Facilitators and Barriers to Sustainment of a Community Choir Program to Promote Health Among Diverse Older Adults: A Multi-site Study.

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Published in final edited form as: Int J Community Music. 2025 May 31;18(1):9–30. doi: 10.1386/ijcm_00116_1 Facilitators and Barriers to Sustainment of a Community Choir Program to Promote Health Among Diverse Older Adults: A Multi-site Study Theresa A Allison 1 , Julene K Johnson 2 , Anita L Stewart 3 , Elena Portacolone 4 , Michaela Simpson 5 , Shireen McSpadden 6 , Sylvia Sherman 7 , Anna M Nápoles 8 Author information Article notes Copyright and License information 1 Division of Geriatrics, Department of Medicine; Department of Family & Community Medicine at the University of California, San Francisco, 490 Illinois St., Box 1265, 94143 CA, USA. 2 Institute for Health & Aging at the University of California, San Francisco, CA, USA. 3 Institute for Health & Aging at the University of California, San Francisco, CA, USA. 4 Institute for Health & Aging at the University of California, San Francisco, CA, USA. 5 Principal Consultant and Executive Coach at AAIR Consulting, USA. 6 San Francisco Department of Homelessness and Supportive Housing in San Francisco, CA, USA. 7 San Francisco Community Music Center in San Francisco, CA, USA. 8 Division of Intramural Research at the National Institute of Minority Health and Health Disparities in Bethesda, MD, USA. ✉ (corresponding author) Theresa A. Allison, M.D., Ph.D. 490 Illinois St. Fl-08, Box 1265, San Francisco, CA 94143, USA. theresa.allison@ucsf.edu Roles Theresa A Allison : M.D., Ph.D. , Professor Julene K Johnson : Ph.D. , Professor Anita L Stewart : Ph D. , Professor Elena Portacolone : Ph.D. , Professor Shireen McSpadden : M.N.A. , Executive Director Sylvia Sherman : B.A. , Program Director Anna M Nápoles : Ph.D., M.P.H. , Scientific Director Issue date 2025 Mar. PMC Copyright notice PMCID: PMC12326659  NIHMSID: NIHMS2053417  PMID: 40778366 The publisher's version of this article is available at Int J Community Music Abstract This paper reports on the successful sustainment of community choirs for diverse older adults following completion of a cluster randomized trial of choir participation on health and well-being. Trial participants showed decreased loneliness and increased interest in life after 6 months. Following trial completion, we examined the facilitators of, and barriers to, choir sustainment at intrapersonal, interpersonal, and structural/organizational levels. We conducted focus groups with trial participants who continued during the sustainment period. We also interviewed the music professionals and administrators who delivered or supported the program. To further identify barriers, we interviewed trial participants who did not continue in the choirs. We used a mixed inductive-deductive approach for content analysis of the transcripts. On the intrapersonal level, facilitators included a sense of well-being and positive emotions, while barriers included significant health and access issues. On the interpersonal level, relationships and social interactions functioned as both facilitators and barriers, depending on circumstances. On the organizational/structural level, high-quality programs facilitated sustainment; transportation and funding created barriers to sustainment. Facilitators far outweighed barriers to sustainment. Consideration of key facilitators and barriers can provide insights into sustainment of community choirs designed for diverse older adults. Keywords: well-being, community music, mixed inductive-deductive methods, singing, program evaluation Introduction Community choirs provide opportunities to engage in music and to serve local communities through live performance in addition to the benefits of music-making ( Bell 2008 ) without the need for musical instruments or prior training. Singing in a community choir has been associated with improvements in psychosocial well-being ( Clift et al. 2010a ). Choirs designed to bring people together from diverse backgrounds can provide opportunities to belong to new communities ( Balsnes 2016 ), although the experiences of people in multicultural choirs reflect the complexities of diversity and inclusion efforts ( Yerichuk 2015 ). As the population ages, choirs for older adults have been developed by performing arts centers as opportunities for community outreach ( Balsnes 2017 ) and as public health interventions, intended to improve health-related outcomes such as well-being or loneliness ( Davidson et al. 2014 ; Johnson et al. 2020 ). By intervention, we mean that a choir is intended to achieve an outcome, whether musical, social, or health related. For example, a choir started through a music center may be intended to engage older adults in learning musical skills, whereas a choir started as research study intervention may be intended to assess changes in psychological well-being or cognition. Compared to members of the general population, older choir participants have reported better satisfaction with health and quality of life ( Johnson et al. 2017b ) and improved psychological well-being ( Pérez-Aldeguer and Leganés 2014 ). After singing in choirs, participants reported improvements in multiple aspects of personal and social well-being ( Allison et al. 2020 ). While contextual factors, such as culture, social networks, agency interactions and limited economic resources can influence the sustainment of programs designed to improve health more generally ( Proctor et al. 2015 ), relatively little is known about the sustainment of community choirs that are initiated as part of a research study. A sustained choir, no longer constrained by protocols or measurements, becomes a community choir. In order to understand this transition, we designed a study to assess facilitators and barriers to choir sustainment in the six months immediately following completion of a cluster randomized trial of choir participation on health and well-being in the United States (U.S.). Parent Study: The Community Of Voices Trial The Community of Voices (COV), a scientific, cluster randomized trial, examined the effects of community choir participation on the health and well-being of older adults (age 60 and over) from diverse racial/ethnic and socioeconomic backgrounds. ( Allison et al. 2020 ; Johnson et al. 2017a ; Johnson