1
00:00:00,060 --> 00:00:04,170
So over to you, Alex. Fantastic.

2
00:00:04,180 --> 00:00:08,850
Thank you so much, Stephanie. And again, apologies for not being there in person.

3
00:00:10,410 --> 00:00:18,150
So, yeah, I'm Alex Burton. I'm a senior research fellow based within the Social Biobehavioral Research Group here at University College London,

4
00:00:18,780 --> 00:00:21,780
and the teams led by Dr. Daisy Fancourt.

5
00:00:21,780 --> 00:00:28,399
And we're really interested in studying the role of social factors on health, and this includes social deficits.

6
00:00:28,400 --> 00:00:36,420
So things like loneliness, social isolation, social restrictions, for example, during the pandemic as well as social assets.

7
00:00:36,420 --> 00:00:43,770
So thinking about social connections, arts, cultural and community engagement, nature engagement and social prescribing,

8
00:00:44,370 --> 00:00:49,530
and more specifically, we want to unpick the effects of social factors on health outcomes.

9
00:00:49,680 --> 00:00:55,680
We look at the psychological, biological, social and behavioural mechanisms underlying these effects.

10
00:00:56,310 --> 00:01:01,049
We also look for differential patterns, barriers and enablers of social behaviours.

11
00:01:01,050 --> 00:01:07,350
So including thinking about engagement in the arts is a big focus among different groups of people.

12
00:01:08,310 --> 00:01:13,020
And my research is particularly interested in studying the impact of these activities,

13
00:01:13,020 --> 00:01:18,960
these deficits and assets on mental health, and particularly among people with severe mental illnesses.

14
00:01:20,220 --> 00:01:23,190
And I'm predominately a qualitative researcher,

15
00:01:23,220 --> 00:01:32,370
but I also have managed clinical trials and I think when we talk through understandably a lot of these methods complement one another.

16
00:01:34,310 --> 00:01:38,300
So let's see if I can get the slide to move.

17
00:01:38,330 --> 00:01:45,049
There we go. So I'm just going to give a very broad overview of arts and health and briefly describe

18
00:01:45,050 --> 00:01:49,370
some of the methodologies that we frequently used to conduct research in this area.

19
00:01:50,060 --> 00:01:54,020
I'll then move on to talk about the history and the development of the shape of

20
00:01:54,020 --> 00:01:58,670
Postnatal Depression project as a case study example of a mixed message design.

21
00:01:59,180 --> 00:02:03,350
And I'll finish with some thoughts around how we might evaluate mixed methods research.

22
00:02:03,350 --> 00:02:09,800
But I won't go into too much detail on that because I think that's already been covered in your previous lectures.

23
00:02:12,680 --> 00:02:20,419
So it may seem pretty straightforward, but I think it's always useful to begin by defining the broader concepts that we're

24
00:02:20,420 --> 00:02:26,870
interested in exploring within our research and defining what art is and what it is not.

25
00:02:26,930 --> 00:02:36,319
Can be quite a difficult task and it's subject to ongoing debates, depending on who you talk to, thinking about who's delivering the interventions,

26
00:02:36,320 --> 00:02:41,000
who's receiving them, as well as people who are involved in funding these types of interventions.

27
00:02:42,260 --> 00:02:48,650
However, despite these complexities, several characteristics have been recognised as fundamental to a definition of art.

28
00:02:49,100 --> 00:02:52,489
And there's a really, really good resource outlines this debate,

29
00:02:52,490 --> 00:02:58,190
which is the World Health Organisation evidence synthesis written by Foucault and Sydney in 2019.

30
00:02:59,000 --> 00:03:06,620
So in this report the key characteristics outlined include firstly that as an art objects be that physical or experiential,

31
00:03:06,620 --> 00:03:09,080
which is meaningful for those who engage in it.

32
00:03:09,980 --> 00:03:16,790
Secondly, that imaginative experiences often accompany these meaningful engagements in art for both those who create the objects,

33
00:03:17,120 --> 00:03:24,170
as well as those who receive those objects. And they normally comprise or provoke some sort of emotional response.

34
00:03:25,620 --> 00:03:29,250
So within this frame of understanding in relation to health research,

35
00:03:29,760 --> 00:03:34,320
engagement with the arts is being proposed as consisting of five broad categories.

36
00:03:34,920 --> 00:03:38,999
So we look at performing arts activities such as singing in a choir,

37
00:03:39,000 --> 00:03:45,990
which is one of the interventions I'll be talking about digital arts activities, including animation and filmmaking.

