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How group singing facilitates recovery from the symptoms of postnatal depression: A comparative qualitative study

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Background: Previous research has demonstrated that making music can enhance positive emotions as well as support positive psychological functioning. However, studies tend to be limited by lack of comparison with other psychosocial interventions. This study builds on a three-arm randomised controlled trial (RCT) that demonstrated that group singing for mothers and babies, but not group creative play, can lead to faster recovery from moderate-severe symptoms of postnatal depression than usual care. The aim was to elucidate the mechanisms of the group singing intervention in order to account for its recovery properties. Methods: Qualitative research was conducted with 54 mothers who had experienced symptoms of postnatal depression. Mothers completed a 10-week programme of either group singing or group creative play as part of the wider RCT study. Data were collected via a series of 10 semi-structured focus groups conducted at the end of each 10-week programme. These were designed to elicit subjective and constructed experiences of the singing and play interventions and were analysed inductively for emergent themes. Results: Five distinctive features of the group singing emerged: (i) providing an authentic, social and multicultural creative experience, (ii) ability to calm babies; (iii) providing immersive 'me time' for mothers; (iv) facilitating a sense of achievement and identity; (v) enhancing mother-infant bond. Conclusions: Community group singing interventions may reduce symptoms of postnatal depression through facilitating a functional emotional response rooted in the needs of new motherhood. These features are of relevance to others seeking to implement creative interventions for maternal mental health. Trial registration: NCT02526407 . Registered 18 August 2015.
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R E S E A R C H A R T I C L E Open Access
How group singing facilitates recovery from
the symptoms of postnatal depression: a
comparative qualitative study
Rosie Perkins
1,2*
, Sarah Yorke
1
and Daisy Fancourt
1,3,4
Abstract
Background: Previous research has demonstrated that making music can enhance positive emotions as well as
support positive psychological functioning. However, studies tend to be limited by lack of comparison with other
psychosocial interventions. This study builds on a three-arm randomised controlled trial (RCT) that demonstrated
that group singing for mothers and babies, but not group creative play, can lead to faster recovery from moderate-
severe symptoms of postnatal depression than usual care. The aim was to elucidate the mechanisms of the group
singing intervention in order to account for its recovery properties.
Methods: Qualitative research was conducted with 54 mothers who had experienced symptoms of postnatal
depression. Mothers completed a 10-week programme of either group singing or group creative play as part of the
wider RCT study. Data were collected via a series of 10 semi-structured focus groups conducted at the end of each
10-week programme. These were designed to elicit subjective and constructed experiences of the singing and play
interventions and were analysed inductively for emergent themes.
Results: Five distinctive features of the group singing emerged: (i) providing an authentic, social and multicultural
creative experience, (ii) ability to calm babies; (iii) providing immersive me timefor mothers; (iv) facilitating a sense
of achievement and identity; (v) enhancing mother-infant bond.
Conclusions: Community group singing interventions may reduce symptoms of postnatal depression through
facilitating a functional emotional response rooted in the needs of new motherhood. These features are of
relevance to others seeking to implement creative interventions for maternal mental health.
Trial registration: NCT02526407. Registered 18 August 2015.
Keywords: Postnatal depression, Singing, Community, Music, Qualitative, Focus groups
Background
Postnatal depression (PND) is a debilitating condition
characterised by fatigue and low energy, insomnia and
anhedonia. Prevalence figures vary, but it is estimated
that PND affects 12.9% of mothers with at least 75,000
cases per year in the UK alone [1,2]. The impact of
PND can be severe, with suicide being a leading cause of
maternal death in the first year after childbirth [2], and
indications that PND can impact negatively on childrens
cognitive, socio-emotional and behavioural development
[35]. Additionally, PND can continue to impact on
how mothers parent their children after the postpartum
period [6], and maternal PND can impact negatively on
fathersexperiences of parenting [7].
Consequently, there has been significant attention
given to the best treatment models for PND. Boath &
Henshaw identified five main treatment areas: pharma-
cological; psychological and psychodynamic; pharmaco-
logical and psychological; hormonal; and social support
and relaxation [1]. In a 2013 systematic review, Dennis
& Dowswell demonstrated that psychosocial and psycho-
logical interventions significantly reduce the number of
women who develop PND, with professionally-based
* Correspondence: rosie.perkins@rcm.ac.uk
1
Centre for Performance Science, Royal College of Music, Prince Consort
Road, London SW7 2BS, UK
2
Faculty of Medicine, Imperial College London, London SW7 2AZ, UK
Full list of author information is available at the end of the article
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Perkins et al. BMC Psychology (2018) 6:41
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home visits, telephone peer support and interpersonal
psychotherapy showing promise [8]. Focusing on social
support, Boath & Henshaw reviewed a number of social
interventions including support groups, massage therapy
and relaxation. While there were methodological flaws
in the impact evidence provided, their recommendation
was for further research to be conducted into a field that
may well prove fruitful [1]. Subsequently, Honey,
Bennett, & Morgan reported a controlled psycho-educa-
tional group intervention that reduced scores on the Ed-
inburgh Postnatal Depression Scale (EPDS), but led to
no changes in perceptions of social support, coping or
marital relationships [9]. Creative social interventions
have also received attention. Perry, Thurston, & Osborn
reported that a creative arts group was felt by mothers
to be a relaxed safe space [10] while Feeley, Bell, Hayton,
Zelkowitz, & Carrier showed that mothers perceived cre-
ative activities to provide social interaction and relax-
ation, decrease monotony and meet other personal
needs [11].
Nonetheless, there remain a lack of psychosocial
creative intervention studies for women with PND. This
is perhaps surprising given the rapidly accumulating
evidence base for the positive role of the arts in mental
health and wellbeing [1214]. Crawford, Lewis, Brown,
& Manning (2013) argued that the arts have an import-
ant place in mental health recovery, with the potential to
facilitate spaces of compassion, trust and shared under-
standing [15]. Indeed, studies from music [1619], dance
[20,21] and art [22,23] have all contributed to evidence
that creative arts activities can support and enhance as-
pects of mental health. Singing, in particular, has re-
ceived research attention in relation to its health
benefits. Among the general public, singing has been
demonstrated to be a joyful, life-enhancing activity that
promotes wellbeing [24]. Among participants experien-
cing mental distress, singing has been shown to aid
recovery from serious or enduring mental illness [25],
and to facilitate personal and social impact as well as
functional outcomes for adults living with a chronic
mental illness or disability [26]. Further, von Lob, Camic,
& Clift demonstrated that group singing may be a useful
coping strategy for people living through times of adver-
sity [27]. Finally, Kreutz demonstrated that choral sing-
ing, but not chatting, can lead to increases in oxytocin, a
hormone associated with social bonding [28], a point re-
inforced by other studies [29,30].
Given the prevalence and severity of PND, and chal-
lenges with current treatment models such as low com-
pliance or lack of availability of suitably trained
professionals [2], new psychosocial community interven-
tions that build upon the existing evidence from arts
and health are timely. In particular, the potential for
singing to enhance bonding and to facilitate personal,
social and functional impact may directly address the
psychosocial risk factors connected with PND [31]. In
order to explore this, a randomised controlled trial
(RCT) was carried out [32]. This compared the effects of
a 10-week programme of group singing for new mothers
and their babies with 10 weeks of usual care. While pre-
vious studies have attempted to explain the mechanisms
behind musics impact on health [33,34], these are lim-
ited by a lack of comparison with other, perhaps equally
effective, psychosocial interventions. Consequently, in
order to start to identify whether group singing per se is
an effective intervention or whether other group social
engagement is equally effective, a third arm was included
within the RCT comprising 10 weeks of group creative
play activities for mothers with symptoms of PND and
their babies.
The RCT revealed that symptoms of PND reduced sig-
nificantly faster amongst mothers in the singing group
with moderate-severe PND than for mothers in the
usual care group. Interestingly, there was no significant
difference in recovery between the singing and play
groups, as measured by EPDS scores at baseline, week 6
and week 10, or between the play and control groups
[32]. This suggests that group singing may have specific
benefits over and above the comparison psychosocial
intervention. Yet why this happened, and the mecha-
nisms underpinning the singing group, remain unknown.
As DeNora and Ansdell argued, RCTs run the risk of
the middle period, in other words the time in which
music is active, [being] left in shadow, which means that
the processes by which music might be having an ef-
fectare left in darkness, made mysterious([35], no
page number). Indeed, that qualitative methods can in-
form and/or illuminate the results of an RCT is also ac-
knowledged within wider mental health research [36,
37]. Therefore, this study aimed to explore how the
group singing programme facilitated recovery from the
symptoms of PND through a qualitative analysis of the
experiences of mothers involved in the singing group
and comparisons with qualitative data from mothers in
the play group. The driving research question was:
What are the specific features of a community group
singing intervention known to support recovery from
symptoms of PND?
