the programme that seems to make a difference to people. The most widely evidenced of these from the data were
(1) Doing something different to normal / something outside of the house or care home environment, and
(2) Enjoyment and an ‘uplifting of the senses’ promoted by being outdoors and doing something constructive with their time..
Carers reported feeling comfortable in leaving attendees at the Countrymen’s Club underpinned crucially by their perception that the attendees were having a particularly worthwhile, valuable and/or enjoyable experience, therefore removing potential feelings of guilt.
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Theme
(percentage of interviews that each
theme was evidence in is given in
brackets)
Total
number of
references
to theme
Example(s)
Calming environment 13 (39%) Very relaxed, laid back.’
‘I think this is more relaxing’ [Than other similar places ]
Enjoyment / senses uplifted 26 (79%) ‘(Physically healthier?) Yes. Like I say it’s the air and the smell, you know.’
‘But I enjoy the singing because when I was here, we’d got the old guitar going, had a little sing song. That’s great really.’
‘Because he loves it. I do when I get here… I can feel when he’s going somewhere where he’s going to enjoy himself’
Physically active in outdoor
environment
20 (61%) ‘I don’t mind going home then, but I don’t want to be stopping indoors all day. I want to go out nice and early, out and about. I’m not a sitting down person. I like to get out and do, you know.’
You know he’s out and about and doing things, certainly far more than he does at home…’
Sense of control 6 (18%) Try and work out what I’m going to do, you know.’
‘What I find with that is that it has put me in a more settled frame of mind, that I am curing it with the help, great help of people here and myself rather than somebody just calling back on faith and other people, it is me and other people’
They can be like they were before something happened to them. they get a bit of that feeling back again of independence and that they are, well I think it gives them that … It is the independence…. Yes, I think so….As you said, and we are not flapping about behind them…They feel more like they were.
Each day they come it’s something different, they might be in the barn singing if it’s you know it’s raining, they might be out in the field. It’s what they want to do...
Maintain / reconnect with positive
identities
16 (48%) ‘My husband likes working [unclear] because he can drive a tractor again because he has had to surrender his driving licence, so on a couple of occasions yes, he has been able to do some rolling and some chain’
‘Sometimes I do a bit of gardening, helping people’
Something different / out of the
house or care home setting
12 (36%) ‘Because I was indoors, I would be stuck in the pub not going, because there is no bus service I can’t get out, so I will be stuck in a pub. I would probably be sleeping upstairs watching telly and I was down in the bar, but this has got me out.’
‘You do look forward to a change of scenery and different people to mix with here.’
‘(Question: What do you like about coming
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Theme
(percentage of interviews that each
theme was evidence in is given in
brackets)
Total
number of
references
to theme
Example(s)
here?) Change of environment from being at home…at home... I am not allowed to do anything… she’s (carer) over protective.... and she won’t allow me to explore my limits.’
Older men feel listened to and
understood
9 (27%) ‘I would advise anybody to come… For different reasons. The staff, as I’ve already said, the staff are multi-talented and they look after all sorts of different aspects. And if you introduced anybody they would find out what the needs were for that particular person… And they would build a helpful environment for that person… So I would recommend them to come here.’
‘…you know and being able to mix with others and express your feelings because he's you know got mental health issues’
Develop positive relationships with
staff and other attendees
23 (70%) The staff treat me and talk to me and the other, you know there are some very intelligent clients here which we talk and everything and yes, yes it does bring out the best’
Oh yes we know that, you know kind of this camaraderie thing, they are singing something that’s clicked with them
Like I said, I have made a lot of friends here.
Carers reduce emotional stress /
worry & improved wellbeing
8 (24%) ‘She comes over, she loves it. She’s going to help with the ladies as well’
‘…anxious, we are not anxious… No… It's lovely that you don't need to give them a second thought
Evidence of outcomes
From our interview data the most widely evidenced resilience-related Outcomes were those of (i) being more physically active and (ii) the improvement or maintenance of self-knowledge, self-worth, self-esteem, pride and sense of purpose.
There was evidence that the rural outdoor environment was an important contributor to physical activity behaviours, particularly as noted in comparison to the behavioural affordances of staying at home.
Rather than if you’re at home you’re just sat in the chair and you don’t you know, it makes you get up and go’
Oh yes it’s a routine… you need a structured life don’t you? You can’t just amble along, I mean, you know, I could just sit at home and vegetate
The qualitative data suggests a link between the choice about which activities attendees do and the Change mechanism of sense of control, and in turn the outcome of self-esteem:
I get a lot of satisfaction from what we do here, whereas the opposite happens at home—where there’s something that needs doing and I know I can’t do it. So I try
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to do it and I can’t, that’s the very opposite, it’s demoralising… It helps to keep the balance. Trying to do things at home, I get the feeling that I’m totally useless, whereas here, they show me that I’m not useless
In countrymen less severely affected by dementia, there was also linkage between (i) use and maintenance of their practical skills / knowledge, (ii) maintenance or reconnection with positive identities and (iii) feeling more positive about life, as well as a greater sense of purpose
I came over on a Friday, one Friday, and a cow was calving, getting ready to calf that night. I came back in the morning, on the Saturday and helped Julie sort the calf and everything out, you know, that sort of thing… well it makes you feel useful
Theme
Total
number of
references
to theme
Example(s)
Calmer, less agitated / anxious 20 (61%) Just makes me feel good.