et al. 2015 ; Johnson et al. 2020 ). The study involved a community-engaged partnership between the University of California, San Francisco, the San Francisco Community Music Center, and the San Francisco Department of Disability and Aging Services. In the COV trial, we hypothesized that group singing would promote health among older adults through three engagement pathways: cognitive, physical, and psychosocial ( Clift et al. 2010a ; Cohen et al. 2007 ; Johnson et al. 2013, Johnson et al. 2015 ). Therefore, each session included culturally tailored activities that targeted the three pathways, such as learning new music (cognitive), full-body warm-up exercises (physical), and a social break during sessions (psychosocial). We developed standardized procedures to ensure fidelity across sites and documented the procedures in a manual (accessible at https://cov.ucsf.edu/ ). Community-based music professionals delivered 90-minute weekly sessions at senior centers for twelve months ( Johnson et al. 2015 ). We measured outcomes using validated instruments focused on cognitive, physical, and psychosocial well-being. COV Trial Results In the parent study, the choir itself was considered the music-based intervention. The COV intervention included not only singing in rehearsals, but also whole-body warm-up exercises, structured opportunities to socialize, and opportunities to perform and give back to the community through concerts. Twelve U.S. Area on Aging-supported senior centers were randomized to receive a COV choir intervention either immediately (intervention group, n =208 participants across six choirs) or after a six-month delayed start (control group, n =182 participants across six choirs). We enrolled participants who spoke either English or Spanish (either monolingual or bilingual). In comparison to waitlist controls, the immediate-start participants showed statistically significant reductions in loneliness and increased interest in life after six months, which was the main randomized comparison ( Johnson et al. 2020 ). The intervention did not result in differences in cognitive or physical function. Retention in the trial was 92%. In the post-intervention focus groups and interviews, choir participants, music professionals, and administrators identified multiple psychosocial benefits associated with the COV choirs, including improved emotional well-being, self-esteem, self-confidence, social support, and decreased loneliness ( Allison et al. 2020 ). This diverse group of participants reported that participating in the choir supported their sense of cultural identity. Participants’ country of origin included not only the United States but also Canada, China, Cuba, El Salvador, Guatemala, Hong Kong (special administrative region), Mexico, Peru and the Philippines. Choir participants reported a developing a strong sense of multi-cultural appreciation as they learned songs from other cultures ( Allison et al. 2020 ). Sustainment Period and the Sustainment Study At the end of the trial, the research team obtained supplemental funding to sustain a subset of the choirs for six months to examine facilitators and barriers to sustainment. We refer to the sustainment of five choirs for six months as the ‘sustainment period.’ We restrict the definition of sustainment to the continuation of the processes and practices of the intervention ( Berta et al. 2019 ). The sustainment study focused on the factors affecting the continuation of the choirs. No longer part of the original trial, the choirs became part of the San Francisco community music scene, where the focus of intervention became the engagement of choir participants in ‘active musical knowing and doing’ ( Higgins 2012 : 5). From a community music vantage point, this study examined the sustained choir as a musical social phenomenon rather than a health-focused intervention, although the choirs continued to focus on promoting health and well-being. During the sustainment period, the community music partner continued to coordinate the staffing of professional musicians and the senior centers integrated the choirs into the usual program of activities for their clients. The research team no longer provided technical support, fidelity checks or protocol oversight during the community-led sustainment period. Without immediate funding as an issue, we were able to examine other factors affecting sustainment. Three overarching research questions guided this study: What factors served as facilitators to sustained participation in the choirs? What factors functioned as barriers to sustained participation in the choirs? Did these facilitators and barriers affect sustainment on intrapersonal, interpersonal, and/or organizational/structural levels? METHODS We designed the study to use qualitative methods because qualitative approaches can provide an in-depth understanding of the factors influencing program sustainment at all stages ( Farquhar et al. 2016 ). Inductive methods such as focus groups and semi-structured interviews allow participants to offer new insights into sustainment, particularly the sustainment of complex programs, multiple community sites or diverse populations ( Oakley et al. 2006 ; Toroyan et al. 2004 ). Because the sustainment of the community choirs across multiple senior centers involved intrapersonal, interpersonal and structural/organizational factors, we took a mixed inductive-deductive approach to analysis ( Hsieh and Shannon 2005 ). We used these a priori constructs (intrapersonal, interpersonal, and organizational structural levels; facilitators and barriers) to organize the questions. We took an inductive approach to coding, however, to remain open to the emergence of new codes. To develop an in-depth understanding of the factors influencing sustainment, we solicited input from multiple groups. During the final (twelve-month) assessment at the conclusion of the COV trial, we asked trial participants if they planned to continue in the program; and if so, whether they would participate in a focus group (in English or Spanish) at the end of the sustainment period. To triangulate participant data, and to identify potential group or organizational factors influencing sustainment, we also invited the music professionals (choir directors and accompanists), who led the program at each site, and the administrators (senior center and music organization