Implementing a group singing intervention for postpartum depression within the Italian health service.

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.

What are the research priorities in dance for dementia? A co-created agenda to support equitable research.

BACKGROUND: There is a gap in the field of dance for dementia regarding how to engage in and improve equitable, moral, and rights-based ways of working with those with lived experience to co-design research priorities. We set out to create a collaborative research agenda for this field. METHODS: A series of collaborative activities were conducted, including an in-person workshop (n = 59 people), online workshop (n = 23 people), digital communications, podcasts, and co-writing, including with people living with dementia (PLWD), health and social care professionals, artists, arts organisational representatives, and academic researchers. RESULTS: Three key themes were constructed: 1) Improving access to dance participation; 2) Prioritising co-produced approaches; and 3) Enabling innovation in measurement and methods. CONCLUSION: This is the first co-produced agenda for the field of dance for dementia. Underpinned by diverse perspectives and lived experience, it outlines themes and associated research questions that can be used in future research.

A fRAmework of the DetermInants of Arts aNd Cultural Engagement (RADIANCE): integrated insights from ecological, behavioural and complex adaptive systems theories.

Background: Arts and cultural engagement (ACEng) is ubiquitous across every human culture since palaeolithic times, but in contemporary society, ACEng is unevenly distributed, demographically, socio-economically, geographically and politically. But what are the "determinants" of ACEng (i.e., the facilitators or barriers to people's engagement) and how can they be optimised? Despite a large body of theory and evidence on individual determinants, this work has largely occurred in disciplinary silos, which has led variously to contrasting discourses and approaches, criticism, and inconsistent findings. What we lack is a rigorous comprehensive understanding of these determinants (both those already theorised and those that have been little recognised as determinants to date) that goes beyond descriptively showing inequalities, instead explaining why these inequalities exist and how they can be overcome. This paper explores the currently recognised determinants of ACEng, and existing theoretical approaches to these determinants. Methods: Drawing on the theoretical bases of ecological systems theory, ecosocial theory and complex adaptive systems science, we conducted a review and iterative theorising process. Results: We propose a new theoretical framework of the determinants of arts and cultural engagement (RADIANCE) developed through cross-disciplinary literature reviewing, domain mapping, and consensus building. Conclusions: Overall, we identified 35 different factors that can act as determinants of ACEng across micro, meso, exo, macro and chrono levels. We broadly categorised these as social (i.e. a primary feature being the interaction of people), tangible (i.e. a primary feature involving physical assets or resources or the production of physical assets), and intangible (i.e. constructs that do not have a primary physical basis but instead have a virtual or imaginary basis). The relevance and implications of this framework for broader research, policy, and practice and case studies of it in use are presented.

All cultures across history engage in arts and cultural activities. But in modern-day society, arts engagement is unevenly patterned. Why is this and what are the factors that prevent people from engaging equitably? Much research on this topic has, to-date, happened in silos. We lack an overall theoretical framework for the barriers and enablers of arts engagement. In this article, we propose a new framework (RADIANCE) that we have developed through literature reviewing and engagement with disciplinary experts. RADIANCE proposes 35 factors that act as determinants of arts engagement at individual, community and societal levels. We define these factors and explain their interconnections as well as exploring the implications of RADIANCE for research, policy and practice.

A realist interview study of a participatory public mental health project "#KindnessByPost".