He is very relaxed
Better sleep 1 (3%) Well somebody mentioned the other day, does he sleep better? Well he does sleep very well, I’m fortunate there. But I think probably yes he does.
More physically active 19 (58%) What do you like about coming here?) Change of environment from being at home. And the fact that we get some exercise, walking round…’
‘Well I think the thing is here, I mean you’ve got to keep more active and obviously on a day like this you can walk round the farm’
‘It's got him walking again I am so pleased about. He's reluctant to come out walking, you know I say we really ought to do a walk today… And it gets him walking which is so good and I know they are watching him. So I don't have to feel anxious
You know he’s out and about and doing things, certainly far more than he does at home…’
Improved diet and nutrition 4 (12%) Improve or maintain self-
knowledge, self-worth, self-esteem,
pride, sense of purpose or
achievement
14 (42%) It’s helped a lot. It’s done me the world of good… because they come over here, they help over here. Judy helps and... It’s a purpose, isn’t it.
He did do a picture and he seemed quite pleased… you know do another one, but that was good and we talked about doing that and felt a sense of achievement I think
More positive about life 7 (21%) It's just, I just feel good for it, you know
Oh it makes you feel good
He has become interested in birds and he feeds them regularly. The bird feeder stimulated this as well. You are doing so much good.
Better / maintain sense of
belonging / inclusion
16 (48%) ‘I know they work here, a sense of that they are part of it as well and once you come in with that group and not afraid of the mind, you are part of it
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Theme
Total
number of
references
to theme
Example(s)
like a big family.’
‘Yes we all stick together, I will be in one group like when I am in the tunnel I have got the … some of the chaps with the hoes getting the weeds out and I do with the fork and spades and every time they come with the rake and rake it all over. It is all teamwork.
I was quite active in my young days. I used to play rugby and that sort of thing. And then I got Parkinson’s disease. But I don’t want to give up. I come out here and there are people who are the same as you.
Improved social resources, skills,
networks
11 (33%) ‘An important part of my life, yes. Very important. And I assume they’re very important to everybody, you know. Everybody who comes here. They should be anyway.
‘I think they make him become involved and I think it is a group of men together’
I don’t really know whether it influences, but you do go away and people ask you questions so you talk about it.‘
Have better / maintain relationships
with carers
22 (67%) His attendance at FR is marvellous for me, mainly because he is a different person when he comes home.
It’s helped me and the wife a lot. I don’t know what would have happened if I hadn’t done this’
‘…and he communicates better with me after he's been here that's another thing.
Q: How do you think it would be differently if you weren’t coming here?
A: Oh I would be at my wits end. I would be nasty unfortunately, I am sure because the tension you get from just watching people or caring for them
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Views of families / carers
Families / carers were consulted in two ways; qualitatively through a small number of interviews (see above); and quantitatively through a carer questionnaire which was distributed by Future Roots staff. Eighteen carer questionnaires were completed, which represents around seven in ten of the countrymen known to have carers living with them.
Carers were asked two main questions. Firstly they were invited to rate the different aspects of the Countrymen’s Club by how important it was to their husband / family member. The following chart shows that—in practice—nearly all aspects of the Countrymen’s Club that we asked about were seen as important by all carers. The exceptions are working with animals and making a connection to working life. However, the fact these aspects remain important to some suggests it is still a relevant part of the model.
X AXIS
LOWER LIMIT
UPPER LIMIT
CHART TOP
Y AXIS Y AXIS LIMIT
6
CARERS VIEWS ON THE MOST IMPORTANT ASPECTS OF THE COUNTRYMAN’S CLUB
18 Carer questionnaires
1
1
1 3
1
4
2
1
4
7
4
4
4
3
3
7
9
12
13
14
14
15
0 5 10 15
Reconnecting with working life
Working with animals
Meeting men with similar experiences
Safe / welcoming environment
Being in an outdoor environment
Stimulating activities
Getting out of the house
Missing Not important at all
Not very important Niether important nor unimportant
Somewhat important Very important
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Carers were also asked the extent to which they felt Future Roots had made a positive difference for their husbands / relatives across each aspect of the adapted Qol_AD, as shown in the chart below. The principle benefits were seen in terms of mood, and then physical health and physical activities. Fewer carers perceived benefits around family / living situation, memory, or diet / nutrition. However, it is worth noting that at least one respondent saw a great deal of benefit for each measure, and at least five respondents saw at least a ‘fair amount’. Again this points to the idea that the model can have a range benefits, even if they don’t apply in all cases.