community partners) to participate. Music professionals and administrators completed interviews following the six-month sustainment period. The UCSF Institutional Review Board approved the study (IRB Protocol 12–09005), and a new consent form was used. Although focus groups and semi-structured interviews have been used interchangeably in the health sciences, each has relative strengths and weaknesses ( Namey et al. 2016 ). Singing in a choir involves the group as a cohesive unit. Therefore, we decided to use focus groups with program participants to maintain the group as focus of inquiry and for efficiency. We chose individual, semi-structured interviews with music professionals because each choir differed in terms of language, music style, and music leadership approach. We chose individual semi-structured interviews with administrators so that they could describe factors unique to each site hosting the sustained program. For participants who chose not to continue with the program but who agreed to provide information on their reasons for leaving the choir, we conducted a brief telephone interview. Sample The choirs were started at twelve different sites with different start and completion dates. Participants involved in the first five sites completing the trial (three intervention and two delayed-start sites) were given the opportunity to continue in their respective choirs, which were also opened to new older adults. We conducted telephone interviews with fourteen trial participants who discontinued choir participation. Interviews lasted 20–30 minutes. We conducted five focus groups with 31 participants in the sustained choirs: one focus group for each choir. Two focus groups were conducted in Spanish. Focus groups lasted 60–90 minutes. Four focus groups included 6–11 participants, but one focus group involved only a single participant. Participants completed a brief survey of demographic characteristics including sex, age, race/ethnicity, Spanish language (yes/no), foreign born (yes/no), and country of origin. Music professionals and administrators reported sex and race/ethnicity. All music professionals and administrators participated in semi-structured interviews, including three choir directors, three accompanists, five senior center administrators and one community music center administrator. Semi-structured interviews with music professionals and administrators lasted 60–90 minutes. Table 1 summarizes the demographic characteristics of each group. Table 1. Participant characteristics Participant Group Administrators at senior centers and community music center Music professionals (choir directors, accompanists) Participants who continued during sustainment Participants who discontinued during sustainment (n=6) (n=6) (n=31) (n=14) Age (mean, SD) NA NA 74.5 (7.5) 70.8 (6.5) Sex (female/male) 6/0 4/2 21/10 11/3 Race/Ethnicity* Non-Latino Whiteo 2 2 4 4 Non-Latino Black 2 1 9 3 Asian /Pacific Islander 0 2 3 0 Latino 2 1 15 7 High school (including GED) or less NA NA 7 5 Married or partnered NA NA 11 3 Completed interview in Spanish, n 11 7 Open in a new tab Interview and Focus Group Questions and Procedures COV trial (program) participants We designed the focus group questions to explore key features of the sustainment period. Questions included: How did the sustained choirs differ from the choirs in the trial? What did you perceive as facilitators and barriers to continued participation? Experienced moderators led focus groups at the senior centers hosting the program (two in Spanish and three in English). Moderators included members of the research team with graduate training and expertise leading focus groups. Bilingual-bicultural research staff translated the English-language interview and focus group guides into Spanish. The research team addressed differences of opinion in translations through discussion and consensus to ensure accuracy in the final transcript. Telephone interviews with participants who discontinued after the trial included questions about facilitators and barriers to continuing the program, and reasons for discontinuing. Music Professionals and Administrators We designed semi-structured interview questions to understand factors that facilitated or impeded sustainment, particularly at the organizational/structural level. These interviews were conducted by research team members who had advanced training in qualitative methods. The research team member with expertise in ethnomusicology conducted the music professional interviews, and another team member conducted the administrator interviews. Topics included: 1) facilitators and barriers to continuing to provide weekly sessions after completion of the trial, 2) changes to the choir program curriculum during the sustainment period, and 3) operational/structural changes impacting the program during sustainment. Data Analysis The data set included professionally transcribed audio recordings of focus groups and semi-structured interviews. Bilingual/bicultural members of the research team translated Spanish-language transcripts into English. We used a mixed inductive-deductive approach to content analysis ( Hsieh and Shannon 2005 ; Miles et al. 2014 ) using ATLAS.ti software. To minimize bias, two researchers not involved in the original COV trial conducted initial open coding. In addition to the open codes, we created ‘barrier’ and ‘facilitator’ code groups to ensure identification of factors influencing program sustainment. For example, as part of the open coding phase, the coders developed the code ‘choir director involvement’ for each statement that identified choir director activities, and then grouped statements as either barriers or facilitators. Each coder independently read and coded the transcripts, and identified themes through the process of axial coding, making connections among codes and writing analytical memos ( Crabtree and Miller 1999 ; Hsieh and Shannon 2005 ). A third researcher independently read all of the transcripts and engaged in further axial coding until no new themes were identified ( Hsieh and Shannon 2005 ; Miles et al. 2014 ). For example, the open code ‘choir director involvement’ merged into the overarching theme of ‘social connection’ as an interpersonal facilitator. Throughout data collection and coding, we looked for disconfirming evidence. For example, the open code ‘uplift’ did not include