Methods
Procedure
The interventions
The RCT on which this study is based had three arms:
singing (experimental), creative play (comparison) and
usual care (control). RCT participants randomised to the
singing and play groups received free 60 min workshops
for them and their baby every week for 10 weeks in a
community childrens centre. Between 8 and 12 women
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plus their babies were recruited into each group, and five
singing groups and five play groups ran over a
six-month period in 2016 (n= 134 women completed
the RCT and provided full data). Groups were led by one
of two professional workshop leaders, specially recruited
to work on the project and with experience of facilitating
music and/or creative workshops in community settings.
The leaders were supported by a team of seven
specially-trained conservatoire students (one per each
10-week programme) and a project coordinator. The
two leaders led both singing and creative play sessions
to ensure consistency between the two conditions, and
worked together to plan materials and content. Singing
workshops involved mothers listening to songs sung by
the leader, learning and singing songs with their babies
and creating new songs together reflecting aspects of
motherhood. Creative play workshops involved mothers
engaging in sensory play with their babies, doing arts
and crafts and playing simple games together. Songs and
creative play activities were selected initially by the
workshop leader, but were also suggested by the partici-
pants. They were designed to be engaging for the
mothers as well as to support the mothers interacting
with their babies (e.g. through singing lullabies or
through designing art work based on the babieshand-
prints). Participants provided background and demo-
graphic data as well as completing the EPDS at baseline,
week 6 and week 10. The median number of sessions
attended by women was eight for the singing group and
six for the play group. Full details of the RCT interven-
tion and outcomes are published elsewhere [32,38].
Methodology and methods of data collection
The study was underpinned by social constructionism,
assuming that the interventions were socially con-
structed and that the ways in which mothers reported
their salient features represented socially constructed
knowledge. The qualitative design therefore sought a
rich understanding of the features of the singing groups
as they were reported by the participants themselves. In
an attempt to isolate the specific features of the singing
group that might have led to a faster reduction in PND
symptoms, this study qualitatively compared the experi-
ences of mothers in the singing group with the experi-
ences of mothers in the play group.
Data were collected via a series of 10 focus groups,
divided equally between five focus groups for singing
and five focus groups for play. Focus groups were se-
lected to account for and capture the shared experiences
and understandings constructed within each group over
the 10-week period, although in one case there was only
one woman in attendance and so this was conducted as
a semi-structured interview. Focus groups were held im-
mediately or soon after the final session of each 10-week
programme, and women self-selected to attend. The
schedule concentrated on experiences of the interven-
tion and of new motherhood. Each focus group was
facilitated by one researcher, comprised on average 5.4
members (see Table 1), and lasted for between 16 and
26 min. The women attended with their babies and
therefore it was not appropriate to aim for a lengthy dis-
cussion, so the facilitator aimed to draw out the salient
points as efficiently as possible. This point may also
account for the low uptake in some groups, as attending
data collection with a baby included significant logistical
challenges. The focus groups were audio recorded with
permission and fully transcribed.
Participants
Participants included in the RCT were women with ba-
bies up to 40 weeks post birth who scored 10 or higher
on the EPDS at baseline, indicating some symptoms of
PND. Women were recruited through midwives, doc-
tors, perinatal psychiatrists, health visitors and General
Practitioners (GPs) in the Greater London area of the
United Kingdom (UK), as well as through social media,
leaflets and by a project coordinator in childrens centres
and in the local community. Women were excluded
from the RCT if their baby was outside the specified age
range (09 months), if a healthcare professional advised
that the intervention was not suitable for them (in prac-
tice we recorded no instances of this), if they did not or
could not provide informed consent or if they lived
outside the Greater London area. Women were not
expected to have any prior experience or knowledge of
singing. The UK National Health Service (NHS) South
East Scotland Research Ethics Committee approved the
project [reference 15/SS/016], and women gave written
informed consent.
All women who had participated in either the singing
or play groups as part of the wider RCT study were
invited to take part in this study through email and oral
communication at the sessions, and 54 women volun-
teered and consented to take part. Of these, four did not
provide data for the RCT study, meaning that of the 91
women who completed the singing and play workshops
in the RCT, 50 (55%) are represented in this study. Par-
ticipant characteristics are presented in Table 1; across
the 54 participants, 92% were first time mothers. Na-
tionalities represented in the sample included British,
French, Polish, Canadian, Columbian, Australian, Jap-
anese, Italian and North American.
Analysis
An inductive thematic analysis of the transcripts was
undertaken, acknowledging that there is as yet no one
established theory as to musics effects on mental health.
The analysis proceeded in four main steps, specifically
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designed to provide a qualitative description [39] of the
constructed features of the singing intervention. First,
each transcript was read for familiarity before, second,
important units of meaning were selected and labelled
as emergent nodes in NVivo10 by the first author. The
units of meaning emerged inductively, but there was
a pre-determined focus on the features of the singing/
play activities constructed by the participants as im-
portant or meaningful. Third, the units of meaning
were cross-checked by the second author and addi-
tions or changes were discussed until consensus was
reached. Finally, the units of meaning were clustered
into sub-themes and, ultimately, overarching themes
that characterise the main features of the singing and
play activities, again cross-checked between two re-
searchers. Sub-themes were only classed as such when
they were represented across at least three of the five
respective focus groups. Reflexivity was addressed
through the interplay between the two analysts, both
of whom had a different position in relation to the
research and the participants: one as the lead
researcher, only in attendance at a small number of
the sessions and the second as the project coordinator,
in attendance at the vast majority of sessions over the
course of the RCT and the first point of contact for
the women. These different positions enabled both
analysts to engage with the data from their own start-
ing points, to recognise where different interpreta-
tions may lie and to agree a shared understanding of
the central themes.
Results
Four overarching themes identified the main features of
the two interventions: (1) activity mechanisms (features
of the activity itself ), (2) environmental mechanisms
(features of the environment created within the
sessions), (3) social mechanisms (social features of the
activity), and (4) psycho-emotional mechanisms (psycho-
logical and/or emotional features of the activity). A total
of 13 sub-themes emerged for the singing activity
(labelled S) and a total of 9 sub-themes emerged for the
play activity (labelled P), as summarised in Table 2.
In what follows, each overarching theme will be
described in turn. Sub-themes from the singing activity
will be presented alongside sub-themes from the play
activity, either to demonstrate consistent features
across the two activities or to illustrate differences.
Indicative quotations are used to support each
sub-theme, but interpretation is reserved for the follow-
ing discussion.
Activity mechanisms
Two activity sub-themes were consistent across both
singing and play. First, both groups reported that they
took away new skills or ideas from the activities
(sub-themes new singing skillsand new play ideas):
Ive found it very rewarding to have something to take
away with me each week as well. Coming in to being
a mum, and knowing a few songs, but not many, its
been really nice to learn songs [Sing 3].
I find its hard to imagine what to do creatively at
home with him and now weve got lots of really
creative ideas and I feel really inspired [Play 4].
Additionally, the play group reported that they appre-
ciated the variety of activities introduced across the
programme, and the flexibility with which the leaders
introduced activities to meet the needs of the group
(sub-theme varied play activities):
Table 1 Participant characteristics, organised by focus group
Focus Group Number of
participants
Age range of
mothers (years)
Mean number of
weeks post-birth
Mean EPDS score
1
Educated to
degree level
2
(%)
Household income
above £61 k (%)
With a
partner (%)
Sing1 9
Sing2 7
Sing3 7 2243 19.36 14.51 88.57% 65.63% 91.43%
Sing4 5
Sing5 9
Play1 2
Play2 4
Play3 2 3145 17.13 13.50 87.50% 75.00% 87.50%
Play4 8
Play5 1
3
Note 1: EPDS 10 indicative of possible symptoms of PND. EPDS 13 indicative of moderate-severe symptoms of PND
Note 2: Missing data points excluded from all % calculations
Note 3: Run as a semi-structured interview
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I think the nice thing about this group is that there is a
structure, but its been changing based on the feeling of
the day of the group and I think that is the best kind of
group. You have some kind of structure, but then its
very kind of whats the word flexible [Play 1].
Second, across both groups, the activities learned
were reported to be transferable to other contexts
(sub-themes singing outside of classand playing
outside of class), whether at home or in other, some-
times challenging, circumstances:
It gives good ideas, when you go home and youre like
oh I can play with this or make that[Play 2].