BACKGROUND: #KindnessByPost (KbP) is a participatory public health initiative in which people anonymously send and receive cards containing messages of goodwill with others also taking part in the programme. Quantitative evaluations of KbP consistently find evidence of improvements to people's mental wellbeing and feelings of loneliness after participation and three months later. Our aim in the present study is to develop a programme theory of KbP, which describes for whom the KbP intervention improves mental wellbeing, other reported impacts, in which contexts it has these effects, and the mechanisms by which it works. METHODS: We use a realist interviewing methodology to develop the programme theory. We conducted a focus group with the KbP executive team, and 20 one-to-one interviews with KbP participants. During analysis, a co-production working group iteratively developed a Theory of Change model comprising context-mechanism-outcome statements [CMOs] to map out the mechanisms present in KbP. RESULTS: We developed 145 CMO statements, which we condensed and categorized into 32 overarching CMOs across nine thematic topics: access to scheme; pathways to involvement; resources; culture; giving post; receiving post; content of received post; community; long term impact. These CMOs set out pathways through which KbP benefited participants, including from doing something kind for someone else, of receiving post and appreciating the effort that went into it, and from the creative process of creating post and writing the messages inside them. Effects were sustained in part through people keeping the cards and through the social media communities that emerged around KbP. DISCUSSION: Both giving and receiving post and the sense of community benefited participants and improved their mood and feelings of connectedness with others. Connection with a stranger, rather than friends or family, was also an important feature of the initiative for participants. Our wide range of CMO pathways by which KbP produced positive outcomes may mean that the intervention is applicable or adaptable across many communities and settings. Taken together with evidence from the quantitative evaluations, KbP is potentially an effective, low-cost, and highly scalable public health intervention for reducing loneliness and improving wellbeing.

Expanding the social cure: a mixed-methods approach exploring the role of online group dance as support for young people (aged 16-24) living with anxiety.

There is an increased interest in whether online arts interventions support mental health and social connections. This study explored eight weeks of online group dance as support for young people (aged 16-24) living with anxiety. The applicability of the 'social cure' theoretical framework to the novel context of an online dance class was sought. The study utilised an embedded QUAL+quan design, incorporating participatory focus group discussions (n = 3 groups; n = 11 participants) and one-on-one interviews (n = 2 participants), creative reflections (n = 16 participants) and ethnographic fieldnotes, and a repeated measures design with surveys at three timepoints (week 1, n = 27; week 4, n = 18; week 8, n = 14). Thematic analysis identified two overarching themes demonstrating how the dance classes (i) provided the opportunity to co-construct a meaningful shared identity and (ii) supported holistic wellbeing. The quantitative findings supported this, suggesting lower anxiety, depression, and loneliness and higher wellbeing, self-esteem, self-efficacy, and group closeness. This study expands the social cure to its application to an online dance context for the first time.

Online 'chats': fostering communitas and psychosocial support for people working across arts and play for health and wellbeing.

Loss of work, furlough, and increased social isolation were prevalent for many working in the broad context of cultural and community engagement for health and wellbeing. This study set out to explore if and how regular online group interactions may foster social cohesion and provide support for these individuals during the critical time of the COVID-19 global pandemic. It was conducted in the context of the 'social cohesion chat' series led by a network called the Arts Play Health Community which was initiated in response to the pandemic as a way to bring those working in or connected to arts, play and health together during times of social isolation. Two qualitative focus groups with creative, participatory components were conducted with artists, researchers, evaluators, and arts/play managers (n = 11), and then analyzed using thematic analysis. Researcher ethnographic reflections and fieldnotes were also collected and analyzed. The authors engaged in reflexive online discussions to integrate and synthesize findings across different data. Four themes were constructed through the analysis procedure: (1) 'Building an online community as processes of communitas', spotlighting the importance of the non-hierarchical structure of the 'chats' particularly in relation to there being 'no end goal' to the online dialogues; (2) 'Individual and shared emotional experiences' that underpinned feelings of connection to others and the online space; (3) 'Psychosocial benefits' such as improving confidence and providing an opportunity to 'have a voice' in the community; and (4) 'The importance of facilitation', highlighting the opportunities the chats provided for participants to feel validated and valued as an active member of the community. The article concludes that constructing an inclusive and welcoming online community, where active participation is at the heart of regular social interactions can provide support for those working across arts and play for health and wellbeing. This was particularly important during the societal turbulence of the COVID-19 pandemic. It further concludes by noting the unique structure of these online dialogues as not being connected to institutions, with this playing a key role in allowing those in the community to 'be themselves' within it.

Interventions to Modify Psychological Well-Being: Progress, Promises, and an Agenda for Future Research.