quotes pertinent to sustainment. Rather, uplift served as one aspect of a larger experience of emotional well-being, a key benefit to singing in the choir throughout the trial rather than a facilitator of sustainment ( Allison et al. 2020 ). Once we identified specific facilitators and barriers, we sorted them into intrapersonal (micro), interpersonal (meso) and organizational/structural (macro) levels ( Bronfenbrenner 2000 ). Throughout the analysis, senior researchers provided input and reconciled differences through discussion, until an overarching thematic conceptual framework emerged ( Brady et al. 2020 ) [See Figure 1 ]. Figure 1. Open in a new tab Facilitators and Barriers to Sustainment Reflexivity and Bias The research team had expertise in health services research, clinical neuroscience, disparities research, research in multi-lingual populations, geriatrics, music anthropology, choral conducting, medical sociology, psychology, and music-based interventions research. The research team members involved in data collection and coding had either doctoral level training or had been trained by one of the university faculty researchers. Bilingual-bicultural research staff also served as focus group moderators. To ensure rigor and validity, data were triangulated across groups with attention paid to disconfirming evidence. Results The results suggest that multiple intrapersonal, interpersonal, and organizational factors influenced sustainment. Social connection, emotional well-being, and positive emotions emerged as facilitators across all three levels. One administrator summarized the desire to have the program sustained, saying ‘They want to hear that it’s not going to end.’ The sections below summarize the facilitators and barriers by intrapersonal, interpersonal, and organizational/structural levels. Minor details were changed to preserve anonymity. Facilitators Facilitators included factors that supported individual participation in the program during the sustainment period as well as sustainment of the program itself. See Table 2 . Table 2. Facilitators to sustaining a choir intervention identified by administrators, music professionals and trial participants INTRAPERSONAL LEVEL Theme Core Features Illustrative Quotes Emotional well-being, positive emotions • Enjoy attention, connections with past through music, singing, learning, physical exercises; improved emotional well-being, less stress; health benefits (e.g., improved physical health, cognition) • ‘It’s important for our seniors, our participants, to have a forum, somewhere they can sing. You know, because it gladdens their heart, you know, make them feel better. It makes them feel like they’re doing something that’s good and that they can look forward to doing, you know, every day.’ (trial participant) • ‘Well, the fact that the choir members feel good about it helps us feel good here. And I’m sure that it makes the Community Music Center feel good too.’ (administrator) INTERPERSONAL LEVEL Social connection, belonging, social support •Enjoy new social connections • Feel part of a group, ownership • Enjoy professional connections with music professionals, music center director and senior center directors • Enjoying relationship with music professionals • ‘Because we are extended [sustained] and because we have melded and joined, we feed off of each other and we have become cohesive and friends and this is very positive.’ (trial participant) • ‘It was kind of amazing to us how that group evolved and then became this totally different feeling and this really kind of intimate, supportive feeling. So that was a neat kind of evolution.’ (music professional) • ‘What I did see was the core group, the people that came the most consistently, they took ownership. They started gathering each other’s phone numbers. If there was anything that happened – if, for instance, one of the members’ siblings had passed or got sick, one or two members would get a card and have everyone sign it, collect the love offering. After the research study, they felt comfortable to do that.’ (music professional) • ‘I think it’s that sense of belonging to, to a larger group, they’ve made friendships, again, it makes them feel empowered, they feel active, you know, they have a sense of belonging.’ (administrator) ORGANIZATIONAL/STRUCTURAL Senior center involvement and structure • Appreciate strong senior center involvement • Appreciate open door participation policy • Like snack break • Availability of funding • Convenient schedule • Strong working relationship between community partners • ‘We thank [the senior center] for giving us some, some snacks, food, something. [The senior center] supports us. So, we’re very happy with that’ (trial participant) • ‘I think that one nice thing that we see is, the choir members do feel an affection for the senior center. They appreciate the environment.’ (administrator) • ‘I believe we [music professionals and senior centers] have a good relationship. We’re in constant communication. If they need me to do something, our staff to do something, as far as getting the choir out in the community, and scheduling rides. Just being in contact with each other. I believe the relationship is good.’ (administrator) Weekly session content delivery, organization and structure • Effective content delivery • Clear organization of weekly session • Appreciate program’s summer break • ‘And with great teachers, because we have very good teachers, they direct us well, they explain each thing to us, if we’re doing well, if we’re not getting the tone. They always are careful that we bring out our voice and I just love that.’ (trial participant) • ‘I need the summer break because I have a medical emergency and that means I drop out during the whole season if I don’t have the summer break. The summer break allows me to do something personal.’ (trial participant) Open in a new tab Intrapersonal Level Emotional wellbeing and positive emotions strongly facilitated sustainment. Program participants expressed enthusiasm for the program, including comments like, ‘The act of being in the choir, music feeds the soul as they say, but aside from that, it relaxes you. And aside from that, it transports you to wonderful memories. It makes you happy.’ Positive emotions felt by program participants included: overall enjoyment of the program and the singing, a strong sense of wellbeing, and enjoyment of specific aspects of participation, such as visibility, connections with the past, enjoyment of learning, and physical exercises. Administrators similarly reflected on the extent of positive emotions, saying, for example, ‘Well, the fact that the choir members feel good about it helps us feel good here.’ Interpersonal/Relationship Level Across the focus groups, participants reported that social connection, belonging, and social support supported ongoing participation in the choirs. As one participant explained, ‘I think it’s that sense of belonging to a larger group. They’ve made friendships, again. It makes them feel empowered. They feel active, you know, they have a sense of belonging…and so they come, they’re anxious to come together to practice, to share, and now they’ve become friends.’ Both the music professionals and administrators commented on the emergence of friendships within the program, including participants who continued to meet during the breaks or to send cards to fellow choir members during an illness. In addition to relationships among participants, relationships developed between the participants and music professionals. Program participants described deep admiration for the music professionals, observing that ‘because we have very good teachers, they direct us well, they explain each thing to us, if we’re doing well, if we’re not getting the tone. They always are careful that we bring out our voice and I just love that.’ The music professionals similarly highlighted the importance of relationships. ‘What I’ve seen in the choirs, in general, is that that relationship between choir director and participant, and the creation of a social fabric within the group, is very important. Because that sense of community is part of what helps people to stay connected. So, it’s not an isolated activity. In fact, it brings people together. And that’s what helps make it fun and helps people to continue.’ Participants identified strong relationships between the senior center directors and the music center director as key facilitators to sustainment. An administrator summarized that ‘on both sides of the partnership, we know we have happy people, which is how you know you’re having some success.’ Organizational/Structural Level Organizational factors related to the structure, format, and scheduling of the weekly sessions emerged as a primary facilitator. Administrators and participants singled out the professionalism of the music professionals as critical to sustainment. Administrators described the music professionals as ‘very patient, but also clear and firm. And I think the people follow their lead. I think you have to have that, to produce results.’ Professionalism included both the technical aspects of leading the weekly sessions, and the overall organizational skills needed to prepare the group for performances. As a participant explained, ‘The schedules that the teachers gave us were extremely well organized, very well done. It had the whole year, with the vacations, when we were out, when we would go in.’ Beyond scheduling, music professionals explained how the high quality and consistent delivery of the program content facilitated sustainment. For example, music professionals spoke in detail about the importance of developing arrangements appropriate to the vocal ranges of older adults. The sustainment phase provided opportunities to further refine the curriculum: ‘The curriculum of the choir sessions got stronger, with a more codified approach to customizing these choir sessions, which really came out of a community development model or a community arts model.’ The sustainment period provided a time in which administrators and music professionals ‘learned more about how to deliver a choir program, specifically for older adults.’ Organizational involvement emerged as an understated but critical aspect of sustainment. The involvement and support of senior center staff supported sustainment through scheduling, reserving rooms, and providing space for weekly sessions. Strong senior center involvement, however, did more than make sustainment possible; it ensured the sustainment of the program. As a music professional explained, ‘When the centers took over, they [the senior center administrators] pretty much nursed us through the transition.’ The music professionals and administrators also described the importance of strong, supportive relationships at the organizational level. One administrator acknowledged this saying, ‘I think that one nice thing that we see is, the choir members do feel an affection for the senior center. They appreciate the environment.’ Another administrator explained that organizational-level relationships are important ‘because one organization cannot do it by themselves. It takes a couple of organizations getting together to make sure that these things happen, so we all put a little piece in the pot, and it works. I love it.’ Barriers Although we found fewer barriers than facilitators in this sustained program, barriers nonetheless occurred across intrapersonal, interpersonal, and structural levels. The reasons for discontinuation did not reach the level of thematic saturation. Intrapersonal Level Health issues emerged as a primary reason for participants to decrease attendance or to drop out entirely during the sustainment phase. These included serious life events such as cancer, chronic illness management requiring regular medical appointments, and intercurrent illnesses. Seasonal infections impacted attendance enough that the administrators noticed. As one administrator observed, ‘By the holidays it [attendance] has kind of drizzled down a little bit, and then like I said, the weather, and you know, them being a little under the weather.’ Interpersonal Level Participants described negative social interactions, although with less frequency than the positive interactions listed above. A few participants described interruptions by other participants during weekly sessions, but only one program participant described having insufficient opportunities for social interaction. Several participants expressed frustration with the skills of new people who joined the choirs during the sustainment period. In one site, a music professional reported that ‘at least the group… absorbed the newcomers,’ but then qualified the statement, noting that there ‘was a bit of friction with the newer people who stayed, when it opened up to the community.’ Competing family obligations created barriers to attending sessions, and sometimes led to discontinuing participation in the program. When one participant observed that ‘a few of our seniors, they had still caregiving positions, or taking care of grandbabies,’ another echoed, ‘taking care of grandbabies,’ following which the first speaker continued, ‘great grandbabies – great-great-grandbabies.’ Participants described in detail their need to help adult children as well as the next generations, prioritizing familial relationships over those created through participation in the program, while expressing regret that the familial relationships interfered with sustained participation. Organizational/Structural Level Participants struggled with transportation to the senior centers, located in a city known for poor accessibility. A participant explained his complex situation as follows: ‘I don’t have easy access to a car, even though I have one. My daughter has a nanny, and she gets the car. And I could easily call a cab…. But I just hate spending money when I don’t really have to. So, if I can walk someplace, it’s great. But, at night, in the dark, in the wintertime, I don’t want to be walking alone in the street, to and from the bus stop.’ Several participants and music professionals identified limited parking as a barrier to timely arrival for rehearsal, summed up most succinctly by a music professional as ‘The parking, just the parking.’ Programming and issues related to weekly scheduling sometimes undermined relationships or created barriers to participation. Although most music professionals described support from the senior centers, in one case, the transition impacted communication after the trial ended. As this transition was taking place, the music professional noted the critical nature of the coordinator in sustainment ‘Easier, would be to have definitely a coordinator, someone that’s not a director, not an accompanist… Otherwise it’s just – it’s too much for one or two persons to do.’ Additionally, several participants identified changes to rehearsal time as a critical obstacle to continuation. Others disliked a summer break that had been added to conform to the long-standing music center schedule. These issues created only minor friction and were reported infrequently. Site-specific issues included both modifiable and unmodifiable barriers. The clearest example of ongoing attempts to reduce modifiable barriers involved issues of noise that were ameliorated, but not entirely fixed, by a change in seating rearrangements: ‘So everything – that has all improved in the extension. Now if we could just get rid of the fans, things would be great. Super loud fans.’ In contrast to modifiable seating arrangement issues, the size and availability of the rooms created barriers to participation. In one case, the move to a smaller room caused frustration for several participants. The transition from academic to senior center program management impacted music professionals and administrators, even though participants overwhelmingly described the management transition as positive. In one case a music professional identified that one senior center had ‘a very difficult time at having site retention [e.g., attendance and recruitment]. I don’t know why.’ Another music professional described a specific transitional issue, the need for water (which had been provided during the trial by the research staff) during the social break in the middle of the rehearsals. The music professional said that initially, ‘I felt the pulling away of the support of [the university] around the food,’ but that, ultimately the issue was resolved through support of the senior center. Administrators identified funding as the ultimate barrier to sustainment. In contrast to music professionals and participants, all administrators identified funding as the most important factor underpinning sustainment of the choirs, as with any other community-based program. One administrator said, ‘what happens over and over again, time and time again, is that there’s funding that comes down for programs that are good concepts. People get behind them, they organize them and all that, and they’re great for a while, and then the funding dries up. And then, there’s no more programs.’ Every administrator expressed the desire to support the programs but noted that they would require additional funding to do so. As one summarized, ‘It all comes down to resources because we have the framework.’ Conceptual framework for community choir program sustainment Taken together, a new conceptual framework for sustainment of the choir program emerged, reflecting themes at the intrapersonal, intrapersonal, and organizational levels. See Figure 1 where these themes are presented by two broad categories of facilitators and barriers with subgroupings. DISCUSSION This study identified key facilitators and barriers to the sustainment of an evidence-based community choir program developed to promote health among diverse older adults. On an intrapersonal level, experiencing positive emotions and well-being were facilitators, while health issues created barriers. Interpersonal-level relationships and social interactions either facilitated or impeded sustainment, depending on whether the interactions were positive or negative. Organizational structures and processes also functioned as either facilitators or barriers, with high-quality program content as a facilitator, and transportation and funding as barriers. Taken together, these findings offer insights into the key factors that help sustain a community-based arts program that is designed to promote health for older adults. The involvement of diverse older adults and perspectives from choir participants, music professionals and administrators strengthened the findings, leading to a conceptual framework that functions as mid-level theory in the design or dissemination of community choir programs. The observation that positive emotions and a deep sense of well-being facilitate participation in community choirs supports the many studies that document improved well-being as a benefit of group singing for older adults ( Clift et al. 2010a ; Clift et al. 2010b ; Li and Southcott 2012 ; Livesey et al. 2012 ). But our study found that music professionals