Day centres for older people - attender characteristics, access routes and outcomes of regular attendance: findings of exploratory mixed methods case study research

The first author conducted individual face-to-face semi-structured interviews, with prompts, between September 2015 and December 2016. Qualitative interviews followed a thematic guide which comprised questions concerning what a ‘usual week’ looked like; why, and how, they started attending the day centre and any benefits they had experienced, including whether attending the day centre added anything to their life they felt they would not otherwise have experienced (i.e. something unique) (see Additional File 1 for interview questions). Outcomes data were also gathered by using the Adult Social Care Outcomes Toolkit (ASCOT INT4) [33] validated instrument. Socio-demographic data were then collected, with participants’ health, wellbeing and social networks characteristics gathered using validated tools: the Edmonton Frail Scale (EFS), the Short Warwick-Edinburgh Mental Wellbeing Scale (SWEMWBS) and the Practitioner Assessment of Network Type (PANT). Tool use was registered and the PANT training pack [34] obtained.

The qualitative parts of interviews took place in participants’ homes (n = 16) or in private spaces at day centres (e.g. meeting rooms, vacant hairdressing salon) (n = 7) and lasted, on average, 42 min. One attender’s support worker was present at her interview. Qualitative interviews were recorded and transcribed externally. Participants were not requested to comment on transcripts.

Raw data for PANT and ASCOT were entered into two specially-designed tools: an SPSS syntax file computed PANT network type [45] and an ASCOT Microsoft Excel data entry tool (v2.9) computed unweighted and weighted scores [46]. EFS and SWEMWBS scores were calculated manually using guidance. After removing identifiers, qualitative data were entered into NVIVO (version 11) [47], a Computer-Assisted Qualitative Data Analysis Software. Individuals’ attributes and validated scale scores were assigned to participants’ NVIVO records to enable interrogation of data by day centre and participant characteristics [48].

Attenders’ usual weeks were recorded on ‘maps of the week’ which were entered into MS Excel, colour-coded by type of activity, then manually analysed for descriptive purposes. Maps were not analysed for patterns due to small numbers.

Analysis of qualitative data was inductive, iterative and thematic [49]. The first author undertook coding and analysis, supported by team meetings with the second and third authors in which data saturation and analysis were discussed and verified. Familiarisation with data involved listening to audio recordings, correcting and anonymising transcripts while concurrently noting down codes. These codes were grouped into themes and sub-themes, under each research question, and entered into NVIVO. Iterative lumper coding [48] was then undertaken. This included reviewing and re-reviewing coded data, adding, amending, merging and deleting codes as necessary (see Additional File 2 for the coding frame). Text was simultaneously coded where relevant to more than one code [50]. Qualitative data was coded after calculating ASCOT scores, but ASCOT domains did not influence decisions about qualitative outcome themes. Cross-case analyses of individual participant group data were undertaken; themes were identified across the different day centres and participant sub-groups [51].

Mixed methods data presentation is potentially problematic, affected, for example, by word limits [52, 53]. Given that qualitative and quantitative findings about outcomes are complementary and triangulate with each other, these are presented together. Pseudonyms are used in this paper.

A Study Advisory Group supported the study and met three times. Members, all with experience of day centres, were consulted about study materials [51] and interpretation of findings. A separate Advisory Group that acts as a critical friend to the researcher’s host Unit also provided feedback on study materials and the first author’s interpretation of findings at two of its meetings. Case study site representatives (six local authority staff responsible for service commissioning or referral and 2 day centre assistant/managers) attending a workshop were also consulted about these.

Most attender participants were widowed, divorced or single, and two-thirds lived alone (see Table 2). Their average age was 83.3 years (range 68–101 years), three-quarters were women and one-quarter were educated beyond secondary school. All identified as heterosexual and as not having changed gender. Three-quarters held religious beliefs. Ethnic minority groups accounted for a quarter of the total number, but were only in two of the four centres, reflecting local demography. Indicative of relative deprivation, two-thirds lived in rented homes while just under one-third were owner-occupiers. Although similar numbers received means-tested benefits as those who did not, almost two-thirds self-funded their centre attendance (n = 14). Self-funders included people whose financial assessment, after being assessed as eligible for services, required them to pay for themselves (n = 3) and people not mentioning any assessment (n = 11). Others reported being fully local authority (LA) (means-tested) funded (n = 6), sharing payment with the LA (n = 1) or being unaware of who paid (n = 2).