Psychological well-being, characterized by feelings, cognitions, and strategies that are associated with positive functioning (including hedonic and eudaimonic well-being), has been linked with better physical health and greater longevity. Importantly, psychological well-being can be strengthened with interventions, providing a strategy for improving population health. But are the effects of well-being interventions meaningful, durable, and scalable enough to improve health at a population-level? To assess this possibility, a cross-disciplinary group of scholars convened to review current knowledge and develop a research agenda. Here we summarize and build on the key insights from this convening, which were: (1) existing interventions should continue to be adapted to achieve a large-enough effect to result in downstream improvements in psychological functioning and health, (2) research should determine the durability of interventions needed to drive population-level and lasting changes, (3) a shift from individual-level care and treatment to a public-health model of population-level prevention is needed and will require new infrastructure that can deliver interventions at scale, (4) interventions should be accessible and effective in racially, ethnically, and geographically diverse samples. A discussion examining the key future research questions follows.

The arts in public health policy: progress and opportunities.

There is a growing body of evidence indicating the arts have a role to play in promoting good health and preventing and managing illness. WHO has called for governments to take an intersectoral approach, both within and across traditional areas of policy, to realise the potential of the arts for public health. To explore what global progress is being made towards this aim, we present examples of arts and health policy development from diverse government areas: health, arts, local governments, and cross government. These examples, which have been selected from a scoping review of 172 relevant global policy documents, indicate that many health and arts policy makers view the relationship between arts engagement and improved health in quite general terms, although some are investing in more targeted applications of the arts to address specific public health issues. The most promising and concrete commitments are happening when health and arts ministries or agencies work together on policy development.

Making space to learn about teaching: expanding teaching horizons through postgraduate education.

Clinicians develop as teachers via many activities, from on-the-job training to formal academic programmes. Yet, understanding how clinicians develop the sensibilities of an educator and an appreciation of the complexity of educational environments is challenging. Studies of teacher development have maintained a relatively narrow definition of educational practice. A more expansive view encompasses clinical teachers' roles in relation to elements beyond learners or content, such as the cultures and other structures of healthcare institutions. In our online Postgraduate Certificate in Clinical Education, space and structure are intentionally created for teachers to think and talk about education with colleagues in other disciplinary contexts. We interviewed 17 students about how their approaches to teaching had changed over a year of part-time study, using their teaching philosophies, written at the start of the programme, as points of contrast. We took an abductive approach to data analysis, drawing on the literature and, unavoidably, our own reflexive interpretations of our practice outside of the research context, such as conversations with students and colleagues; our experiences of teaching and our concurrent research and scholarship. Our themes of repertoire building, perspective shifting, embodied practice, and appreciation of context, describe the increasing complexity of individuals' considerations of teaching. We use our analysis as the basis for a discussion of the blurring of boundaries between staff and students on such programmes as both groups are engaged in an ongoing continuum of development as all teachers, continue to be learners of educational practice. These insights can inform the ways in which postgraduate programmes can make space for clinical teachers to share and reflect on practices, perspectives and contexts.

Implementing a singing-based intervention for postpartum depression in Denmark and Romania: a brief research report.

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.

Understanding changes to perceived socioeconomic and psychosocial adversities during COVID-19 for UK freelance cultural workers.

There is a dearth of qualitative research exploring how freelancers working in the cultural industries have been affected during COVID-19. In particular, there is a lack of research exploring how socioeconomic and psychosocial adversities may have changed or evolved, and how these changes have been perceived and subjectively experienced by freelance cultural workers. This study builds on qualitative interviews carried out in July-November 2020 (n = 20) by exploring findings from follow-up interviews conducted in May-July 2021 (n = 16). It presents an inequality of experiences connected to a range of socioeconomic and psychosocial factors, showing how some freelancers experienced small changes (e.g. to the kind of work carried out), with others experiencing major changes (e.g. leaving the sector completely). It concludes with a call for highly bespoke financial and psychological support, as well as a need to rethink what cultural value is for this workforce in the "new normal", considering changing valuing processes.

Scalability of a singing-based intervention for postpartum depression in Denmark and Romania: protocol for a single-arm feasibility study.