Just this weekend we were back in the hospital and she
was having to have blood taken and she was going
mental, and I found myself singing the [folk lullaby] song
to her and it just gave me something that I might not
have ... I dontknow,anurseryrhymeorsomething,I
might not have thought to do that, but something about
the repetitiveness and the fact that weve done it lots of
times.Itmadeadifferencetohavethat[Sing3].
One further feature emerged from the singing group,
which was seen as a form of authenticmusical engage-
ment (sub-theme authentic musical engagement). Par-
ticipants felt that the groups were natural and calming
rather than commercial, with singing that drew upon di-
verse influences and music contributed both by the
leader and the participants:
Ive been to some other music classes and things like
that and Ive found them, really really cheesy and
almost like sensory overload by the end of it, and I
like how [leader] really pays attention to reading all
the babies and calming things down when she needs
to and livening it up when theyre ready for it and
stuff like that, and that it doesnt feel like commercial
and cheesy, it feels very authentic, lovely music that
you can sing at home and not feel like a cartoon
character or something [Sing 2].
I love that they were quite global songs, like some are
Indonesian. Thats just a wonderful thing. To be in a
group of women singing global songs was quite
powerful I thought, so that was nice. Not just nursery
rhymes [Sing 4].
Its been really nice to learn songs from different
cultures and know that you dont necessarily need
to know what they mean, and they dont need to
be English words. Its just really lovely to know
different songs. You can use them with a little bit
more amusing music to calm [baby] and entertain
her [Sing 3].
Indeed, singing was seen as particularly beneficial
when it was multimodal,or presented in parallel with
another activity or resource:
[It] was really nice because it was combined - Ill read
her a book; Ill sing her a song. I never really thought
to do that; to actually bring those things together was
really nice [Sing 3].
To summarise, both groups felt that they learned new
activities to do with their babies and reported increased
confidence in doing so, as well as transferability outside
of the sessions. The mothers in the singing group appre-
ciated the authentic nature of the musical engagement,
and particularly the multicultural experience as well as
the use of other creative forms (such as stories) to
accompany the singing.
Table 2 Overarching themes and sub-themes
Themes
1
Sing sub-themes Play sub-themes
1. Activity mechanisms S1.1 Authenticmusical engagement
S1.2 New singing skills
S1.3 Singing outside of class
P1.1 Varied play activities
P1.2 New play ideas
P1.3 Playing outside of class
2.Psycho-emotional mechanisms S2.1 Singing feels good
S2.2 Singing time for mums
S2.3 Singing as immersive
S2.4 Singing as achievement and purpose
S2.5 Singing supports bonding
P2.1 Play feels good
3. Social mechanisms S3.1 Singing impact on babies (calming)
S3.2 Singing as part of group
S3.3 Singing supports routine
P3.1 Playing as part of group
P3.2 Play supports routine
P3.3 Play impact on babies
4. Environmental mechanisms S4.1 Calm and inclusive singing environment
S4.2 Importance of singing leader
P4.1 Calm and inclusive play environment
P4.2 Importance of play leader
Note 1: Overarching themes are organised in terms of qualitative strength for the singing group. Sub-themes are organised into qualitative strength for the
singing and play groups respectively
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Psycho-emotional mechanisms
Across both groups, the activities were perceived as
enhancing positive emotions (sub-themes singing feels
goodand play feels good):
Its one of the activities that I look forward to and we
will certainly miss not coming to the sessions any
more () You feel kind of uplifted and pleased that
you came [Play 1].
Its very uplifting. I leave here a lot happier than I
started [Sing 2].
Indeed, the activities were seen as particularly uplifting
or supporting in the context of a challenging time in
new motherhood:
No matter how bad the night youve had, no matter
how knackered you are, youve got to still just get out
and go to the group. Because it just makes you feel
better, dont you think? [Sing 1].
I think parts of this course has actually helped me get
through the sort of darker elements of ... the darker
days of when it does feel endless, and when it does
feel tough.because its [the singing] a fixed thing, its
something Ive got to get out of the house for, and its
something that I know that even if its crappy to get
here, actually once Im here I know that it will be nice
and it will be a relaxed atmosphere. Whether shes
crying, or whether shes hungry, or whether shes
sleeping, or whether shes playing, all of that is
actually nice, and accepted, and fine [Play 5].
Despite this transversal experience, however, it was in
this theme of psycho-emotional mechanisms that the
most striking differences emerged between the singing
and the play groups.
First, women in the singing group perceived the session
as a time for mothers, and not only an activity designed
for their babies (sub-theme singing time for mums):
Everything is for the baby. You go to a class and its
always for the baby. Then you go out and meet for
coffee with your friends and you talk about your
babies. This [singing] is also good for the baby, but at
the same time its something for us as well [Sing 3].
Perhaps as a result of this perceived focus, the singing
sessions also emerged as a form of me time, where the
mothers could do an activity for themselves:
I hadnt really thought about music really, helping me.
Especially at the beginning, youre just surviving, I
think. But as soon as I started singing, it seemed to
relax me and really made a big difference to [my
baby] [Sing 4].
I think even though youre actively participating it
almost does feel like a bit of down time as well. Itsa
bit of relaxing time. Another woman: Yeah, thats why
its nice for mums as well [Sing 3].
Linked with these points, the singing sessions were
also reported to be immersive for some of the
mothers (sub-theme singing as immersive):
Because Im still working, I work throughout, Im
always using my mobile phone and itstheone
time that I actually have never picked up my
phone. Normally in a class Ill just check my
phone, Ill just check my emails, but actually I
havent in this class. So thats been hugely
beneficial to me, just to have that time out that I
dont normally give myself [Sing 2].
I think its so helpful just being here, like being in the
present, instead of thinking about what am I going to
do in five minutes. I need to prep this, prep that ()
Here, Im just being here singing, and thats a huge
difference [Sing 5].
Interestingly, some the features of the singing itself
seem to be instrumental to this immersion, facilitating a
musical experience that can also be aesthetically
absorbing:
With the singing I find that, I said before about
how its nice all the songs having a beginning and
an end, and I find the way [the leader] would
sometimes make it fast, sometimes slow,
sometimes loud, sometimes quiet, thatssomething
really lovely about getting lost in the song in that
way [Sing 2].
Moving on, the singing also enabled a sense of achieve-
ment (sub-theme singing as achievement and purpose):
Sometimes it makes me anxious that you are doing
all that is expected, taking care of your baby, but
other than that you are doing nothing ()Soin
this sense as well, I think coming to here and I
started to sing ... I feel like I was doing at least
something in a more tangible way. I was coming
here, I did something today [Sing 4].
We went through a period of her not being very well,
but with breastfeeding not working, and her losing
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weight that was quite stressful. Coming to this made
me feel like I was doing something that was really
nurturing her while I felt like I was struggling to
nurture her, so that really made a difference in that
time [Sing 3].
We see here the women reflecting on the daily chal-
lenges that they faced as new mothers, and the ways in
which singing helped them to discover a sense of accom-
plishment. Singing also appeared to support a reconnec-
tion with a sense of self and purpose that had been lost
in the transition to motherhood:
Speaker 1: When I first came () I wasnt very well,
and as a result, was slightly lacking in confidence and
I think over a period of time, as Ive gotten better and
sort of been on medication as well as coming to the
class and as well as interacting with lovely people -
mothers, again - its been hugely beneficial to me, I
feel. I feel like new again and I think in a big way in
the beginning that wasnt there. I never thought I
would feel like me again, post baby. Speaker 2: You
came back to yourself again. Speaker 1: Yes [Sing 2].
I think just feeling, like you go from work, which is
another identity, and then you go off a bit lost into
motherhood identity, where you know your role but
you probably dont know what it means. Having
songs, and having this, it helps you to be able to add
to your purpose, and youve got some strings to your
bow. Were all great mums, but sometimes you feel
like youre not. You need, if you come to something
like this, you feel like youve got different songs and
things [Sing 3].
Finally, a small number of women reported that sing-
ing helped them to bond with their baby (sub-theme
singing supports bonding):
It helps the bond between us, too. Something that
[the leader] first said, on the first day was actually that
they want to hear the sound of your voice, so dontbe
scared about singing [Sing 3].
I have a good relationship with him because I sing to
him every day, some songs - so its useful [Sing 5].
To summarise, mothers in both groups reported that
their activity facilitated positive emotions, especially in
relation to the challenges of new motherhood. Among
the singing group only, the mothers also reflected on
singing being a form of me time; a space for them as
well as for their baby that could also be immersive.