All reported having health conditions or disabilities that impacted greatly on their life, with half reporting at least two forms of these. All, except two, had some levels of Apparent Vulnerability or frailty when measuring general health status with the EFS. Levels of health conditions were under-reported by attenders; some did not report certain health conditions in the interview that the researcher was later made aware of in family carer interviews, by centre staff during discussions or by the attenders themselves, for example, that one participant had dementia and another had terminal cancer and had survived a stroke. Three-quarters of attenders had average or good wellbeing as measured by the SWEMWBS.

Two-thirds were at greater risk of isolation, depression, loneliness and other mental ill-health because of their PANT social network type. Only one-third had a stronger social network type.

Apart from marital status and living arrangements, the profiles of attenders varied between centres. DCLA was most age-diverse. DCHA was the least gender diverse. People who could be classified as having Severe Frailty were highest in number at DCHA, despite its younger profile; levels of Apparent Vulnerability were matched across the remaining three centres. DCHA and DCLA attenders had the highest levels of mobility difficulties and more long-standing health conditions, while deafness was most prevalent at DCV1 and DCV2. Owner-occupiers prevailed at DCV1 and DCV2 and renters at DCLA and DCHA.

Circumstances when starting to attend a day centre mainly related to loss and a desire for something different in life. These were classified into six themes: 1) social isolation (mainly due to bereavement or having lost existing social networks), 2) loss of mobility (declining physical health, sometimes suddenly, or no longer driving their car), 3) activity-related (stopping attending another day centre or club due to closure or changed entry criteria, stopping volunteering or retirement, wanting ‘something to do’ for stimulation or a change, or ‘somewhere to go’), 4) mental health or emotional problems (feeling depressed or very low, lonely, having lost confidence or reporting a diagnosed anxiety disorder), 5) feeling ‘stuck’ at home or not getting out enough, and 6) carer-related (recognising the need for family to have a break, feeling isolated as a spousal carer, accompanying cared-for to a day centre).

Principal motivations for starting to attend a day centre reflected these circumstances in that participants had wanted social contact, something to do, to get out of their home or to improve their mental health. Additional motivations were to meet goals for better physical health through exercise and meals, to improve mental health and to accompany a partner for whom the participant provided care. Although length of attendance ranged from a few months to decades, these motivations are likely to reflect attenders’ marital status, living arrangements and health. Behind one principal motivation for attendance were different clusters of circumstances which interacted and overlapped, often triggered by an event or a series of interlinked events. Table 3 illustrates the complexity of two attenders’ circumstances when they started thinking about attending a day centre.

Attenders had accessed their day centres through different routes. Almost half (n = 11) reported starting attendance following contact with social care or health professionals (social workers = 7, district nurse = 1, hospital rehabilitation service = 1); the tenth was unsure of the professional’s identity and the eleventh had spoken to a GP, then a social worker. Six had found out about centres from family (n = 4), from its manager who was an acquaintance (n = 1), and by another attender’s recommendation (n = 1). Some paths were less straightforward. Two had been told by a local councillor (politician) and a GP, and had subsequently had social work involvement. The former received a social worker assessment after starting to attend. The latter, after a ‘bad’ first experience at another centre she had been referred to by her GP, had asked her family to find an alternative centre. In the event, the LA-provided home care worker had linked them to a social worker who arranged the current centre place. Two had proactively approached social workers about centres. Four participants were unsure how they found out about their centres.

Average weekly centre attendance was for 1.8 days. Overall, just over half (n = 13, 56%) attended once weekly, one-third (n = 8, 35%) for two (n = 4) or three (n = 4) days and two (9%) for four or 5 days a week. It was the only weekly outing for 5 participants (22%). Participants had been attending their centres for anything between 6 months and 32 years.