INTRODUCTION: Postpartum depression (PPD) affects around one in seven women globally, with these women in need of non-pharmaceutical treatment strategies. There is a long history of the benefits of singing for maternal mental health, and promising research exists showing the clinical effectiveness of group singing. Group singing interventions are being scaled up to support new mothers in the United Kingdom, but we do not know if such an intervention may benefit women in different cultural contexts. This protocol focuses on exploring the feasibility of implementation and perceived impact of a 10-week group singing intervention for new mothers in Romania and Denmark eliciting signs of PPD. METHODS AND ANALYSIS: Data will be collected from up to 48 women with a score ≥10 on the Edinburgh Postnatal Depression Scale (EPDS) participating in a 10-week group singing intervention in Denmark or Romania, as well as a range of project stakeholders. The singing classes will take place in person and be facilitated by professional singing leaders. Feasibility of implementation will be analysed through qualitative data (eg, focus groups, interviews) and quantitative data (eg, the Feasibility of Intervention Measure). Perceived impact will be explored via surveys that include mental health measures (EPDS, Multidimensional Scale of Perceived Social Support, WHO Five Well-Being Index) from singing intervention participants (at weeks 1, 6, 10) and focus groups. Descriptive statistics, repeated measures analysis of variance and analysis of covariance will be used to analyse quantitative data. Framework method and thematic analysis will be used to analyse qualitative data. ETHICS AND DISSEMINATION: The national ethics committees in Romania (IRB-PH Protocol #2021-211217-012) and Denmark (case number 1-10-72-274-21) have approved the study, as has the Ethics Review Committee at the World Health Organization (ERC.0003714). All participants will be required to provide informed consent. Results will be disseminated by reports published by the WHO Regional Office for Europe, peer-reviewed publications and at conferences.

What are the active ingredients of 'arts in health' activities? Development of the INgredients iN ArTs in hEalth (INNATE) Framework.

BACKGROUND:  There is a scarcity of research concerning what it is about arts engagement that may activate causal mechanisms leading to effects on health and wellbeing outcomes: their active ingredients. Further, the limited studies that do exist have tended to be relevant to specific contexts and types of art forms. The aim of this study was to carry out a comprehensive mapping of potential active ingredients, construct a shared language, and propose a framework and toolkit to support the design, implementation, and evaluation of arts in health activities.  Methods: Drawing upon Rapid Appraisal techniques and collaborating with 64 participants, we engaged in a three-phase process: 1) a scoping review to inform the development of an initial framework; 2) consultation on the initial framework; and 3) analysis and construction of the INNATE framework.   Results: The study identified 139 potential active ingredients within the overarching categories of  project, people, and  contexts.  Project components relate directly to the content of the arts activity itself, intrinsic to what the activity is. The  people category denotes how people interact through engagement with the activity and who is involved in this interaction, including activity facilitation.  Contexts relates to the activity setting comprising the aggregate of place(s), things, and surroundings. Aligning with complexity science, Ingredients may overlap, interconnect, or feed into one another to prompt mechanisms, and may not be experienced as distinct by participants.   Conclusions: Our mapping exercise is the most extensive to date. In relation to arts in health activities, the INNATE framework can support with: design and implementation, such as co-producing an intervention to meet the needs of a particular population; evaluation, such as facilitating the comparison of different interventions and their efficacy; and replication, scalability, and sustainability through enabling detailed reporting and specific articulation of what an arts in health activity entails.

Group singing in bereavement: effects on mental health, self-efficacy, self-esteem and well-being.

OBJECTIVES: Bereavement is associated with negative affective, cognitive, behavioural and physiological responses. However, factors, such as coping, self-efficacy and self-esteem, can buffer negative effects of grief, and can be increased through mutual support interventions, such as shared leisure activities. This study used a non-randomised controlled design to explore the effects of group choir singing on mental health among people who have been bereaved due to cancer. METHODS: A total of 58 adults bereaved in the last 5 years who had not started psychological therapy in the last 12 weeks or medication for anxiety or depression in the last month were recruited and elected to join a choir (n=29) or participate in the non-intervention control group (n=29). Joining a choir involved engaging in 90 min weekly singing and social sessions for 12 weeks with a post-intervention assessment at week 24. We used linear mixed effects models adjusted for demographics, health-related variables, musical engagement and time since bereavement to model changes over time between the two groups in symptoms of anxiety, depression, well-being, self-efficacy and self-esteem. RESULTS: Participants who sang in a choir had more stable symptoms of depression and levels of well-being, as well as gradual improvements in their sense of self-efficacy and self-esteem over the 24 weeks. In contrast, those in the control group showed gradual increases in depressive symptoms, reductions in levels of well-being and self-esteem and no improvement in their self-efficacy. These results were independent of all covariates. CONCLUSIONS: Weekly group singing could be a promising mutual support intervention for people experiencing grief. TRIAL REGISTRATION NUMBER: NCT02756780.