Additionally, singing facilitated a sense of achievement
for the mothers, particularly in relation to nurturing
their babies and rediscovering a sense of self and
purpose. Finally, for some of the mothers singing was a
means of enhancing the mother-baby bond.
Social mechanisms
Both sets of mothers reported that they benefited from
being part of a group (sub-themes singing as part of
groupand playing as part of group):
I felt like I was really part of the group () with so
many of the other drop in classes and groups and
things, you dont really get to know the babies that
well and youre more focused on you and the baby
and whats going on, not like you and everyone else
and their babies ()Soits been really nice to feel
part of a group [Play 2].
You feel part of the community, and ()its lovely
[Sing 4].
In addition to the experience of being a group mem-
ber, this social forum also provided a means of learning
from other mothers:
I think you learn from other mums as well. You see
how they are with their children ()soits not only
just about the music, its about like you get to interact
with other mums and see how they parent their
babies and I might implement like that in my routine
with my child and so its a lot more than just the
music [Sing 2].
You can learn a lot from each other () just how
much you can learn off each other in really informal
way [Play 1].
That the mothers are brought together regularly each
week appears to create an opportunity for sharing tips
and resources that are beneficial to their ongoing experi-
ences of motherhood. Finally, among the singing group
this social cohesion seems to be strengthened through
the act of singing:
I think if it was shorter, if it was only two or three
sessions, it wouldnt really work. I think the first
time I came, I came away saying Oh, thats nice,
but its nothing that you wouldnt get from another
group or somethingbut then after ten weeks, you
really do feel like the songs become the group
[Sing 3].
Singing as a group, thats one of the things that I like
[Sing 2].
Perkins et al. BMC Psychology (2018) 6:41 Page 7 of 12
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
While all participants experienced the benefits of feeling
part of a regular group and learning from other mothers,
those in the singing group also benefited from the social
cohesion facilitated by the music itself.
Furthermore, both singing and play participants
described their activities as a motivation and structure for
getting out of the house with a young baby (sub-themes
singing supports routineand play supports routine):
I had a difficult labour and first few months keeping
the baby healthy, and I was home a lot with the
challenges and this gave me an opportunity to meet
other people, so that Im not alone with kids [Play 4].
I think it was really good for me to have something to
go to, that meant I wasnt home all the time. It was
also something different, away from just walking to
[the] park again [Sing 3].
In addition to facilitating a change of scene, the activ-
ities also provided routine within the mothersweek:
I always have something to do each day. And knowing
that we have something to come to [Play 4].
I didnt have ideas of how to start or how to start
again, reorganise my daily life and to have routine.
So having the session every week, every Friday at the
same time, actually I think it helps to re-establish your
rhythm [Sing 4].
Additionally, the mothers reported that they enjoyed
seeing the impact of both singing and play activities on
their babies (sub-themes singing impact on babiesand
play impact on babies):
Its just the way that [the babies] are with each other
and you can see that they remember each other ()it
just shows that once a week and with the music and
the drum and then the singing, theyve all developed
and theyve all grown up so much [Sing 2].
Seeing the babies develop and change week on week, in
a kind of creative setting, has been really lovely [Play 2].
For mothers in all the singing groups, it was also re-
ported that singing calmed their babies, including out-
side of the sessions:
The songs have () been calming for [baby] when
hes really crying. Just standing like this, singing some
of the songs. Sometimes you just get into a zone
where youre just singing them on repeat in a trance
singing it [Sing 1].
I can use them. Lots of times, like in the middle of the
night, I sing hours on end. Rocking him [Sing 5].
Socially, then, the activities provided a sense of group
belonging for the participants, in which knowledge
about motherhood could also be shared. For the singing
group in particular, this sense of social cohesion was
strengthened by the act of singing itself. Both activities
provided a sense of structure and routine in the mothers
lives and a shared experience of seeing their babies de-
velop. Finally, singing was also reported as a useful way
to help calm and soothe babies.
Environmental mechanisms
For mothers in both groups, the environment in the
sessions was reported to be calm (sub-themes calm and
inclusive singing environmentand calm and inclusive
play environment):
I think it was also a really calm environment. That
was good [Play 3].
Its much calmer than any of the other baby classes
that we go to together [Sing 2].
Furthermore, the mothers experienced the spaces as
non-judgemental, particularly in relation to their babies
behaviour:
I knew that nobody would mind if she [baby] was
squawking and people have been really supportive
about her wanting to be carried around, ok lets take it
in turns to do that (...) I remember when I started this
group, I was still slightly in the phase of I would go to
things and be slightly on edge about whether shedbe
in a meltdown, and I can feel that Ive relaxed. Not
necessarily in every setting, I wouldnt like it if it
happened on the train or something, but here, yes, I
know that its absolutely fine and it will be okay, and I
think thats helped my confidence with her as well, so
thats been really nice [Play 5].
I think its been nice about this group its because
wherever you go, as a mum, you feel judged. But here,
its just like naked. Were all in exactly the same
position [Sing 1].
Linked with this, the mothers appeared to appreciate
the lack of pressure put on them to participate in the
activities in a certain way or to a certain degree:
That it, theresnopressuretogetsuperinvolved
[Play 2].
Perkins et al. BMC Psychology (2018) 6:41 Page 8 of 12
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
I dont sing very well at all, but we dont judge each
other here and its just all about just being isntit
[Sing 1].
In the play group, some of the mothers also recognised
the value of the sessions as an opportunity to talk
alongside the creative play activities in a trusting
space:
It felt a little more comfortable here to discuss certain
things and quite open conversations, and its all felt
very comfortable and very trusting, warm
environment [Play 1].
Moving to the final sub-theme, both groups empha-
sised the vital importance of the leader in facilitating
effective interventions for new mothers (sub-themes
'importance of singing leaderand importance of play
leader):
I think [leader] was a really lovely moderator, and I
think the atmosphere that she created was very
relaxed and very positive. So a big element is actually
having her as the person whos brought it all together
[Play 5].
[Leader] brings her experience and positivity. I think
she brought a lot of humanity into it, thats probably
why we really liked it and the kids reacted that way
[Sing 1].
In sum, the calm and inclusive leader was identified as
important to the mothers, as was the quality and tem-
perament of the workshop leaders.
Discussion
This article has scrutinised the features of a community
group singing intervention known to support recovery
for mothers with moderate-severe symptoms of PND. By
situating data from the singing group alongside data
from women in a parallel creative play group, the aim
has been to illuminate the specific features of the singing
group. Nonetheless, across both interventions a series of
transversal mechanisms emerged to account for the po-
tential benefits of more generic creative interventions
for postnatal mental health recovery: (1) a shared experi-
ence for mothers of seeing babies develop and enjoy a
creative activity; (2) learning new activities to do with
babies, and increased confidence in doing this outside of
the intervention sessions themselves; (3) an enhanced
sense of feeling good; (4) a sense of group belonging, in
which knowledge about motherhood can be shared; (5) a
sense of structure and routine in daily life; (6) a calm
and inclusive environment, facilitated by high quality
creative leaders and support team. Given that low levels
of social support are widely acknowledged to predict
PND [31], it is particularly interesting that many of the
social benefits of being part of a creative group were
evident across both singing and play, perhaps helping to
account for the lack of a significant difference in
recovery speed found in the RCT between these two
conditions [32]. However, as we also know from the
RCT, singing but not play led to more rapid reduc-
tions in moderate-severe symptoms of PND than usual
care [32], suggesting that there are other factors that
may differentiate the impact of singing.
Indeed, a number of features emerged that may ac-
count for this activitys ability to reduce PND symptoms.
Beck includes self-esteem as a predictor of PND based
on her meta-analysis of 84 studies [40]. That singing al-
lows women to feel a sense of achievement, specifically
in caring for and nurturing their baby, is of relevance
here, contributing to what Leahy-Warren, McCarthy, &
Corcoran term maternal parental self-efficacy, or
mothersbeliefs about their ability to be successful in
the parenting role([41], p.390). Leahy-Warren, McCar-
thy, and Corcorans research posited a link between ma-
ternal parental self-efficacy and reduced symptoms of
PND, suggesting that the role of singing to enable a
mother to feel able to look after and care for her baby
may be important. Further, that singing can calm babies
may also support this point; with the toolof singing to
support being able to calm down a crying baby, mothers
may feel more competent and able to deal with challen-
ging infant behaviour or situations. Indeed, other studies
have pinpointed the importance of postnatal interven-
tions in supporting aspects of maternal confidence [42],
although evidence on this is limited [43].