Attenders’ regular activities outside their day centres varied, but most seldom went outside the home. Table 4 provides examples of six attenders’ typical weeks at the time of data collection. Additional File 3 shows examples of two usual weeks.

The following paragraphs provide an overview of the whole sample’s contexts.

In addition to their day centre days, the number of days attenders left their homes each week ranged from none to three (average 1.3 days), plus monthly outings. Three-quarters saw family at least once weekly. While two saw family fortnightly or monthly, three saw family irregularly, not at all or had no family. A handful reported at least twice weekly telephone conversations with adult children. Two-thirds had no regular unstructured non-familial social events, such as seeing friends. Those who met with friends relied on friends or family providing transport. Two-thirds had no regular structured non-familial social events. The one-third who did either also attended another day centre, a social club or bingo session weekly, or went on monthly outings or ‘tea parties’ run by the day centre provider or a national charity. Two were enrolled at a skills centre for the visually-impaired. One-third undertook weekly or fortnightly food shopping outings, mostly with support from family, friends, dial-a-ride (mobility service for disabled people) or a voluntary organisation’s support worker. Two attended church regularly, and two received weekly or monthly Holy Communion at home from a visiting priest. One visited a gym weekly.

Two-thirds managed their personal care without paid support, including a handful who had weekly or monthly hairdresser home visits but no other personal care help. Most of the one-third who had personal care received this every day. Just over half of attenders had no paid home care. One-third received once weekly help with housework from home care workers, cleaners or neighbours and, for two, this was daily. Two attenders’ family members undertook housework for them. A handful of attenders had regular medical appointments.

Some participants provided further context about their lives more broadly and their characters. Home maintenance and self-care had become, or was becoming, increasingly effortful for many. While some talked about how independent they had always been, one was still mourning her recent loss of independence. There was a sense of resignation to the situations in which they found themselves, in that some had adjusted to these. A small number mentioned how helpful neighbours were. While some considered themselves to be ‘joiners’ of activities, others said they were not.

Many valued having social contact which contrasted with usually being alone:

‘It’s like, if somebody is married and they are not happy in their marriage, they look for a way out. Well I am not happy being at home on my own and so that’s my way out.’ (Tina).

‘I get conversation instead of talking to myself… And I’m mixing with human beings.’ (Nellie).

Attenders enjoyed doing things in company:

‘We sit together and play together, like cards or any other games or … the memory class, and of course, the exercise.’ (Mariana).

The group environment enabled the opportunity for laughter or fun. There was a good deal of banter in some centres, sometimes group-based, or one-to-one between attenders or one-to-one with staff or volunteers:

‘I think that’s one of the things that I like about it. You have heard [female attender] and Iroarwith laughter before now, haven’t you? …I can make her laugh so easily. I love it. I know when she laughed her head off 1 day when one of the questions was what did Richard II lose in the bushes and I called out, “his virginity.” She said, “for God’s sake.” I don’t know. I just like laughing anyhow.’ (Kaye  - emphasis underlined and emboldened).

Participants highlighted how they looked forward to regular contact with day centre friends:

‘You look forward to seeing friends again, you know.’ (Elizabeth).

There was mostly no contact between attenders outside centres on non-attendance days; some considered it unnecessary as they saw each other regularly at centres. For others, co-attenders were simply acquaintances whom they saw regularly at centres:

‘They are just Friday people.‘ (Thomasina)

Around half of the participants mentioned that increasing proportions of cognitively impaired attenders, either due to dementia or a learning disability, impacted negatively on levels and quality of connection possible. Although one attender referred to a co-attender living with dementia as ‘a sweet little thing’ (Jenny) and was impressed how well she joined in with games, she considered that the latter’s poor memory had hindered the development of friendship. Another reported that she was not able to build a relationship with some of her co-attenders was because ‘you are talking to them and they are just looking at you’ (Olive).