As should probably be expected, the amount of positive difference reported by a carer increases the longer a Countryman has been using the service. Calculating a crude composite measure by giving a ‘great deal’ a score of 3, a ‘fair amount’ a score of 2 and ‘not very much’ a score of 1, reveals an average score of 16 ‘impact points’ for countrymen who joined before 2016 and 9 ‘impact points’ for those who joined during the year.
X AXIS
LOWER LIMIT
UPPER LIMIT
CHART TOP
Y AXIS Y AXIS LIMIT
7
CARERS PERCEPTIONS ON THE IMPACT OF FUTURE ROOTS FOR THEIR HUSBANDS / RELATIVES
18 Carer questionnaires
3
4
3
2
4
3
3
2
1
6
6
4
9
3
4
1
1
1
4
2
4
3
2
4
4
3
2
3
5
5
6
8
7
8
8
3
3
2
2
2
1
3
3
5
Diet and nutrition
Family
Memory
Living situation
Calmness
Energy
Physical health
Physical activity level
Mood
Missing No difference at all Not very much difference
A fair amount of difference A great deal of difference
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Disaggregation of service users’ data
As a final piece of analysis we looked at all the data across all 33 service users and our judgment is that there is:
• Strong evidence of impact (i.e. from more than two sources): 10 Countrymen (30%)
• Moderate evidence of impact (i.e. from 1 – 2 sources): 11 Countrymen (33%)
• Limited evidence of impact (up to one source): 7 Countrymen (21%)
• Not enough data to make a judgment: 5 Countrymen (15%)
To be clear, this does not mean that there is no impact for the men lower down this list, just that we do not have enough evidence to support the claim.
Although sample sizes are too small for statistical comparison, evidence of impact is likely to have been judged as stronger for:
• Longer term service users (as might be expected)
• Levels of engagement (as rated by staff) – those with higher engagement tend to have stronger evidence while those with slightly lower tend to have more moderate evidence.
• Those men not suffering from Alzheimer’s / dementia. We found strong evidence for half of those without dementia and for only one of the 11 Country Men with the condition (who was also someone with a mild form of the disease). Part of the explanation for this might be the extra difficulty collecting data from this group, but it might warrant some further investigation / consideration.
• Countrymen who previously worked in farming / agriculture.
• Self or family referrals compared to other types of referrals (although this difference is very marginal).
On the other hand we could not determine any difference between countrymen by:
• Site – i.e. Rylands vs Whitfield
• How often they attend (perhaps surprisingly)
• Age – equally strong evidence for those above and below the age of 80.
• Whether they live alone or with a partner
Because of the small sample sizes we should avoid drawing too definitive conclusions from this analysis, but it may indicate trends / tendencies that are important.
The stakeholders we interviewed also expressed perceptions on who the Countrymen’s Club works less well for:
• They felt that it might be less effective for people with poor mobility as the farm is out of town, possibly including those affected by stroke.
• Those with challenging behavior, especially around animals.
• Those not suited or used to agricultural settings. Although this concern is partly refuted by other data collected in the evaluation which suggests that countrymen without farming backgrounds have engaged equally well as others.
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Illustrative Case studies
The following examples of how individuals have engaged are included to illustrate the data collected. They are representative of those more actively engaged in the programme who we were more likely to have interviewed. Names have been changed.
Tom
Tom is a relatively young, physically able man and was referred to Future Roots after experiencing declining cognition which increased his anxiety when things were out of his control. Staff report that at first, he was reluctant to stay and nervous without his wife. However, he settled in and with the appropriate support and reassurance, now engages very well in activities and with others. Staff note that there is a noticeable reduction in the number of times he asks for his wife during sessions and is often found joking around with other participants. Examples of activities he engages with include ivy clearing, singing and gardening and he takes pride over his work. Once when playing football Tom stated that he “felt like a lad again today, having a kick about” and that it “made him feel young”. It is clear from our interview with him that Tom enjoys coming to the Countrymen’s Club stating that ‘it is lovely to be here.’ His wife says that he is always smiling when she comes to pick him and is grateful for the few hours’ respite she gains when Tom attends Future Roots’ sessions.
Donald
Donald comes from a navy background. He suffered a stroke after which he began attending Future Roots sessions and also suffers from moderate temporal arteritis and diabetes. From staff accounts John particularly engages in the social aspect of Future Root’s service. Donald states in his interview that ‘the social side of it is probably the best thing.’ Staff have recorded that he is well engaged, always chatty and has a great sense of humour. He gets involved with activities such as sanding and painting however it is clear his favourite activity is chatting with the other men in the group. His carer states that Future Root’s service has made a great deal of difference to their family situation and a fair amount of difference to his mood and physical activity level. Despite not coming from a farming background, Donald thoroughly enjoys Future Root’s service.
When asked about his initial impression of Future Roots, John stated:
‘I tried other things because my daughter’s were very keen to get me doing things. None of them really suited me because they were probably for older people than myself. So that’s how I ended up here… I can’t really fault it because everybody’s very friendly. You certainly get value for money in terms of what happens here.’