The mothersreports of the singing sessions as relax-
ing and immersive, creating me time, also set them
aside from the play sessions. Indeed, within mental
health research more widely, there is some evidence
albeit limited that relaxation techniques could support
recovery from depression [44]. For the mothers, singing
appeared to offer an immersive experience that provided
some relief from the practical and emotional concerns of
early motherhood. Importantly, the activity was also seen
as a unique opportunity to engage in something de-
signed for the mother rather than only for the baby,
highlighting the mothers own needs for care and
nurture, a point also made by Feeley et al. [11]. Linked
with this point is the value that the mothers placed on
what they perceived as the authenticity of the singing
activity, which moved away from more standard reper-
toire for mothers and babies (such as nursery rhymes) to
include songs and music from around the world. This
enabled mothers to contribute songs from their own cul-
tures and backgrounds for the group to learn together,
Perkins et al. BMC Psychology (2018) 6:41 Page 9 of 12
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
further emphasizing the feeling of community and group
learning. This may be a key feature of the intervention, as
it appeared to facilitate an emotional and social connec-
tion specifically with the music that allowed the mothers
to relax and become absorbed in the activity with their
baby, subsequently providing some relief from the symp-
toms of PND. Indeed, others have reported on the role of
lullabies in enhancing feelings associated with mother-
hood and in understanding babiesresponses [45].
Finally, the enhanced mother-baby bond that some
mothers reported as a result of singing is of note. It has
been posited that singing may have developed out of
motherese, a form of speech directed by mothers at
their infants that consists of formalisations, repetitions,
exaggerations and elaborations of ordinary adult vocal
communication [46,47]. Motherese is thought to be an
interactive process between mother and baby [48], and
singing may achieve similar responses from a baby such
as enhanced engagement, visual attention and modula-
tion of infant arousal [49,50]. PND has been linked with
reduced mother-infant bond [51], and it appears that
singing may provide one mechanism for supporting this
bond through the shared interaction of singing vocalisa-
tions. Indeed, singing with other populations has also
been reported as a means of enhanced interpersonal
communication and bonding [2730]. Further, Mualem
& Klein [52] demonstrated that musical interactions pro-
vided more opportunities for synchronisation between
mothers and one-year olds, as well as positive emotional
arousal, than play. It is possible that singing facilitates a
unique mother-infant bonding experience, and further
work is required in this area.
What, then, can we infer as to the specific benefits of
community group singing for reducing symptoms of
PND? Interestingly, the majority of the mechanisms dis-
tinct to singing were categorised under the psycho-emo-
tional mechanismssub-theme. These mechanisms are
concerned with the mothers affective and psychological
response to the singing activity, and may relate to sub-
jective feelings, expression, action tendency or regulation
invoked through the musical experience [53]. Music has
for a long while been associated with strong emotional
responses [54], and it could be argued that what we see
in this group singing intervention is the use of singing to
facilitate an emotional response to music that is
context-specific to the experience of new motherhood.
Indeed, Sloboda and Juslin [55] make clear that emo-
tional responses to music occur in a complex interaction
between the music, listener and situation, and are
dependent on the goals and motives of the listener.
While both singing and play elicited feel goodemotions
such as happiness and a feeling of being uplifted, only
singing appeared to elicit a more functional emotional
response rooted in the needs of new motherhood: to
have time to reframe the self, to feel immersed in an
activity beyond looking after the baby alone, to feel com-
petent as a mother and to feel bonded with the baby.
The experience of functional positive emotions in rela-
tion to the experience of motherhood, facilitated
through the creative act of singing, may help to explain
the faster reduction in symptoms that this intervention
elicits. Indeed, this response may also reflect the ability
of the workshop leaders to recognise and respond to the
womens emotional state through the singing itself,
modifying the songs to allow women to rest, be close to
their baby or to learn new repertoire to take away from
the session.
Finally, this work contributes to the wider body of lit-
erature pointing to the mental health benefits of singing.
We saw in the opening of this article that singing can be
life-enhancing [24], support recovery from serious or en-
during mental illness [25]and provide a useful coping
strategy in times of adversity [27]. Our findings confirm
the recovery potential of signing, both in terms of sup-
porting women to feel good(Hedonia) and to function
well(Eudaimonia) [56]. Further, as discussed above,
singing emerged as a tool to facilitate a feeling of close-
ness or bonding between mother and baby, which can
be compromised when a women is experiencing symp-
toms of PND [51]. This supports Kreutzs argument that
singing may have emerged to enhance social bonding
and mutual attachment [28] and echoes findings from
our recent study demonstrating that singing, but not
chatting, is associated with increases in maternal percep-
tion of emotional closeness with their baby [57]. Finally,
our study resonates with the so-called functional out-
comesof singing identified in a previous study [26],
with singing appearing to be a tool that can be modified
to meet participantsemotional needs in their particular
context. Our findings make it clear that, for the women
in this study, the impact of singing appeared to be
specific to their needs as new mothers. Whether or not
this specificity arose as a result of careful leadership
from the facilitators and/or the innate qualities of sing-
ing itself requires further investigation. Indeed, this issue
of specificity will be important to continue unpacking if
we are to fully uncover the potential of singing to sup-
port diverse participant groups.
Conclusions
This article uses a comparative qualitative methodology to
describe the specific features of a community group sing-
ing intervention known to reduce moderate-severe symp-
toms of PND more rapidly than usual care: (1) the
authentic, social and multicultural nature of the singing
experience, which was not seen as commercialand which
drew upon global songs that were meaningful to the
mothers as well as other creative forms; (2) the ability of
Perkins et al. BMC Psychology (2018) 6:41 Page 10 of 12
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
singing to calm babies, both in and out of the sessions; (3)
the singing session as me timefor mothers, that can be
both relaxing and immersive; (4) the ability of singing to
facilitate a sense of achievement and identity for mothers,
particularly in relation to nurturing their babies and redis-
covering a sense of self and purpose after the transition to
motherhood; (5) singing as a means of enhancing the
mother-baby bond. In summary, the psycho-emotional
mechanisms of the activity emerge as central to the re-
ported benefits, with community group singing appearing
to facilitate the experience of functional positive emotions
in relation to the experience of motherhood. Further re-
search is needed to scrutinise the extendibility of this find-
ing, as well as to further understand the complex
interactions of responses to singing and recovery from
symptoms of PND.
Limitations
While one of the first to attempt to account for the
mental health benefit of singing for new mothers, this
article is not without its limitations. More women com-
pleted the singing intervention than the play interven-
tion [38] and therefore more women were represented
in the singing focus groups than the play. Although this
means that the perspectives of fewer mothers are in-
cluded in the play data, this is arguably a function of the
singing intervention being the most effective for postna-
tal mothers. Additionally, not all mothers were able or
willing to participate in the focus groups, potentially dis-
torting the resulting data, and biasing them in favour of
mothers who reported predominantly positive outcomes.
Similarly, the focus groups were relatively short and
therefore the richness of the data may be compromised.
Further, the singing intervention was shown to be par-
ticularly effective for mothers with moderate-severe
symptoms of PND [32], yet the focus groups were open
to all mothers who participated in the activities, includ-
ing those with milder symptoms. Indeed, the data are
also limited by the characteristics of the sample, which
includes a high percentage of degree-educated women in
relatively high earning households. Further research will
benefit from addressing these limitations in order to
continue building the evidence base for the role of sing-
ing in maternal mental health.
Abbreviations
EPDS: Edinburgh Postnatal Depression Scale; GP: General Practitioner;
NHS: National Health Service; PND: Postnatal Depression; RCT: Randomised
Controlled Trial; UK: United Kingdom
Acknowledgements
The study team acknowledge the support of the National Institute of
Health Research Clinical Research Network (NIHR CRN). The authors
would like to thank the hospitals involved as Participant Identification
Centres, the workshop leaders and assistants and Diana Roberts, Miss
Sunita Sharma and Prof Aaron Williamon for their support with the RCT
on which this study is based.
Funding
The study was funded by Arts Council England Research Grants Fund, grant
number 29230014 (Lottery) with additional support from CW+ and Dasha
Shenkman. The funders had no role in the design of the study and
collection, analysis, and interpretation of data or in writing the manuscript.
Availability of data and materials
Data are not available as (1) the study protocol stated that data are only
available to the immediate study team and (2) participants consented to
anonymised data being included in scientific publications or presentations
but did not consent to raw data transcripts being made available.
Authorscontributions
RP designed the study, collected data, led analysis and wrote the first draft
of the manuscript. SY collected and analysed data and contributed to the
final manuscript. DF designed the study, collected data and contributed to
the final manuscript. All authors read and approved the final manuscript.