Socioeconomic and Psychosocial Adversities Experienced by Freelancers Working in the UK Cultural Sector During the COVID-19 Pandemic: A Qualitative Study.

There are concerns that the socioeconomic consequences of COVID-19, including unemployment and financial insecurity, are having adverse effects on the mental wellbeing of the population. One group particularly vulnerable to socioeconomic adversity during this period are those employed freelance within the cultural industry. Many workers in the sector were already subject to income instability, erratic work schedules and a lack of economic security before the pandemic, and it is possible that COVID-19 may exacerbate pre-existing economic precarity. Through interviews with 20 freelancers working within the performing arts, visual arts, and film and television industries, this article explores the impact of the pandemic on their working lives. Findings suggest the pandemic is affecting the psychological wellbeing of freelancers through employment loss, financial instability and work dissonance, and illustrates the need for urgent economic and psychosocial support for those employed within the cultural sector.

Psychosocial singing interventions for the mental health and well-being of family carers of patients with cancer: results from a longitudinal controlled study.

OBJECTIVE: The mental health challenges facing people who care for somebody with cancer are well documented. While many support interventions focus on provision of information or cognitive behavioural therapy, the literature suggests that psychosocial interventions could also be of value, especially given the low social support frequently reported by carers. Singing is a psychosocial activity shown to improve social support, increase positive emotions, and reduce fatigue and stress. This study explored whether weekly group singing can reduce anxiety, depression and well-being in cancer carers over a 6-month period. DESIGN: A multisite non-randomised longitudinal controlled study. SETTING: The Royal Marsden National Health Service Trust in Greater London. PARTICIPANTS: 62 adults who currently care for a spouse, relative or close friend with cancer who had not recently started any psychological therapy or medication. INTERVENTIONS: On enrolment, participants selected to join a weekly community choir for 12 weeks (n=33) or continue with life as usual (n=29). OUTCOME MEASURES: The primary outcome was mental health using the Hospital Anxiety and Depression Scale. The secondary outcome was well-being using the Warwick Edinburgh Mental Wellbeing Scale. Using linear mixed effects models, we compared the change in mental health and well-being over time between the two groups while adjusting for confounding variables including demographics, health-related variables, musical engagement and length of time caring. RESULTS: Participants in the choir group showed a significantly greater decrease in anxiety over time than participants in the control group (B=-0.94, SE=0.38, p=0.013) and a significantly greater increase in well-being (B=1.25, SE=0.49, p=0.011). No changes were found for depression. Sub-group analyses showed carers with anxiety or below-average well-being were most likely to benefit. CONCLUSIONS: This study builds on previous research showing the mental health benefits of singing for people with cancer by showing that weekly singing can also support anxiety and well-being in cancer carers.

How does the process of group singing impact on people affected by cancer? A grounded theory study.

OBJECTIVE: This study aimed to build an understanding of how the process of singing impacts on those who are affected by cancer, including patients, staff, carers and those who have been bereaved. DESIGN: A qualitative study, informed by a grounded theory approach. SETTING AND PARTICIPANTS: Patients with cancer, staff, carers and bereaved who had participated for a minimum of 6 weeks in one of two choirs for people affected by cancer. METHODS: 31 participants took part in Focus Group Interviews lasting between 45 min and an hour, and 1 participant had a face-to-face interview. FINDINGS: Four overarching themes emerged from the iterative analysis procedure. The overarching themes were: building resilience, social support, psychological dimensions and process issues. Following further analyses, a theoretical model was created to depict how building resilience underpins the findings. CONCLUSION: Group singing may be a suitable intervention for building resilience in those affected by cancer via an interaction between the experience and impact of the choir.