Arnold
Arnold is an extremely avid attendee of the Countrymen’s Club. To date, he has attended 79 sessions across two of Future Roots’ sites. Prior to retirement, he worked in various professions including farming and gardening. He suffers from early stage Parkinson’s disease. The weekly activity forms state that in general Arnold engages well in sessions, has good participation and enjoys working with other men. When interviewing Arnold, it was clear that he especially enjoys working in the greenhouse and singing. During his time at Future Roots his condition has worsened which has led to feelings of frustration and reduced mobility. Over time staff relate that Arnold become more relaxed about his situation and continued to engage in sessions enthusiastically.
‘I enjoy coming to the club for the social side, it is better than sitting about doing nothing. I look forward to coming twice a week and it has given me a new interest and I hope I can give something back by working in the garden in the spring.’
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‘(The service) just makes me feel good. It’s helped me and the wife a lot. I don’t know what would have happened if I hadn’t done this.’
Terry
Terry was in the services prior to retirement. He suffers from advanced dementia. The weekly activity forms note that when Terry first started to attend Future Roots sessions, he was enthusiastic to be involved with activities however had minimal engagement with other men. It is clear Terry likes to be involved with activities such as woodwork, pyrography, painting signs and singing as well as farm based / outdoor activities. As Terry spent more time at Future Roots, his engagement with other men has increased. One member of staff noted in his weekly activity form that he ‘seems to feel at home here and that he belongs’ and that he finds his way around the farm amazingly well. This is shown by his relaxed manner and greetings when he arrives. ‘He is always smiling’. When interviewing Terry he said that he enjoyed coming, particularly being in the outdoor environment, but he did think the site could be kept tidier and more organised.
I quite enjoy coming here, and if I can be of any assistance I’m more than happy to do so.
If I though my father was unhappy here I wouldn't allow him to come
Richard
Richard is a former engineer and suffers from heart failure and diabetes. His main motivation for attending Future Root’s sessions was to combat loneliness. From the weekly activity forms he appears to be very engaged, fully participating in sessions and very supportive and helpful to other countrymen. He is involved with a wide range of activities including making wreaths, woodwork, painting, playing horseshoes, poetry, signposting, sanding, reading and was interviewed by the local newspaper.
Neil
Neil used to be a farmer and now suffers from moderate Alzheimer's. He was prompted to attend Future Root’s sessions to engage with farming again. From the weekly activity forms he enjoys the farm based activities and in many sessions engaged with farm animals; for example cleaning and grooming a horse. It was noted he had a mixed level of engagement depending on the session but in general Neil participated. He also enjoys the social aspects saying that ‘its just nice sitting round.’ His carer has seen a great deal of difference in mood, physical activity level, diet and nutrition and a fair amount of difference in physical health, energy, memory, calmness. The carer states that the best thing about Future Roots is the staff and the connection to his previous working life. Future Roots gives her ‘a great sense of relief to know Neil is safe, happy and enjoying himself.’
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What has been learned?
From speaking to staff and stakeholders it seems that a lot has been learned during the early years of the programme and that the Countrymen’s Club has been adapted, mainly through listening and engaging with the men themselves. Amongst the key learning points are:
• Offering two sessions per week. Future Roots services for young people take place once a week and this was the initial plan for the Countrymen. This was changed because many carers needed more than one session for respite to be effective, and to secure the full engagement of the men. Future Roots is now getting requests for three days a week.
• Timing. Afternoon sessions have been seen to work best because the men go home tired and relaxed and there is less rush in the morning for the carer. Future Roots know that some carers would prefer full days but they believe this would be too much for the men in that environment – especially given that travel can add an hour either side.
• Referral patterns. Usually carers are the initial referrer and encourage men to attend. But Future Roots has found that typically within 3 sessions the man will make his own choice. If a man is unable to choose himself then the carer will decide based on whether he returns home relaxed / happy.
• The role of food. This importance of the food is not so much about the quality or nutrition, but more about encouraging socialisation through eating with friends. For those with particular communication problems, eating can be seen as replacing conversation - as something to do with other people.
• ‘Look and feel’. To enhance engagement the environment needs to be non-clinical and reflect the men’s interests. Future Roots have learned to present the programme as a ‘club’ where they can engage in practical things and help out or volunteer. They have also learned that for the men to engage they need to see they have a purpose to come and not feel that they are compelled to do so.
• Focus on men. Future Roots did initially allow women to join the group but found that it changed the dynamic; for example the men wanted to please them and let them make decisions. Having said this, female workers (and younger people) are not unwelcome for passing interaction.
• The role of reminiscence. Future Roots believe that conversations need to be real / relevant so planned reminiscence around topics has not been as popular as conversations about the farm, the weather, equipment and health etc. What ‘reminiscence’ there is tends to focus on what is around farm that they might not notice eg. bird song, ice hanging on the branches etc.