A small number also commented upon conversational faux pas and what they described as ‘annoying’ or disruptive behaviours, such as constant rocking, swearing or making unintelligible burbling noises which ‘would be frightening to some people’ (Francine) or showing aggression:

‘Some are a little bit annoying (…) One time she started smacking people with her stick’ (Elizabeth)

Two of the five male participants expressed a preference for higher numbers of men since they maintained that men and women chat about different things.

The second ASCOT domain in which centre attendance made a significant impact (p-value < 0.001, 99% CI) on participants as a group was that of ‘occupation’, or meaningful activity. This was also a unique contribution centre attendance made to participants’ lives. Attendance was an activity which meant doing something instead of doing nothing at home:

‘…just quite different to what you are doing at home’ (Kaye).

‘I just sit here from when I get up to the time I go to bed.’ (Ruby).

Having regular day centre days gave some attenders purpose within their week:

‘…something to wake up in the morning to do’ (Nellie).

It also gave them something to think about, something also benefiting family relationships:

‘It’s enriched my life (…) Well I suppose it gives me an interest, doesn’t it? It’s a big interest. And it gives me something other to talk about and to think about.’ (Jenny).

Attenders enjoyed being occupied or they enjoyed specific activities they did at their centres. In most centres, activities were varied although not all attenders’ (mainly sensory impairment) needs were always catered for. Joining in these was said to be enjoyable, stimulating, and, in some cases, satisfying:

‘I like to be doing something.’ (Lenny).

‘Ienjoythe art. Ienjoythe singing. Iloveto sing. I don’t mind whether there is one or two singing.’ (Wilma).

Activities cited as particularly enjoyable were art, craft, cooking, computer classes, charades, discussion groups, memory exercises, raffle/tombola, singing and music sessions, sweet shop, trips out, poetry reading, food tasting, table games, listening to background music, reading the paper, sitting in the garden, visiting speakers, therapy dog visits and performances by folk and belly dancers. Quizzes, bingo, card games, and exercise provoked mixed reactions.

A qualitative theme, being enabled to ‘get out of’ their home, another of centre attendance’s unique contributions to their attenders’ lives, was framed in two ways.

Firstly, it was tantamount to escaping from their home in which they felt they were ‘stuck’, or even imprisoned:

‘It’s like being a prisoner in my house now … That’s how it feels now and again, because you don’tseenobody there now.’ (Olive).

Others did not feel imprisoned and were more concerned with having a change of scene:

‘Well, it gets me out of my four walls for a start.’ (Nellie).

‘Well, it gets meoutonce a week, which I wouldn’t do otherwise.’ (Ruby).

Secondly, the day centre was somewhere to go when you had ‘nowhere else to go’ (Nellie). It was also a place to go and gather; saying hello to an acquaintance in passing was ‘not the same as actually going to a function with the people’ (Bob).

There was much stoicism and acceptance of current situations in which some attenders said they would never have imagined themselves. For some, centres appeared to be a good substitute for what they may have preferred to do had their abilities been different:

‘I used to like going here, there and everywhere. Now I can’tdothat so I don’t mind coming here…I am happy with it…It gives me a chance to come out. (…) if I could go round and do things that I would like to do and so I’d go shopping and maybe walk around.’ (Dorothy).

Participants reported improved mental wellbeing and health as a further unique contribution of attending their centres. Not only did participants enjoy certain aspects of what was provided by centres, but many enjoyed the whole experience.

‘Oh, Ilovegoing. Oh yes. Yes.’ (Kenneth).

‘Well it’s my life. It’s all I’ve got. It literallyismy life.’ (Nellie).

They gained a sense of purpose, felt like they belonged, felt in control or more independent and ‘felt better’ generally. The ASCOT domain of control, the third highest scoring, falls within this theme.

They had something to look forward to that they enjoyed – and some found fun. Enjoyment was derived from social contact, the activities, getting out of the house, feelings of freedom, the meals and additional extras linked with a centre’s location, transport to it and to attending a centre as an activity in itself. Attendance also counteracted boredom and life’s monotony, helped participants gain a better perspective of their own situations and feel more relaxed, less lonely or depressed or more confident, mentally stimulated or energised. Centres were also referred to as a ‘lifeline’.