Ethics approval and consent to participate
The study was approved by the National Health Service South East Scotland
Research Ethics Committee (15/SS/016). Women provided written informed
consent to participate.
Consent for publication
Women provided written informed consent for their anonymised data to be
published.
Competing interests
The authors declare that they have no competing interests.
PublishersNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
Centre for Performance Science, Royal College of Music, Prince Consort
Road, London SW7 2BS, UK.
2
Faculty of Medicine, Imperial College London,
London SW7 2AZ, UK.
3
Present Address: Faculty of Medicine, Imperial
College London, London SW7 2AZ, UK.
4
Present Address: Department of
Behavioural Science and Health, University College London, London WC1E
7HB, UK.
Received: 17 January 2018 Accepted: 24 July 2018
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... Previously, participation in an evidence-based 10-week community singing group (Breathe Melodies for Mums (M4M)) was associated with signi cantly faster recovery in women experiencing moderate to severe PND symptoms compared to women attending play groups and non-intervention controls (20). These changes were attributed to a range of mechanisms with participants reporting an increased ability to calm their babies through singing, an enhanced sense of achievement, rediscovery of self-identity as a new mother, and enhanced mother-infant bonding (21). Having established clinical effectiveness, M4M is currently being scaled up and tested in the community as part of a large 'Scalingup Health Arts'-research programme (SHAPER) (22). ...
... These ndings help us to understand why participating in M4M-online led to reductions in stress, anxiety and PND symptoms in the feasibility trial (27). Most of the mechanisms identi ed in the present study also mirrored those produced by the in-person M4M groups including increased bonding between mothers and their babies, supporting mothers to establish new routines, an enhanced sense of identity and singing as a tool for mothers to calm their babies (21). These same mechanisms have also been reported in research into other online creative health programmes including increased positive emotional response (38, 40, 41), increased con dence in communicating with others (38) and reduced loneliness and isolation (38, 41,42). ...
Preprint
Full-text available
Background Social distancing restrictions and the suspension of in-person treatment and support contributed to an increase in postnatal depression during the coronavirus disease 2019 (COVID-19) pandemic. Creative health interventions can help to alleviate anxiety and depression, with studies showing that singing is particularly effective for supporting the mental health of new mothers. We adapted an in-person group singing programme (Breathe Melodies for Mums (M4M)) to online delivery during the COVID-19 pandemic to support the mental health of new mothers, and, in a feasibility study, found improvements in postnatal depression (PND) symptoms at 6-month follow up. The current qualitative study aimed to explore how and why M4M-online impacted the mental health of those taking part. Methods We took a theory-based approach using the Ingredients in Arts in Health (INNATE) Framework of ‘active ingredients’ and the Multi-level Leisure Mechanisms Framework of ‘mechanisms of action’ to identify and categorise intervention components and change mechanisms. Iterative consensus building between three researchers were complemented by qualitative semi-structured online interviews with 24 women experiencing PND symptoms who took part in M4M-online. Data were analysed inductively using reflexive thematic analysis. Results Consistency was found between the online and in-person interventions in active ingredients relating to project design, content, programme management and the composition of the group. Key differences were in the social and contextual ingredients. Psychological, social and behavioural mechanisms for improved mental health and wellbeing included: 1) Increased self-confidence as a mother, 2) Increased positive emotional responses, 3) A supported change in identity, 4) Reduced loneliness and isolation, 5) Increased social bonding and connections with family and 6) Enhanced sense of time through new routines. Conclusions Participating in online group singing can support new mothers experiencing PND by triggering psychological, social and behavioural responses that lead to improved mental health. Key programme features are identified which can be used to design future online creative health interventions or tailor in-person activities for remote delivery to support populations who may face practical and social barriers to attending in-person.
... The study found that the singing intervention led to rapidly recovery for women with moderateto-severe PPD compared to the usual care group (11). While both the singing and play groups shared some mechanisms, the singing group had additional specific features that allowed women to feel a sense of achievement, relaxation, and immersion, providing 'me time' and relief from the concerns of motherhood (12). In addition, group singing was perceived as an authentic, social and multicultural experience that calmed the baby and strengthened the mother-child bond, with mothers attending more singing sessions on average (13). ...
Article
Full-text available
Background In the United Kingdom a singing intervention for Postpartum Depression (PPD) titled “Music and Motherhood” was found to be effective. The World Health Organization Regional Office for Europe coordinated a study to assess the feasibility of implementing and adapting the intervention in other countries. In Italy, recent studies have highlighted the need to promote the availability of effective interventions for PPD in primary care. Aim To describe the implementation of “Music and Motherhood” within the Italian primary care services dedicated to pregnancy and postnatal care in three different geographical locations, thus providing an example of strategies for implementing an arts and health intervention in primary care that can improve health and well-being. Methods A 10-week group singing intervention for mothers with PPD was conducted as part of a single arm feasibility study. Data were collected through one-to-one interviews, focus groups and questionnaires from the professionals involved in the implementation and selected participating mothers. A conceptual framework including acceptability, appropriateness, feasibility, fidelity, implementation process, costs and sustainability was adopted for analysis. Number of sessions attended by mothers and implementation outcome measures for acceptability, appropriateness and feasibility, each consisting of four items rated on a 5-point Likert scale were also gathered. Results The intervention was found to be inclusive of women from different socio-cultural backgrounds and appropriate to the context. The group setting and the use of an arts-based intervention helped to de-medicalise the process of care maximising resources. Singing helped mothers to express their feelings and find strategies to improve interaction with their child. Attention to mothers’ needs and the co-presence of the professional singing leader and a health professional were among the key factors. The median number of sessions attended was nine out of 10. In terms of acceptability, almost 90% of the professionals were in complete agreement that they liked and approved the intervention. Conclusion Our study adds to the evidence that an arts and health intervention proven effective in one culture and linguistic context can be adapted to another. Collaboration among health professionals and artists in the implementation process and adequate funding are instrumental in moving from project to programme level.
... The results of this study are largely in keeping with previous research into related interventions; shared lived experience among creative health programme participants has been identified as important for increasing feelings of social support. 47 48 Engaging in creative health programmes has been found to contribute to a renewed sense of identity, 49 increase confidence in communicating needs and experiences to others 47 and reduce feelings of loneliness and social isolation. 50 51 Some of the barriers to engagement identified by a minority of participants in the current programme appear to be novel findings such as feeling self-conscious when engaging in drama activities and the emotional consequences of sharing experiences within a group. ...
Article
Full-text available
Objectives To determine acceptability and feasibility of a theatre-based wellness programme to support the health and well-being of people with long COVID. Design Single-group, repeated-measures feasibility study. Setting Community centre and online. Participants Adults with diagnosed long COVID experiencing breathlessness, pain and/or loneliness. Intervention Six-week participatory creative programme delivered to one online and one in-person group facilitated by movement, voice and drama consultants using breathing, visualisation, singing, poetry, storytelling and movement exercises. Primary outcome measures Programme acceptability and feasibility measured via uptake, reasons for non-attendance and barriers to engagement. Secondary outcome measures Feasibility of recruitment and data collection procedures measured through proportion of missing data and follow-up rates, mechanisms of action of the programme identified through qualitative interviews, changes in mental health, well-being, quality of life, loneliness, social support, fatigue, breathlessness and post-COVID-19 functional status at 8-week follow-up. Results 21 people expressed interest in participating, 20 people took part in the programme, 19 completed baseline and 16 completed follow-up assessments. Participants attended an average of 4.8 of 6 sessions (SD=1.5, range 2–6). Exploratory analyses demonstrated significant improvements in self-rated health (t-test mean difference=0.12, 95% CI=0.00, 0.23, p=0.04) and chronic fatigue symptoms (mean difference=−3.50, 95% CI=−6.97, –0.03, p=0.05) at 8 weeks. Key mechanisms of action that supported health and well-being included: increased sense of community, illness acceptance, experiencing joy, increased confidence in managing everyday life, increased ability to relax and reconnection with previous identity. Barriers to engagement included: activities being outside of the participant's comfort zone, ongoing long COVID symptoms, emotional consequences of sharing experiences and connectivity and connecting online. Conclusions A 6-week theatre-based programme was perceived as acceptable to most participants and resulted in some positive psychosocial impacts. The findings provide a rationale for supporting the ongoing development and scale-up of this and related arts programmes to support people living with long COVID.
... Findings from this review suggested a potential for music-based mother-infant group interventions to improve maternal anxiety, stress and self-e cacy. Qualitative research conducted alongside one of the studies showed mothers found singing facilitated social cohesion (21). A subsequent process evaluation (22) of this singing intervention found postnatal mothers recommended the opportunity for coffee after each session to allow for socialising with other mothers (22). ...