• Encouraging mobility. Having a safe established walk around the farm enables the men to have freedom and independence which they may no longer experience.
• Changing seasons. Future Roots has sought to emphasise the weather and the seasons because they believe the men need to feel the different conditions and the contrasts between indoors and outdoors. Moreover, the change in temperature seems to be stimulating to many of the men.
• “Dementia friendly”: Dementia friendly sites talk about need for strong visual recognitions and open spaces. Some anecdotal evidence from carers suggests that men who often get lost at home don't get lost at the Club - which Future Roots attributes to strong sensory link to different areas.
• Mixed abilities. As per their work with young people, Future Roots believe that mixed ability groups seem to work best because the different skills, health conditions, interests, experiences creates more lively discussions, atmosphere and camaraderie.
• Roles of games / completion. Future Roots has learned not to advertise singing and games as part of the club because the fact it is a work environment tends to be more appealing. However, they have leaned that games like boules, quoites or challenges are particularly engaging for some of the most impaired men. They seem to very quickly see what they are supposed to do by watching and can be fully engaged, not just throwing, but concentrating and really trying to win - which prompts huge smiles when they do.
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• Role of singing. Many of the men do enjoy singing songs – but not everyone. The ones that don't want to sing need to be able to do something else, usually in the same room, but usually see the benefit to some of the men and may join in for them..
• Role of art. After having an art teacher at the farm Future Roots found that many men—including some farmers—enjoy learning about art. It can be something they have never tried before but have a natural ability for.
Suggestions for the future
Countrymen and carers were not able to identify areas for improvement (beyond relatively minor quibbles about the food, tidiness and particular activities they didn’t like as much).
Stakeholders were generally very positive about the service, and want to see it grow and expand. Hence their suggested areas for improvement mainly focussed on how the organisation might increase delivery and diversify income. Ideas included:
• Taking people from outside the county and potentially having accommodation to create wider income generating opportunities.
• The scope to move into the residential care home market which struggle with providing outdoor activities. Although, cost is a significant barrier to making this happen as care homes already operate at extremely low cost and relatives who might pay are stretched by the cost of care.iii
• The potential to develop the carer’s service further – although this did not emerge as being particularly important from the evidence we collected.
They also highlighted some areas of potential concern related to growth:
• The perception that the organisation as-a-whole has the right ethos but lacks refinement. And with this the need for more ‘structure’ as an organisation to take it forward and a slightly more business-like and robust approaches. In part this perception might be driven by lack of familiarity with the organisation and traits generally associated with smaller and more innovative programmes. Indeed Future Roots has been actively working to tighten-up procedures and processes during 2016, with funding from the Sustainability Fund, so it may be that this concern has already been addressed.
• Whether there is dependence upon particular individuals, including / particularly the founder.
• The need to increase profile and outreach so that the organisation is better joined up with other stakeholders in health care and social care who could refer to them. In recent months the Sustainability Fund has helped support this process and Future Roots have engaged with the Parkinson’s and Alzheimer’s Society, the Care Farming UK conference London and public health in Bristol, as well as a range of other groups commissioners and local authority representatives.
• Similarly, the need to be better at linking with other organisations, providers and local community groups who can feed into their work. For example, volunteer opportunities from large organisations and schools to make it part of a community intervention rather than working in its own silo.
• The need to focus on outcomes and directly link this to the business case of each commissioner. When applying for contracts, focusing on national priorities, value of money and commissioners overall objectives on older people.
• The need to provide training and ensure quality at an increasing number of sites and with an increasing number of delivery staff.
iii Future Roots is in fact piloting a new approach in which aspects of the experience are taken to care home settings
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Monitoring and evaluation recommendations
The evidence presented in this report should be sufficient to be recognised as level one in the Nesta Standards of evidence (“you can describe what you do and why it matters, logically, coherently and convincingly”) 124.
There is good indicative evidence that supports arguments around levels two (“you capture data that shows positive change, but you cannot confirm you caused this”) and three (“you can demonstrate causality using a control or comparison group”). There is also strong evidence from existing academic research. But the Countrymen's Club does not yet have the quantitative data for accredited at level 2 or 3 under the criteria that are generally applied (which is quite normal for a programme at this stage of development and give the evaluation challenges highlighted on page 6 above)
To further this aim we would suggest continuing to collect data using the Qol-AD and carer satisfaction rates. We also suggest continuing to measure engagement through staff, although we need to review whether the tools developed are fit-for-purpose.
In our view, if the Countrymen’s Club is to grow further then better data collection procedures and practices will need to be adopted.
• A consistent set of data needs to be collected at the point of referral
• Attendance and engagement should be tracked
• Outcomes should be tracked on a fairly regular basis through standard assessments and consultation with carers
• Staff should be encouraged to share observations and learning in an informal
• All of the above would be supported by investment in a fairly basic case management system that everyone uses consistently
The prize for doing the above will be an increasingly large dataset that provides more confidence in outcomes being achieved and enables Future Roots to explore how the service supports peoples different levels of need.