‘I just enjoy it there. Because I am alone. I am on myown. Sometimes I feelsad. I feel better when I go to the centre I have a little bit of talking, conversation and some socialising. (…) I enjoy it very much. To tell you the truth, before Monday I had been waiting for Monday to come. (…) I feel happy and it helps my depression.’ (Miguel)

Furthermore, participants felt valued and respected as individuals which reflected centre staff’s and volunteers’ personalities, behaviour and their delivery of the service (see Theme 10). The ASCOT domain of dignity, the second highest scoring, falls within this theme.

A qualitative theme, practical support, information and access to other services were either provided as part of the day centre service, via occasional or regular visiting professionals, speakers or other centre visitors, or were other services offered by the day centre providers. Most mentioned were the supply of hearing aid batteries or maintenance, and useful talks. Other examples provided were lunch clubs, holidays, shopping trips, hairdressing, fingernail filing and painting, help with arranging health or other appointments, referrals to, for example, occupational therapy to get a shower installed at home, or to the local authority to get a personal falls alarm installed, help to claim taxi vouchers (discounted taxi fares) and visiting chiropodists or massage therapists or clothes-sellers. Benefits gained included, for instance, feeling safer or having peace of mind, enjoying trips out, saving or having more money:

‘Before that I was buying the batteries because… I could get them free from the hospital but I’d have to take a taxi to the hospital to get them. So I used to buy them from [pharmacist]. But [day centre manager] said “oh no, don’t buy them. We’ll give them to you.” … That’s another thing that’s been a great help. (…) I can clean part of it but I can’t take the things apart and clean it properly.’ (Francine).

Not only did Ruth feel more settled at her day centre after a group holiday with other attenders, which she accessed through the centre, but it also helped reduce her depression:

‘And then eventually heard about the holiday (…) Imademyself go and it did me the world of good because since then, mydarkside seems to have lifted. Although I’ve physically got all these problems, mentally I’m fine now, really.’ (Ruth).

Co-located facilities were a bonus. At one centre, the short, midweek religious service was attended by some participants. At another, the library was appreciated by a keen reader who also enjoyed occasional contact with babies at the mother and baby group, as was an advice service.

This theme comprised three parts.

First, attenders reported benefiting from informal health and wellbeing monitoring and follow-up undertaken by day centre personnel, such as being asked how they were or if something was the matter, which they appreciated. Staff, and volunteers, listened to attenders talk about continence or pain, for example, and, with attenders’ consent, spoke to named relatives about health concerns:

‘They come around asking “Are you alright? What’s the matter?”’ (Thomasina).

They also measured blood pressure, made GP appointments, reported safeguarding matters (e.g. about possible elder abuse) to the local authority and replaced a screw in one attender’s reading glasses.

Second, exercise was felt to help maintain mobility and alleviate depression:

Interviewer: ‘So what is it about being here that helps you feel less depressed?’ Denzel: ‘Well, I do exercise three times a week.’

Attenders felt they were more likely to exercise in a group than alone at home:

‘I think I quite enjoy it when there is people come and give us exercises and things, you know, make us to do things. (…) I think it’s good for us. (…) I can sit here all day and not move. [Laughs] I could move, but I think it’s good to make you do a few exercises. If you’re all doing it, you do it.’ (Ruby).

Third, some attenders felt physically safer and less vulnerable at centres compared with at home. ASCOT’s third highest scoring domain of gain, personal safety, although broader in scope, falls within this sub-theme. One attender spoke about feeling vulnerable at home after a doorstep incident with rogue traders, and another, suffering from vertigo, said:

‘Well, I come to the club when I not in hospital. You feel more safer. If I here and anything happened to me, they will call the ambulance.’ (Norma).

A theme emerging from quantitative data only, centre attendance was reported to make a difference to just under one-third of participants in this ASCOT domain, but the average gain score was very small.