38
00:03:46,650 --> 00:03:49,830
Visual arts participation including crafts and design.

39
00:03:50,490 --> 00:03:56,399
Cultural engagement such as visiting a museum or going to a concert or gallery of literature.

40
00:03:56,400 --> 00:04:05,070
Engagement such as reading or writing. And within these categories, there's a diverse range of different types of engagement.

41
00:04:05,220 --> 00:04:09,660
And that includes both active engagement, such as participatory arts program.

42
00:04:09,680 --> 00:04:14,969
So taking part in a drama group or a dance group as well as receptive engagement.

43
00:04:14,970 --> 00:04:26,190
As I've talked about though, with audience viewing objects or objects and similarly defining what health is can also be a difficult task.

44
00:04:26,940 --> 00:04:32,370
And I think it's really important with within arts and health research to consider the complexities of this and what

45
00:04:32,370 --> 00:04:41,040
we mean by health and the World Health Organisation back in 1948 defined health as a state of complete physical,

46
00:04:41,070 --> 00:04:45,990
mental and social wellbeing and not merely the absence of disease or infirmity.

47
00:04:46,800 --> 00:04:55,500
And I think this is really important for the research that we do because it situates health firmly within society and within culture,

48
00:04:55,800 --> 00:05:00,180
such as how health is shaped by the cultural constructs within which it is situated.

49
00:05:01,410 --> 00:05:09,600
And that helps us to consider health at different levels of analysis, including the individual, the group, the community and the societal perspective.

50
00:05:09,990 --> 00:05:16,350
So some examples of the societal perspective include whether you see an integrated or that you're contributing to society,

51
00:05:16,680 --> 00:05:22,230
as well as if you feel accepted and whether you trusted or trust others within social groups.

52
00:05:23,430 --> 00:05:30,180
So as you can see, it's been some time since this definition was put forward by the World Health Organisation and the concept of health continues

53
00:05:30,180 --> 00:05:38,670
to shift and change and it depends on the disciplines that also are studying health interventions that help to improve health.

54
00:05:39,570 --> 00:05:44,430
And but I think one of the key things is that we need to recognise that complete health may

55
00:05:44,430 --> 00:05:50,009
not be as antibodies go and rather concepts of supporting people to live well for example,

56
00:05:50,010 --> 00:05:56,550
with a chronic condition or a life limiting illness are becoming more common.

57
00:05:57,330 --> 00:06:02,819
And I think arguably this approach also aligns with the more recent biopsychosocial model of health,

58
00:06:02,820 --> 00:06:11,310
which considers the importance of biological, psychological and social factors and the complex interactions to understanding health and illness.

59
00:06:14,370 --> 00:06:23,040
So considering these different dimensions of arts and health, this logic model has been proposed to explain how and why the arts may support health.

60
00:06:24,000 --> 00:06:26,250
So arts and culture, understandably,

61
00:06:26,250 --> 00:06:34,170
combine lots of different components that we know are probably beneficial for our health for example sensory activation,

62
00:06:34,170 --> 00:06:37,200
cognitive stimulation and social interactions.

63
00:06:37,800 --> 00:06:43,950
And again, these components can prompt psychological, biological, social or behavioural responses.

64
00:06:44,340 --> 00:06:52,350
So, for example, if an arts intervention involves some sort of cognitive stimulation that may help people living with dementia,

65
00:06:53,400 --> 00:07:00,270
it may help manage symptoms of cognitive decline, or it may even help prevent or lower the risk of dementia.

66
00:07:00,280 --> 00:07:08,670
Developing social interaction may reduce feelings of loneliness, which is a known risk factor for poorer mental and physical health.

67
00:07:09,990 --> 00:07:14,100
And multiple components of arts activities may lead to reduced stress hormonal

68
00:07:14,100 --> 00:07:18,839
responses whereby stress is a known risk factor for many health conditions,

69
00:07:18,840 --> 00:07:26,450
for example, cardiovascular diseases, and that some components of arts activities may include physical activity.

70
00:07:26,460 --> 00:07:36,390
So particularly with dance groups or dance activities which may use an increase in exercise which can then be used to prevent or manage illnesses.

71
00:07:38,110 --> 00:07:40,629
So these are just sort of some of the mechanisms of health.

72
00:07:40,630 --> 00:07:46,600
So the causal processes that these components set in motion and these processes are linked to prevention,

73
00:07:46,600 --> 00:07:51,620
management and treatment of health conditions. And aligning this with the mixed methods approach.