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Background Postnatal mothers can experience anxiety, stress, and difficulty with mother-infant attachment with potential to lead to an anxiety disorder/depression. There has been an increase in interest in non-pharmacological interventions involving music, with limited evidence assessing effectiveness in this population within randomised controlled trials (RCTs). Mamas in Harmony is a novel music/social support intervention. The objective is to assess the feasibility/acceptability of conducting a full RCT to test the effect and cost-effectiveness of Mamas in Harmony compared with usual care. Methods The pilot RCT aims to recruit 60 mother-infant dyads through social media, community organisations and stakeholder networks, randomly allocated on a 2:1 ratio to the intervention and control group. The intervention group will receive eight one hour weekly Mamas in Harmony sessions plus usual care and the control group will receive usual care only. Feasibility measures include recruitment, retention, and attendance at intervention sessions. The process evaluation aims to establish acceptability of the intervention involving survey evaluation and semi-structured interviews. A priori guidelines have been agreed to establish criteria for progression to a definitive RCT. Discussion The current evidence supports the use of music in reducing anxiety and stress with the recommendation for inclusion of social support. This study has potential to provide robust evidence of the feasibility and acceptability of a music and social support mother-infant group intervention in preparation for a future definitive trial, should progression criteria be met. Trial registration ClinicalTrials.gov ID: NCT05930990. Registered retrospectively on 5 July 2023. Recruitment commenced on 16 March 2023. https://classic.clinicaltrials.gov/ct2/show/NCT05930990?term=music+and+social+support&draw=2&rank=1 Protocol version 30/10/2023 Vn 1.0
... Outside autism, music represents a common avenue for social interactions. Early childhood musical experiences, particularly those involving active participation such as joint caregiver-child musical play Politimou et al., 2018) or caregiver-child music classes Perkins et al., 2018), are highly social interactions present in most young children's lives (Ilari, 2016;Lamont, 2008). Among nonautistic children ranging from young toddlers and preschoolers to school-aged individuals, social musical engagement promotes children's prosocial behaviors (Beck & Rieser, 2022;Cirelli et al., 2014;Rabinowitch & Meltzoff, 2017), social attention (Kirschner & Tomasello, 2010), empathy (Rabinowitch et al., 2013), and perceived similarity with others (Rabinowitch & Knafo-Noam, 2015), as well as caregiver's positive social behaviors like smiling (Trehub et al., 2016) and gaze toward their child . ...
Article
Rhythm is implicated in both social and linguistic development. Rhythm perception and production skills are also key vulnerabilities in neurodevelopmental disorders such as autism which impact social communication. However, direct links between musical rhythm engagement and expressive communication in autism is not clearly evident. This absence of a direct connection between rhythm and expressive communication indicates that the mechanism of action between rhythm and expressive communication may recruit other cognitive or developmental factors. We hypothesized that social interactions, including general interpersonal relationships and interactive music‐making involving children and caregivers, were a significant such factor, particularly in autism. To test this, we collected data from parents of autistic and nonautistic children 14–36 months of age, including parent reports of their children's rhythmic musical engagement, general social skills, parent–child musical interactions, and expressive communication skills. Path analysis revealed a system of independent, indirect pathways from rhythmic musical engagement to expressive communication via social skills and parent–child musical interactions in autistic toddlers. Such a system implies both that social and musical interactions represent crucial links between rhythm and language and that different kinds of social interactions play parallel, independent roles linking rhythmic musical engagement with expressive communication skills.
... One mother noted "it's something I have had a countdown on" (Mother Danish Group ID6) in relation to counting down the days between the sessions, with referrers also noting there was "something predictable about it" which was "especially important" for participants (Denmark Local Staff ID1). The value of consistency and "the group" have also been highlighted in previous research exploring singing for PPD (32), and additionally align with broader theories spotlighting the importance of group-level factors to health and wellbeing. Notably, the social cure approach (which combines social identity theory and self-categorization theory) suggests that meaningful identification with a group provides psychological resources that support health (33), and this too can be applied to the context of singing (34). ...
Article
Full-text available
Background There is a burgeoning evidence-base that demonstrates the positive impact of the arts on our health, wellbeing, and health behaviors. However, very few studies have focused on how to optimize the implementation of these activities for different sociocultural contexts. Due to the increasing interest in scaling effective arts interventions as part of public health strategies, and in line with global goals of achieving health equity, this is an essential focus. Aim Using the case study of a singing for post-partum depression (PPD) intervention with empirically-demonstrated clinical effects, this brief research report explores implementation of an arts and health intervention that has been successful in the United Kingdom (“Music and Motherhood”) for the new contexts of Silkeborg (Denmark) and Cluj-Napoca (Romania). Methods Data was collected from participants at all levels of the implementation structure including at local and management levels. The study draws on qualitative implementation data to explore participant experiences, including one-to-one interviews, written testimonies, meeting minutes, ethnographic researcher reflections and focus groups, including data from 46 participants in total. Results and conclusion We explore implementation and adaptation across five key themes: (1) acceptability and feasibility; (2) practical and structural barriers and enablers; (3) adoption and sustainability; (4) broader contextual factors affecting implementation and sustainability; and (5) project structure and processes. Taken together, the themes demonstrate that arts interventions need to be adapted in culturally sensitive ways by stakeholders who have local knowledge of their environments. This research serves as an informative foundation for use by other researchers that aim to expand the reach and impact of arts-based interventions.
... Recent studies have provided irrefutable evidences in favor of the effectiveness of art-based postnatal mother-infant interventions in preventing and even reversing the PPD-associated detrimental changes in birthing women and their offspring [61,62]. Attending and participating in activities such as singing and dancing [63][64][65], craft-making [66,67], painting and drawing [68], and expressive writing [69] for instance, have been shown to be associated with beneficial alterations in maternal and infant psychosocial outcomes. AT can be combined with psychotherapy and IPT strategies for significantly enhanced rescue of depressive symptoms in postpartum women, as evidenced by a study carried out amongst Palestinian Arab population residing in Israel [66]. ...
Article
Full-text available
Postpartum depression (PPD) is classified under postpartum psychiatric disorders and initiates soon after birthing, eliciting neuropsychological and behavioral deficits in mothers and offspring. Globally, PPD is estimated to be associated with 130–190 per 1000 birthing. The severity and incidences of PPD have aggravated in the recent years due to the several unfavorable environmental and geopolitical circumstances. The purpose of this systematic review hence is to explore the contributions of recent circumstances on the pathogenesis and incidence of PPD. The search, selection and retrieval of the articles published during the last three years were systematically performed. The results from the primary studies indicate that unfavorable contemporary socio-geopolitical and environmental circumstances (e.g. Covid-19 pandemic, political conflicts/wars, and natural calamities; such as floods and earthquakes) detrimentally affect PPD etiology. A combination of socio-economic and psychological factors, including perceived lack of support and anxiousness about the future may contribute to drastic aggravation of PPD incidences. Finally, we outline some of the potential treatment regimens (e.g. inter-personal psycho- and art-based therapies) that may prove to be effective in amelioration of PPD-linked symptoms in birthing women, either alone or in complementation with traditional pharmacological interventions. We propose these psychological and art-based intervention strategies may beneficially counteract the negative influences of the unfortunate recent events across multiple cultures, societies and geographical regions.
... Fourth, previous research has demonstrated that in-person group singing can speed up recovery from PND 22 as well as support connections with other mothers and enhance motherebaby closeness. 23,24 While the COVID-19 pandemic catalysed research into the efficacy of online singing groups for PND, 25 evidence in this field remains in its infancy, and further studies are required. Songwriting has been previously investigated in a variety of clinical settings, including for addressing emotional or psychological challenges and facilitating the telling or sharing of stories. ...
Article
Full-text available
Objective: Loneliness is a public health challenge associated with postnatal depression (PND). This study developed and tested an online songwriting intervention, with the aim of reducing loneliness and symptoms of PND and enhancing social connectedness among women with young babies. Study design: This was a two-armed non-blinded randomised controlled trial (RCT, ISRCTN17647261). Methods: Randomisation was conducted in Excel using a 1:1 allocation, with participants (N = 89) allocated to an online 6-week songwriting intervention (Songs from Home) or to waitlist control. Inclusion criteria were women aged ≥18 years, with a baby ≤9 months old, reporting loneliness (4+ on UCLA 3-Item Loneliness Scale) and symptoms of PND (10+ on Edinburgh Postnatal Depression Scale [EPDS]). Loneliness (UCLA-3) was measured at baseline, after each intervention session and at 4-week follow-up. The secondary measures of PND (EPDS) and social connectedness (Social Connectedness Revised 15-item Scale [SC-15]) were measured at baseline, postintervention and at 4-week follow-up (Week 10). Factorial mixed analyses of variance with planned custom contrasts were conducted for each outcome variable comparing the intervention and control groups over time and across baseline, Weeks 1-6 and the follow-up at Week 10 for each outcome variable. Results: Compared with waitlist control, the intervention group reported significantly lower scores postintervention and at follow-up for loneliness (P < 0.001, η2P = 0.098) and PND (P < 0.001, η2P = 0.174) and significantly higher scores at follow-up for social connectedness (P < 0.001, η2P = 0.173). Conclusions: A 6-week online songwriting intervention for women with young babies can reduce loneliness and symptoms of PND and increase social connectedness.