Finally, it is also important to note that future evaluation questions will partly be about impact but also partly about reach and ‘dose’:
• Does Future Roots reach and engage those with the most needs?
• What is the right balance between providing a better and better service to a small group of service users against providing a lighter touch service to a larger group?
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Conclusions and discussion
What does the evidence say about the theory of change?
Both our literature review and the qualitative evaluation data collected provide broad, indicative support for the model articulated in the Countrymen’s Club theory of change.
Through our qualitative research we have seen that both Countrymen and carers strongly support the notions that:
• The Countrymen’s Club is a model and mode of delivery which has been refined progressively, and is transferable. Staff are clear about the way they need to approach the men, the sorts of activities they can offer and how best to engage.
• This type of support is particularly relevant to the needs and experiences of the target group of older men with a range of health conditions;
• Possibly the chief achievement is that the Club seems very effective at overcoming the barriers and reservations that prevent older men from accessing support services (feelings of stigma, feeling in control, not wanting to be seen as a ‘patient’ or ‘dependent’). In this regard there seems to be distinct value in this being a club for exclusively for men, in a working environment that is traditionally associated with masculine identities;
• Few, if any, similar services are currently available that have the same appeal.
Moreover the evaluation data provides near universal support for aspects of the model being relevant / important for those men receiving the service. In particular:
• Many countrymen talk explicitly about the ‘sense of belonging’ they feel and the social relationships that they establish - with both staff and other countrymen.
• Similarly, all countrymen and carers talk about the benefits of ‘getting out the house’ and ‘doing something different’ which helps combat the risk of lethargy and other bad habits. The fact that the Club is available routinely, twice a week, also seems to give families a positive structure / routine which they can rely on.
• Beyond ‘getting out the house’, countrymen talk about the particular value of the agricultural / farming environment, the fact that is ‘stimulating’ to be outdoors, with animals, doing physical activity, drawing on their skills and experience.
I don’t know, it is an atmosphere here, it is out in the country you can smell, you know you have got the farms, you know, you get the farmer coming in with his tractor.. Very good.
• A minority of countrymen also talk about the fact that it is a working environment, and that they can do worthwhile things that contribute to the environment and make use of their skills. There are examples of men feeling a sense of purpose from helping others (e.g. new countrymen). This seems to be a significant hook for some, but perhaps not all.
• There is strong evidence that the Countrymen’s Club is performing a valuable respite function. Carers / family members are very positive about both the free time it gives them, and the sense their men are in a place where they are happy and engaged (so it is “guilt free”). A small number of carers go on to say that they think their relationships have improved as a direct result of the Countrymen’s Club.
I have a few hours a week on my own when I can decide to go to work or meet up with friends. That's the only time when I can be away from my husband and not worry.
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Some aspects of the model are less well supported by the evidence we collected. Fewer men talk about the benefits of diet / nutrition, better sleep and specifically about reminiscence work. Also, the evaluation has failed to establish robust quantitative evidence of success. We have monitored the number of people using the service over the six months, and in particular the impressive retention rate, but quantitative evidence of benefits and impact is only indicative at this stage (albeit a positive indication).
As such, given the scale that the Countrymen’s Club is currently working at, and the limited research methodologies available to us, it is not yet possible to be definitive in our conclusions about impact. But we can assert with a degree of confidence that the countrymen who have engaged and participated during the evaluation do appear to be achieving some / many of the intermediate outcomes articulated in the theory of change. And therefore—if the literature is correct—that sustained impact / outcomes are being achieved.
What might have happened without the Countrymen’s Club?
A degree of additionality for the benefits described above is arguably quite easy to claim, given that there are no similar services available, and it seems very likely that these men would be doing nothing similar if the Club was not available to them. Moreover, all men and carers with experience of other services say that that the Countrymen’s Club is better than these services (much better in some cases).
Service user’s perceptions also support the argument that the Countrymen’s Club itself has made a difference. For example:
It's as if he's still going to work. Doing everything he always did. It's made things almost like they were before the Parkinson's.
Because I was indoors, I would be stuck in the pub not going, because there is no bus service I can’t get out, so I will be stuck in a pub. I would probably be sleeping upstairs, watching telly, and I was down in the bar. But this has got me out. I think coming down since January, I think January, I think, it’s made a lot of difference to me. I won’t part with it.
Great deal of difference on mood - which has lifted. Provides support, activities are good. Good network of people. He looks forward to his visits. It lifts his mood and is more positive about things. Enjoys mixing with other people and chatting to others in the group. Always seems to be in good spirits after his visits.
But this is anecdotal evidence and not everyone will be convinced by it. So, actually measuring additionality will be a challenge for the organisation as it grows. The best options might come through continuing to use the Qol-AD to accumulate data about the ‘before and after’ profile of service users, and through working with a referral partner that could potentially provide data for a comparison group (although this would require significant scale before meaningful data is available). For now a priority is to continue to record perceptions that the service has made from Countrymen, families and staff.