Another theme emerging from quantitative data only, centre attendance was reported to make a difference to just under one-third of participants’ quality of life in the personal cleanliness and comfort ASCOT domain, but average gain was zero. However, while responding to the tool’s questions, two participants implied that attendance did impact positively on them: one commented that attendance affected how clean he felt since he bathed and wore his best shirt on attendance days and the other said she took care of her appearance as she knew men would be present.

Two of the day centres had bathing facilities (suitable for people with disabilities), but managers reported attenders using these only in emergencies.

While certain experiences contribute to the overall centre attending ‘experience’ (e.g. activities offered), others contribute towards ‘process outcomes’. Examples include feeling valued and respected, being treated as an individual, having a degree of control over the way a service is delivered, the extent to which a service fits with other support received and value for money [54]. Some of these outcomes (identified from both datasets) have already been alluded to, particularly under Theme 4, Improved mental wellbeing and health.

Overall, reported experiences and feelings about day centres indicated that attenders experienced mainly positive process outcomes. All planned to continue attending and would recommend their centre to friends, family or somebody in the same situation as themselves. Many considered their centre offered good value for money.

‘Yes, its good value for money.’ (Miguel)

Although a very small number of attenders reported mixed feelings on centre attendance mornings and making themselves get ready as they knew they would enjoy it once there, feelings of positivity were widespread, with many enjoying the whole experience, looking forward to or loving it.

‘I think it’s thebestthing they have done, [local authority], make this place (…). they do a wonderful job here. I don’t think I’d rather be anywhere else but here. I reallydoenjoy being here (…) I am glad I come.’ (Isobel).

‘All I can say is that, anyone who doesn’t go there is missing out on something. I like it there and I think it’s wonderful.’ (Kathleen).

Comments on centre personnel were overwhelmingly positive. The few criticisms related to attenders exhibiting unpleasant or disruptive behaviour not being dealt with, certain staff very occasionally being a bit domineering or lacking understanding of sight loss. In one centre, three attenders but were less enthusiastic about one staff member than others but did not ‘dislike’ her.

The ASCOT domains of dignity (personal sense of significance) and control, the second and third highest scoring, fall within this theme. It is likely that less positive feelings, a judgement that attendance may not have been such good value for money and, perhaps, fewer attenders planning to continue attending may be been more apparent had attenders not found themselves feeling valued, respected, treated as an individual or with a degree of control over service delivery (see Theme 4):

‘The staff of [day centre] are the salt of the earth. (…) They are always there tohelp. No matter what, they are always there, ready. Nothing to fault them for. They are very ordinary, very friendly and they arewonderful.’ (Tina)

This study provides new understandings of the circumstances behind people’s motivations to attend a day centre and of attenders’ lives, going beyond their socio-demographic details, and how they accessed centres. This paper reports individual contexts, in the form of short narratives and grouped experiences, which were previously largely unexplored, and which are useful for offering a richer context in which to situate attenders’ outcomes. Participants exhibited advanced age, declining health and mobility, sensory loss, bereavement and were retired, all of which are risk factors for social isolation [55], and their social network types put many at risk of mental ill-health [44]. Attenders’ profile places them within the National Institute for Health and Care Excellence’s (NICE) category of ‘vulnerable older people’ who are ‘most at risk of a decline in their independence and mental wellbeing’.(56:para 1.5.3). There was low awareness of the existence of day centres prior to attending one and acess to day centres had mostly been facilitated for attenders by social care or health professionals or family, but few by GPs.

This study also provides new understandings of what are ‘the outcomes that matter’ for cognitively intact older people attending day centres. Attendance enhanced quality of life, sometimes significantly, and made a unique contribution to their ‘vulnerable’ attenders’ lives [56] thus demonstrating their policy-relevance.

Day centres emerged as life-enriching gateways to companionship, activities, the outside world, practical support, information, other services, the community and enjoyment for people who had experienced loss, were socially isolated and unable to go out without support. They appear to promote elements of successful ageing, by enabling attendees to maintain social connections, compensate for mobility problems and social isolation, and optimising opportunities for company and chosen activities [57]. A major contribution to participants’ mental wellbeing was through centres supplying a source of enjoyment or fun which significantly contributes to wellbeing [58] with laughter having a positive psychophysiological impact [59].