Article
Full-text available
Postnatal depression is a type of depression occurring after a woman has given birth. Music therapy, which means using music to improve health, is considered an alternative treatment for postnatal depression. This literature review aims to investigate whether and to what extent music therapy has an effect on reducing postnatal depression symptoms. While some results show that music therapy is potentially beneficial, the research done on this topic is very limited and future studies should be done to further explore the impact of music therapy on postnatal depression.
Article
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Provođenje glazbenih aktivnosti s djecom rane i predškolske dobi u kontekstu pandemije Covid-19 novi je izazov koji je postavljen pred odgojno-obrazovne djelatnike. Dok je nastava tijekom lockdown-a bila moguća samo u virtualnom obliku uz suradnju s roditeljima/skrbnicima (Vilacheva i sur., 2021), nastavak provođenja glazbenih aktivnosti u neposrednoj odgojno-obrazovnoj praksi zahtijevalo od učitelja poštivanje određenih epidemioloških mjera. Prikazane su brojne dobrobiti glazbe na cjeloviti razvoj djeteta, među kojima se osobito ističe razvoj meta-glazbene svijesti djece, obogaćivanje meta-kognitivnih vještina i njihov transfer na druga područja. Cilj rada je prikazati relevantna i recentna istraživanja vezana uz provođenje glazbenih aktivnosti s djecom rane i predškolske dobi u vrijeme lockdown-a i pandemije Covid-19. Ističući pravo djece na glazbu u djetinjstvu, National Association for Music Education (NAfME) ukazuje da provođenje glazbenih aktivnosti s djecom treba biti imperativ bez obzira na način provođenja. Zaključeno je da unatoč nedostatcima online načina provođenja glazbenih aktivnosti takav način provođenja ima i neke prednosti. Aktivnim sudjelovanjem roditelja u glazbenim aktivnostima dolazi do razvoja njihovih glazbenih kompetencija te bolje povezanosti i suradnje s djecom. To nadalje rezultira većom učestalošću provođenja glazbenih aktivnosti u obiteljskom okruženju što ujedno doprinosi regulaciji emocija i mentalnom zdravlju kako kod djece tako i kod roditelja. Ključne riječi: djeca rane i predškolske dobi;glazbene aktivnosti;lockdown;odgojitelji i glazbeni pedagozi; pandemija Covid-19
Article
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Among mammals who invest in the production of a relatively small number of offspring, bonding is a critical strategy for survival. Mother–infant bonding among humans is not only linked with the infant’s survival but also with a range of protective psychological, biological, and behavioral responses in both mothers and infants in the post-birth period and across the life span. Anthropological theories suggest that one behavior that may have evolved with the aim of enhancing mother–infant bonding is infant-directed singing. However, to date, despite mother–infant singing being practiced across cultures, there remains little quantitative demonstration of any effects on mothers or their perceived closeness to their infants. This within-subjects study, comparing the effects of mother–infant singing with other mother–infant interactions among 43 mothers and their infants, shows that singing is associated with greater increases in maternal perceptions of emotional closeness in comparison to social interactions. Mother–infant singing is also associated with greater increases in positive affect and greater decreases in negative affect as well as greater decreases in both psychological and biological markers of anxiety. This supports previous findings about the effects of singing on closeness and social bonding in other populations. Furthermore, associations between changes in closeness and both affect and anxiety support previous research suggesting associations between closeness, bonding, and wider mental health.
Article
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Objectives This longitudinal population study aimed to investigate if maternal depression at different time points during the perinatal period impacts children’s social-emotional development at 2 years of age. Methods Participants were women (n = 1235) who gave birth at Akershus University Hospital in Norway. Maternal depressive symptoms were assessed by using the Edinburgh Postnatal Depression Scale at pregnancy week 32 and at 8 weeks and 2 years postpartum, whereas children’s social-emotional development at the age of 2 years was assessed by using the Ages and Stages Questionnaire: Social-Emotional. Bi- and multivariate logistic regression analyses were conducted to examine the linkage between maternal perinatal depression and children’s early social-emotional development. Results Multivariate analyses showed that social-emotional problems in the child 2 years after birth were strongly associated with maternal depression at pregnancy week 32 (adjusted odds ratio (aOR) 3.4; 95 % CI 1.4–8.0), depression at 8 weeks postpartum (aOR 3.8; 95 % CI 1.7–8.6), and with depression at both time points (aOR 3.7; 95 % CI 1.5–10.1). Conclusion Findings indicate pre- and postnatal depression each bears an independent, adverse impact on children’s social-emotional development.
Article
Psychobiological effects of amateur choral singing were studied in a naturalistic controlled within-subjects trial. A mixed group of novice and experienced singers (N = 21) filled out brief ad hoc questionnaires of psychological wellbeing and gave samples of saliva for measuring levels of salivary oxytocin, cortisol, and dehydroepiandrosteron (DHEA) at the beginning of 2 rehearsal sessions and 30 minutes later. The singing condition included warm-up vocal exercises and repertoire pieces. In the chatting condition, dyads of participants talked to each other about recent positive life experiences. Within-subjects, repeated measures analysis of variance (ANOVA) on self-reported and physiological measures revealed significant Time X Condition interactions for psychological wellbeing and oxytocin. Comparisons of mean scores showed patterns of changes favouring singing over chatting. There were no significant interactions for cortisol, DHEA as well as for the cortisol-DHEA-ratio. These results suggest that singing enhances individual psychological wellbeing as well as induces a socio-biological bonding response.
Article
Background This article is a process evaluation of a three-arm randomised controlled trial (RCT) comparing the effects of creative interventions on symptoms of postnatal depression (PND) in new mothers. Methods Analyses of quantitative evaluation data from 91 participants and qualitative interviews and focus groups with 80 participants and 3 members of staff. Results Key assumptions of the RCT, including how the delivery of the intervention was achieved and what the intervention involved, are explored. Data suggest that the intervention was delivered as planned with a high level of fidelity. Key uncertainties surrounding the project, in particular unanticipated challenges that had to be overcome during the RCT, are also discussed and simple recommendations for improvement are made. Conclusion This process evaluation aims to illuminate the outcome and mechanisms data from the RCT and enable organisations or individuals to ascertain the feasibility of establishing their own creative classes for women with symptoms of PND.
Article
This study assessed whether a novel psychosocial intervention could reduce symptoms of postnatal depression (PND) in the first 40 weeks post-birth. Analyses were carried out of 134 mothers with symptoms of PND randomised into 10 weeks of group singing workshops or group play workshops for them and their babies, or usual care (trial registration: NCT02526407). Overall, among all mothers with symptoms of PND, there was a non-significant faster improvement in symptoms in the singing group ( F4,262 = 1.66, P = 0.16, η² = 0.012). When isolating mothers with moderate–severe symptoms of PND, this result became significant, with a faster improvement in symptoms in the singing group ( F3.9,139.8 = 2.74, P = 0.033, η² = 0.028). Declaration of interest None.
Article
Objective The aim of this study was to gain an in‐depth understanding of the experience of women parenting toddlers and babies older than 6 months after taking part in a therapeutic support group for postnatal depression (PND). Method Thematic analysis was conducted following individual semi‐structured interviews conducted in 2014 with eight women whose children were aged between 6.5 months and 2.5 years. Results Three overarching themes and six subthemes reflecting how PND can affect parenting experiences beyond the immediate postpartum period were identified: (1) parental self‐perception; both positive: strength gained and unbroken bonds, and negative: high expectations, comparison to others and concerns about judgement; (2) parenting behaviour including difficulties regaining and managing control, and anger attributed to PND directed at siblings; and, (3) mixed feelings around partner support. Conclusion PND can impact parenting of children into toddlerhood, including parenting of an older sibling even when PND was not experienced at their birth. The importance of support in enhancing parenting skills following PND was highlighted.