How do the results vary for different service user groups?
Levels of engagement
Disaggregating our data points to a relatively small group of service users who attend regularly and appear to derive the most benefit – perhaps about 15 men across the two sites, or half the number of service users at any one time. Analysis of the engagement forms for these men highlights the efforts that staff go to maintain that engagement and manage ups-and-downs; indicating that even the most committed countrymen continue to require a fairly high level of support.
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Alongside this core group we also see:
• Men who are disengaging - mainly for reasons of ill health. We haven’t seen any evidence of established service users disengaging because they are fed up or bored with coming.
• Men who are new to the service. Of these, some seem to take to it with gusto while others are in two minds. As above, staff seem to make a lot of effort with these groups, but inevitably it doesn’t always work - partly because of health constraints. None-the-less, a positive finding is that of the 19 countrymen who signed-up to the service in 2016, 15 were still using the service by the end of November. Suggesting a high retention rate of roughly 80%
Levels of need
In our evaluation it has been difficult to engage those with more severe forms of dementia and therefore our observations on this group of service users are more speculative. Carers were undoubtedly positive about the benefits they received through respite, but we have less evidence about the other impacts.
Despite these difficulties we can speculate that there are in fact two theories of change going on, reflecting the needs of two groups of service users;
• One theory of change for men with relatively mild dementia, or physical rather than mental health conditions, who are likely to have worked in agriculture or other skilled manual occupations. For this group the Countrymen’s Club is way to maintain their connections with their working lives, to stay busy and meet people - as well as all the other benefits in the theory of change
• Another theory of change for men with more severe conditions, for whom it is less about the link to working lives, and more about the opportunity to do something different, to be outdoors, to engage with animals, and other men. Also for this group, the benefits for carers might be more pronounced.
As the organisation grows we think it would be worth considering how well the needs of these two groups sit alongside each other, and whether an explicitly tailored programme of support and evaluation strategy is needed for each group. However the counterargument to this is that both groups derive a lot from interacting with each other and that there is a need to avoid defining people by their condition.
The background of the men
Another challenge is whether or not the appeal of the Club is limited to men from an agricultural background, which was a concern of one stakeholder. There is not much evidence to support this concern. Men with a farming background represented only a minority of the countrymen in the evaluation period. And while the link to farming was clearly a ‘hook’ for some men, there were others who relished it as a new experience.
I have never been near an animal. I have never been near a cow, I have never been near a bull …I have seen them out in fields…While I have been down here.. I have brushed a cow down and a bull coming in. It’s been fantastic, I have learned a lot down here.
Nonetheless, Future Roots should not expect this question to go away, so it will be important to continue to stress the more universal benefits / hooks such as being outdoors/ connecting with animals and the rural environment.
What other explanations are possible?
The relevant question here is whether another type of activity might achieve the same results, particularly if a lower cost service could have achieved similar results for a larger group of men.
To answer this it helps to repeat the core components of the model; sense of community created; the regularity of the service; and the opportunity that countrymen have to do practical things and feel useful. Certainly other
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services could—and do—deliver these benefits. However, none of these services—nor nothing like it—seem to be available in the area, and there does seem to a particular attraction to the outdoor / farm environment that works to enhance that appeal, and arguably ensures both the breath and depth of engagement we have observed.
It could be argued that the fact that many of the countrymen are self-referring is evidence that they are a group that is amenable to support and would therefore have found another service or another way to improve their outcomes. However, there is strong qualitative evidence to counter this argument in that many Countrymen and unsuccessfully tried other things or not found anything else. And that many talked about the distinct benefit the Club had had for them.
Non-users
Another theoretical challenge is whether there are a large number of men in the catchment area with relevant needs who are not aware of—or attracted to—the service, and therefore don’t benefit. In other words, the risk that the service meets the needs of a select few at the expense of many.
We do not think this is a pressing questions for delivery at Rylands and Whitfield, because what the Countrymen’s Club has done to-date is to test and refine the model in a way that we can be reasonably confident is achieving outcomes and impact for those men that come. But the question of relative appeal and engagement may become more significant as Future Roots tries to reach more people in a wider range of communities.
What are the costs of the Countrymen’s Club?
According to staff the annual running cost for the Countrymen’s Club is roughly £75,500. This is made up of:
• Staff costs for one manager (0.33*FTE), one administrative assistant (.4*FTE) and three workers (.57*FTE)iv: c. £52,000
• Food costs: £1 per mealv: C. £1,500
• Fuel and utilities: C. £2,000 (£1,000 per site)
There is no cost for the sites themselves (Ryland’s is owned outright and Whitfield is provided for free), similarly all maintenance is carried out by staff and service users. The same arrangement ought to apply to most scaling options - which do not suggest setting up wholly new farms but rather the adoption of the model by Care Farms with facilities already in place. Although, there is technically an opportunity cost (i.e. the site could be used for something else).
Based on the numbers above, we estimate that the annual cost per individual per session is c. £36 (or £12 per hour). This compares to the NHS reference cost of £131 per day for Day-care facilities for elderly people125 (or c. £19 per hour)vi.