People growing up after World War II are said to recognise welfare as a reassuring ‘safety-net’ (i.e. ref [60], page 59). Day centres were identified as providing attenders with two such ‘safety-net’ outcomes: monitoring attenders’ health and wellbeing, and providing practical support, information and facilitating access to other services. Thus, centres offered added value beyond the purposes for which they were commissioned or funded, beyond what may be assumed to be covered by a service aim of improving quality of life or supporting people to remain at home, and beyond what attenders may have wanted or expected, given their reasons for attending. These added value outcomes emphasise centres’ underlying nature of being long-term maintenance and monitoring services rather than services that deliver specified improvements after which people are discharged. Importance has been placed on single entry points to minimise people ‘falling through’ gaps between services [61].

Notably, outcomes were achieved despite three-quarters of participating attenders using centres for only one or 2 days a week (i.e. 4.5–12 h excluding travelling time), something perhaps attributable to the fact that many outcomes fall within the higher order categories of human need [62].

Attenders’ characteristics cannot be benchmarked against an existing dataset due to the lack of national data about English day centres. This study found attenders were people whose health and mobility had already declined; this decline was due to loss (e.g. of good health) or had resulted in loss (e.g. of social contact). This profile contrasts sharply with that of attenders in studies undertaken in the 1970s–80s, more of whom was younger and more active [63, 64]; during these decades, publicly-funded social care eligibility criteria covered people with low and moderate needs and more ‘low-level’ day centres operated [12, 65]. In the 2000s, increasing disability among English day centre and lunch club users was noted [66] and, in the 2005–17 literature, centres were reported to be mainly used by people whose health had begun to decline [11]. Further corroborating this finding was the exclusion from the present study of 41% of observed attenders due to dementia-related cognitive limitations. This proportion is double the 19% of publicly-funded day centre attenders with dementia reported in the 2013–14 annual survey of Councils with Adult Social Services Responsibilities [4]. This is also despite this present study including older people not referred by a LA or being funded to do so, and some participants reportedly having a diagnosis of dementia. This present study also indicates that generalist day centres – those without the identity of specific nationality or ethnicity-focussed provision – may be acceptable to people from black and minority ethnic backgrounds.

Day centres remain a gendered service. The literature has persistently failed to note the over-representation of women among attenders [67]. In this study, women accounted for three-quarters of participants (and attenders overall). Although women account for 60% of people in England aged 80 and older and 55% of people aged 68 and older [youngest study participant’s age] [68], morbidity rates are higher among older women than men. Also remaining unchanged is their attendance by widowed/single people and people living alone. Feeling the need to get out of the house for a change of environment was a motivation for attendance not identified in the recent literature [11].

This study reports attenders’ religious affiliation, sexual orientation and gender reassignment, three of the nine protected characteristics stated in the UK Equality Act 2010 which cannot be used to treat people unfairly (also age, marriage/civil partnership, disability, race, sex, and pregnancy or maternity) [69], characteristics that were, hitherto, absent from the literature [11, 67]. Such data are needed to enable day centres to consider matters concerning access to centres and to respond to the challenges of supporting different user groups [67].

Social participation related improvement was more widespread compared with the only other identified day centres study employing ASCOT [13], perhaps reflecting this present study’s older and less mobile participant profile and because the strongest effects of social activities are felt amongst those least physically active [70]. Day centres have not previously been conceived as gateways, as sources of enjoyment, or as offering added value. Only day centres in one Bahranian study aimed to provide ‘fun’ [71]. People have been reported to enjoy attending centres and to laugh there, but this has previously been conceived as contributing to overall life satisfaction [72, 73] rather than enjoyment being considered as an outcome in its own right. Enjoyment of activities has been conceived as contributing to whether attending has made a difference to people’s lives [74]. Findings confirmed two previous English studies reporting day centres’ high emphasis on process outcomes [75] and attenders’ high satisfaction with their relationships with day centre workers, workers’ behaviour and their work [13].