delivering the intervention and senior center administrators also reported positive emotions related to the choir program. While a few studies have documented the benefit of music programs on both patients and bystander staff in clinical settings ( Ando 2017 ; Shibazaki and Marshall 2017 ), our study highlights how such positive emotions influence the senior centers’ commitment to sustaining the program. Like other studies with older adults ( Bethancourt et al. 2014 ), health issues, and family obligations interfered with continued participation in the choir program. On the interpersonal level, all groups identified relationships as essential to sustainment of the choir program. These findings corroborate other studies that found continued engagement with group singing depends upon social relationships ( Lamont et al. 2018 ) and social connections ( Joseph and Southcott 2018 ; Lee et al. 2016 ). Our findings also identify the critical nature of relationships between music professionals and senior center administrators. This study demonstrates that, when community partners build supportive, appreciative relationships, those organizational relationships support program sustainment. On the organizational/structural level, administrator appreciation of and commitment to the program served as a powerful facilitator, similar to other studies demonstrating the importance of local leadership support in the sustainment of community-based choirs ( Chuang et al. 2011 ; Dattalo et al. 2017 ). Our study provides an example of how external partnerships can be central to program sustainment ( Dattalo et al. 2017 ). As is widely acknowledged in the implementation science literature ( Proctor et al. 2015 ), funding remained the rate-limiting step for sustainment by all senior center administrators because they wanted to continue the program past the sustainment period. Ongoing program sustainment depends on the fit between the intervention and the mission of the organization ( Hartzler et al. 2016 ; Stumbo et al. 2017 ). The COV trial design incorporated organizational fit, including music and language tailored to each senior center (for example using Spanish language music at centers serving a Spanish-speaking older adults). Organizational fit also supported sustainment following trial completion. The ongoing sustainment of the choir program suggests that the barriers were outweighed by the facilitators. Since completion of the sustainment evaluation, all twelve sites have been sustained, and the intervention has been disseminated to three new community centers. In addition, the music center began piloting two Cantonese language choirs in collaboration with affordable senior housing sites. Activities transitioned to virtual platforms during the COVID-19 pandemic, but all fifteen choirs returned to in-person rehearsals. Limitations The study duration limits the generalizability of the findings. The sustainment period under investigation lasted only six months. Evaluation of facilitators and barriers over a longer timeframe would strengthen the findings. Future research should follow sustainment over longer periods of time. Although the study queried multiple participants groups, the sample sizes for the administrators and those who discontinued participation were relatively small. Further research is needed to determine whether these findings pertain to other community music settings. Implications Increasingly we recognize the potential for the arts to promote a ‘culture of health’ ( Sonke et al. 2021 ). This study demonstrates how a music-based intervention was sustained through involvement of multiple community organizational partners who had access to intervention sites and expertise, and a population who benefitted from the intervention. This study has several implications for sustainment of arts-engaged studies to promote health among diverse older adults. First , our study highlights the importance of considering multi-level factors of sustainment when designing a community-based intervention, such as a community choir. We recommend assessing intrapersonal, interpersonal, and organizational factors when evaluating the sustainment of a new program. Second , emotional wellbeing and positive emotions facilitate both sustainment and lasting individual behavior change. This study suggests that choir programs have strong potential for sustainment so long as the administrators and music professionals, as well as the participants, receive positive emotional benefit from the programs. Third , we found that interprofessional collaboration strengthens sustainment, particularly when collaborations involve organizations with complementary expertise, including professional artists. In our study, the Department of Disability and Aging Services provided access to the population of interest as well as the infrastructure needed to host the intervention. As in other programs that embedded artists into the research team ( Springs and Baruch 2021 ), the community music center provided a cadre of experienced professionals capable of delivering the intervention and disseminating the intervention to other sites. Based on this finding, we encourage community music settings to consider new partnerships with organizations outside of their area of expertise, such as between music and aging services organizations. Fourth , our study highlights the importance of situating community-engaged research in the community of interest. By conducting the large cluster-randomized trial in existing Area on Aging-supported senior centers, the intervention was embedded in the community from its inception, one step closer to full-scale implementation. In clinical practice, sustainment is supported by attention to micro, meso, and macro levels of engagement, by partnerships that bring together complementary services, and by a focus from the outset on community involvement. Table 3. Barriers to sustaining a choir intervention identified by administrators, music professionals and trial participants INTRAPERSONAL LEVEL Theme Core Features Illustrative Quotes Health issues • Poor health • Frequent medical appointments • ‘When you’re dealing with seniors, you’re dealing with doctors’ appointments all throughout the week. You’re dealing with arthritis. You’re dealing with various cornucopia of illnesses and things.’ (trial participant) INTERPERSONAL LEVEL Negative social interactions • Negative social interactions • Feeling lack of group cohesion or commitment • ‘There are always new people that don’t know the songs and there are always people that were at the choir and that for x or y reason they leave.’ (trial participant) • ‘I liked it better when we didn’t have people dropping in and out whenever they felt like it.’ (trial participant) Familial obligations • Caregiving responsibilities • Family obligations • ‘My niece had just arrived from El Salvador, and I had to go with her to look for housing… then a friend from the church I go to got sick and didn’t have anyone to look after her.’ (trial participant) • ‘People travel, have family commitments. They’re adults. It’s hard.’ (administrator) ORGANIZATIONAL/STRUCTURAL LEVEL Transportation and access • Difficulty with transportation and parking • ‘I used to come on two buses…. I would be traveling like for two hours to get here.’ (music professional) • ‘I noticed that we lost a few people at [the senior center] because paratransit. They’d never come on time. (music professional) Weekly programming and schedule • Unclear communication during transitions • Rehearsal schedule issues • Found the summer break disruptive • ‘I don’t know what the schedule is. I wanted to call someone and say, ‘When’s the next rehearsal or when’s the next performance?’ I have nobody to call.’ (trial participant) • ‘Unfortunately, the schedule didn’t suit me very well because sometimes I had my appointments.’ (trial participant referring to medical management of chronic illnesses) • ‘[re: summer break] It breaks the continuity for people who are stuck in town for the summer.’ (music professional) Space and communication • Inadequate rehearsal space (noisy, small) • Inadequate coordination, communication • ‘We tried to accommodate a choir performance here a couple of times, and we just can’t fit the size of our choir into our space.’ (administrator) • ‘In one senior center case, there was a last-minute cancellation, and the communication was not executed well. So, we had to really have a conversation and a way to ensure that that wouldn’t happen again.’ (music professional) Transition of program from academic to senior center • Feelings that partnership was unequal • Changes in rehearsal structure • ‘I think that the choir is really great. I would just want a little more control over things next time out. I mean, we’re hosting… we’re called a partner, but we really haven’t been much of a partner.’ (administrator) • [on changing the snack break]: ‘And everybody just had different feelings. Like, some people wanted to do it, some people didn’t, and then some people were intimidated.’ (music professional) Funding • Funding is challenging but critical • ‘Believe it or not, activities and senior center things are not as easy to write grants for, in the foundation world.’ (administrator) Open in a new tab Acknowledgements. We would like to acknowledge our many community partners: the San Francisco Community Music Center, the San Francisco Department of Disability and Aging Services, and the participating senior centers: 30th Street Senior Center, Bayview Opera House, Bernal Heights Neighborhood Center, Centro Latino de San Francisco, Dr. George W. Davis Senior Center, Golden Gate Senior Services - Castro Senior Center, Golden Gate Senior Services - Richmond Senior Center, IT Bookman Community Center, Mission Neighborhood Center, OMI Senior Center San Francisco Senior Center - Aquatic Park, Veterans Equity Center, and Western Addition Senior Center. We are particularly indebted to the following members of these organizations: Luisa Antonio, Maria Bermudez, Robin Bill, Gloria Bonilla, Sonia Caltvedt, Patty Clement-Cihak, Eduardo Corzo, Maestro Curtis, Nola Curtis, Gina Dacus, Richard Daquioag, Cathy Davis, Helen Dilworth, Sue Horst, Patrick Larkin, Judy Lee, Linda Murley, Barbara Ockel, Leon Palad, Jennifer Peringer, Billy Philadelphia, Martha Rodriguez-Salazar, Kristin Rosboro, Valorie Villela, Beth Wilmurt, and Jackie Wright. We would like to thank all of the UCSF research staff who helped with recruitment and collecting data: Maria Cora, Rachel Freyre, Ariana Paniagua, Dana Pounds, Merima Ribic, Jasmine Santoyo-Olsson, and Ofelia Villero. We thank Maryam Khan for her assistance with manuscript preparation. The study was made possible by these partnerships. This work was supported by the National Institute on Aging at the National Institutes of Health (R01AG042526 and AG042526–02S1 to J. K. J., P30AG15272 to A. M. N. and J. K. J. and A. L. S., and K23AG062613 and RF1AG082292–01A1 to T. A. A.); and the National Center for Advancing Translational Sciences at the National Institutes of Health (UL1 TR000004). Dr. Nápoles’ time was supported in part by the Division of Intramural Research of the National Institute on Minority Health and Health Disparities. The contents and views in this manuscript are those of the authors and should not be construed to represent the views of the National Institutes of Health, the funding sources, or the organizations with which they are affiliated. Footnotes ClinicalTrials.gov registration: The original Community of Voices trial was registered on January 9, 2013, NCT01869179 . Contributor Information Theresa A. Allison, Division of Geriatrics, Department of Medicine; Department of Family & Community Medicine at the University of California, San Francisco, 490 Illinois St., Box 1265, 94143 CA, USA.. Julene K. Johnson, Institute for Health & Aging at the University of California, San Francisco, CA, USA.. Anita L. Stewart, Institute for Health & Aging at the University of California, San Francisco, CA, USA.. Elena Portacolone, Institute for Health & Aging at the University of California, San Francisco, CA, USA.. Michaela Simpson, Principal Consultant and Executive Coach at AAIR Consulting, USA. Shireen McSpadden, San Francisco Department of Homelessness and Supportive Housing in San Francisco, CA, USA.. Sylvia Sherman, San Francisco Community Music Center in San Francisco, CA, USA.. Anna M. Nápoles, Division of Intramural Research at the National Institute of Minority Health and Health Disparities in Bethesda, MD, USA.. REFERENCES Allison TA, Nápoles AM, Johnson JK, Stewart AL, Rodriguez-Salazar M, Peringer J, Sherman S, Ortez-Alfaro J, Villero O and Portacolone E. 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