Based on 33 Countrymen attending every six months, the annual cost per service user is c. £1,680 - with an average attendance of 46 sessions per year (slightly under once per week). Of which, £460 comes from service users fees (27% of total cost).
iv There is also 1 volunteer (uncosted) v The majority of food is donated / home grown vi The comparative cost of the Countryman’s Club would be lower still if we also took into account the time spent in transport – up to 2 hours per session in some circumstances.
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Appendices
The Boing Boing resilience framework for adults
The Countrymen’s Club’s activities and target outcomes have been particularly informed by the Boing Boing resilience framework for adults—an evidence-informed table of elements that contribute to resilience (Figure X).
Figure X: Boing Boing Resilience framework
BASICS BELONGING LEARNING CORE SELFFind somewhere to belong
Keep relationships going (eg educator /support partners/carers/family)
Focus on good times and places
Make friends and mix
CONSERVINGInterpersonal skills, trust Self (eg not passive), family, friends,
mental health professionals, GPInterpersonal skills, empathy Ongoing support issues
NOBLE TRUTHSACCEPTING COMMITMENT ENLISTING
Remember tomorrow is another day Foster talents
Enough sleepMake sense of where the person has
come from Lean on others when necessaryPredict a good experience of someone or
something new Develop life skillsThere are tried and tested
treatments for specific problems, use them
Leisure & work occupations Have a laugh
Take what you can from relationships where there is some hope Fostering their interests
Healthy dietGet together people the person can count
onHelp self-organisation
Help the person take responsibility for
her/himself (self-advocacy)
Calming down & self-soothing (support reflection, not feeling overwhelmed by
illness)Responsibilities & obligations
Exercise and fresh air
Highlight achievements
Tap into good influences (eg peer support)
Engage mentorsPromote understanding of
othersIdentifying & solving
problems (reduce self blame and guilt)Being safe
The more healthy relationships the betterMap out career or life
plan
Putting on rose-tinted glasses
(reframing/reappraising)Help the person to know
her/himselfAccess & transport
Resilience Framework (Adults) – Copyright Hart, Blincow & Cameron (adapted from original) www.boingboing.org.uk
COPING
SPEC
IFIC
APP
ROAC
HES
Good enough housing Make work & learning as successful as possible
Understanding boundaries and keeping within them Instil a sense of hopeHelp understand place in the world, & that
others may face similar situations
Enough money to liveBeing brave
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“Evidence is confidence”
Below we make a tentative assessment of the Countrymen’s Club using the Realising Ambition consortium’s Evidence-Confidence Framework, which highlights the key ingredients for successful delivery of a service 126. It is designed for replicating established services, but can equally be applied to delivering innovative services.
On the left-hand side of the framework are five key ingredients of success. These include ingredients related to the service (for example, a tightly defined service) and to the organisation doing the replicating (for example, its ability to use evidence). Alongside each ingredient are four indicators underpinning that ingredient. We have colour coded a tentative assessment of the Countrymen’s Club.
Figure X: Evidence-confidence framework
A tightly defined service
The theory of change presented in this report shows a very tightly defined service, which is clear about the ‘core’ of the model and what the activities are. There is no ‘manual’ at this stage, nor a clear training programme, although there are documents that include elements of these and the wider Care Farm Quality Framework.
Service is effectively delivered to those that need it
The data presented in this report provides clear evidence that the service has reached and engaged people in the targeted audience and that it has been delivered by high calibre staff. This should be expected at pilot sites and the challenge will be to maintain this fidelity going forward.
Evidence is used to learn and adapt, as required
The delivery of the Countrymen’s Club to date has been very adaptive in changing with the needs / preferences of the men. It has also been very tailored to individuals, as you would expect with a small service. However
12
“EVIDENCE IS CONFIDENCE”
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knowledge and learning is quite ad hoc and informal, and until this evaluation, engagement and outcomes were not systematically monitored. The Countrymen’s Club is at a stage where more systematic recording of client information and data are needed in order to maintain quality and impact as the service expands.
There is confidence that outcomes will improve
The Countrymen’s Club is strongly supported by the literature on ‘what works’ to engage and improve outcomes for older men. There is good indicative evidence from this evaluation that men and their families have benefited from their involvement. As above, the organisation needs to improve how it monitors engagement and impact as is starts to deliver the service to a wider range of people.
The service is cost-beneficial and sustainable
The cost of the service is slightly lower than the NHS reference cost for elderly day care services (which is without taking into account any additional benefits that might be generated by the model itself). Given that the indicative evaluation findings show potentially substantial improvement in wellbeing for a hard-to-engage target group, we can be fairly confident about value for money.
To be sustainable, the service needs to continue to find funds or contracts to cover the 80% of the budget not gathered through service user fees.
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References
1. Kail A, Lumley T. Theory of change: The beginning of making a difference. New Philanthropy Capital; 2012.
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