As part of the Adult Social Care Outcomes Framework (ASCOF), the local authority Adult Social Care Survey (ASCS) gathers quality of life data using a different eight-question version of ASCOT. Current ASCOT INT4 quality of life scores are comparable with this data if agreggate, non-preference-weighted scores are calculated. It should be noted, however, that publicly-available ASCOF data are not separated by service type. Covering part of the same period, the 2016–17 ASCOF in England [76] reported an average current SCRQoL score of 18.9 across England among service-using respondents aged 65 and older; the average across the four local authorities participating in the present study was 18.95. Study participants’ average score of 19.4 compares favourably to these figures when converted to be comparable [38].

The contextual data about day centre attenders’ lives beyond the centres are missing from the literature and are a unique contribution of this study, thus expanding the evidence base on which to make clinical commissioning decisions [15].

In line with Outcomes Frameworks, this study identified mainly positive experiences and evidence that outcomes of day centre attendance address those targeted by health and social care policy. Centres supported their mainly socially isolated and housebound attenders to age in place by focusing on their wellbeing and by preventing deterioration, and acted on any safeguarding or health concerns. Since centre attendance was linked with non-elective withdrawal from social participation, for various reasons, and centres facilitated valued social contact, activities and interventions that improved quality of life, there is potential for day centres to feature on social, or wellbeing prescriptions. Social prescriptions are non-medical interventions whereby primary care professionals refer people with social, emotional or practical needs to non-clinical services with a goal of promoting improved outcomes [77].

Outcomes are of consequence due to the rising numbers of older people living alone [78] and because age influences social exclusion, with people aged 85 or older at greatest risk [79]. Getting out is something older people with high support needs want to do and value [80]. Feeling ‘stuck’ at home (i.e. ref [81], page 59) due to mobility restrictions may lead to social isolation which has a negative health impact [26]. Very old people (≥85 years) spend an average of 80% of their time at home [24]. Staying at home for most of the time due to health constraints is significantly associated with poor wellbeing [25]. Promoting positive wellbeing makes a real impact on older people’s lives and contributes to reducing future demands on health and social care services, families and communities [82]; attenders with a similar profile to this study’s participants may have needed publicly-funded care and support if their centre ceased operating.

The study’s strengths lie in its focus on generalist day centres, its in-depth nature, and its focus on entire experiences of and outcomes of day centre attendance as one single intervention rather than of specific interventions in centres or specific aspects of experiences. Combining a quantitative measure with qualitative interviews added richness and depth, enabling quantification of some of the outcomes emerging using both methods, and providing insight into factors contributing to outcomes experienced and the significance of these to attenders. As a cross-sectional study, the findings provide an in-depth snapshot of 1 day at each centre rather than a longitudinal overview. However, use of an ASCOT tool that measured of hypothetical outcomes in the absence of service at a single time point aimed to compensate for this to a degree. Valuable qualitative data, captured in field notes, also arose while administering a validated tool (see Theme 9), suggesting that following Abendestern et al.’s [83] novel approach of recording conversations during completion of validated tools may broaden and strengthen findings. Data collected using validated scales are comparable. Rigour was maximised by lay scrutiny of interview questions, undertaking regular visits which habituated participants to the researcher and led to a trusting rapport, recording and transcription of interviews and taking a systematic approach throughout. The interviewer kept a reflective diary. Findings’ transparency and trustworthiness are reinforced by feedback from the Study Advisory Group and representatives from each case study site. Their validity is enhanced by the diversity of participating centres despite these not reflecting all typologies. Centre diversity and the emergence of common themes across centres compensated for its limitations which relate to the low number of participating centres in one English region and small sample sizes. Frailer and less cognitively able attenders may be under-represented, although participation was high among those eligible, and, in conversation during fieldwork, many non-participants expressed similar views and experiences to the participants. A risk of bias is that poor-quality day centres may not have agreed to participate.