74
00:07:51,640 --> 00:07:56,799
I think, you know, the point is that we might need different methodologies or we might need combined

75
00:07:56,800 --> 00:08:01,420
methodologies to really unpick some of what's going on within arts interventions.

76
00:08:04,790 --> 00:08:10,880
So as I've hopefully presented that at the arts complex interventions,

77
00:08:11,900 --> 00:08:16,250
there are often multiple components involved in their delivery and the Medical

78
00:08:16,250 --> 00:08:20,329
Research Council recognises the complexity of psychosocial interventions.

79
00:08:20,330 --> 00:08:27,440
So more traditional psychological interventions in health care and design defines these interventions as those that have

80
00:08:27,440 --> 00:08:34,160
several interacting components where there's difficulty of standardising the design and delivery of those interventions,

81
00:08:34,520 --> 00:08:37,700
where there's a sensitivity to features of the local context.

82
00:08:37,700 --> 00:08:45,229
So an intervention might need to be adapted, adapted depending on where it's being delivered and where there's complexity around the

83
00:08:45,230 --> 00:08:49,070
causal chains that link the intervention with the outcomes that we're interested in.

84
00:08:50,240 --> 00:08:55,160
And while all of these characteristics fit in with our definition of arts activities,

85
00:08:55,160 --> 00:09:01,970
I think it's this latter point that resonates with some of the challenges we face when we do research in arts and health.

86
00:09:02,930 --> 00:09:09,140
And our team has recently published a theoretical framework called the Multilevel Nature Mechanisms Framework,

87
00:09:09,860 --> 00:09:14,270
which highlights this complexity specifically within leisure and arts activities.

88
00:09:14,720 --> 00:09:22,580
And it's a review of the evidence. The framework was developed as a review of the evidence, looking at different theories,

89
00:09:22,580 --> 00:09:29,270
different disciplines, different methodologies, all the way from basic lab studies to RC cities.

90
00:09:30,290 --> 00:09:36,470
And the review identified over 600 potential mechanisms that link arts and leisure activities to health.

91
00:09:36,950 --> 00:09:39,380
So it's very complex. It's.

92
00:09:41,090 --> 00:09:51,050
And in terms of research methodologies, most of the work that I do is around testing interventions or community activities,

93
00:09:51,710 --> 00:09:57,590
either through feasibility studies, randomised controlled trials or observational studies,

94
00:09:58,040 --> 00:10:03,110
as well as conducting embedded qualitative work to understand experiences of engagement,

95
00:10:03,200 --> 00:10:09,260
how or why they support mental health in particular, as well as barriers to engagement in the arts.

96
00:10:10,280 --> 00:10:13,560
And a core part of the wider team's work is to look at big data.

97
00:10:13,580 --> 00:10:20,090
So we look at longitudinal evidence, thinking about who's engaging, whether there are predictors of engagement,

98
00:10:20,090 --> 00:10:28,040
whether engagement is linked to health outcomes as well as any characteristics that we find people aren't engaging in the arts.

99
00:10:28,910 --> 00:10:35,870
Some of our work has also looked at basic science studies. So thinking about biological sampling, as I mentioned, in the mechanisms model.

100
00:10:36,620 --> 00:10:43,790
So for example, we might measure someone's stress hormone markers before they engage in that arts activity as well as after.

101
00:10:46,220 --> 00:10:51,170
And I think you've covered this hopefully a lot in your mixed methods course.

102
00:10:52,760 --> 00:11:04,250
But I guess just to reiterate that there seems to be four key mixed method designs that are employed in mixed methods research.

103
00:11:04,670 --> 00:11:09,110
And this is taken from a really helpful summary from Shelton and Smith.

104
00:11:09,620 --> 00:11:16,849
And I think the crucial consideration, again, hopefully you've already learned about this is that thinking about what the aim of your research is and

105
00:11:16,850 --> 00:11:24,110
the research questions you really want to answer and understanding the type of approach you wish to use.

106
00:11:25,160 --> 00:11:32,570
I think the key thing is whether your quantitative and qualitative data will inform, explain or complement one another.

107
00:11:33,500 --> 00:11:41,540
And again, this has an impact on data collection, just applying this to the work that we do and in our team.

108
00:11:41,660 --> 00:11:48,559
So for example, an explanatory sequential design may be the most relevant if we want to,

109
00:11:48,560 --> 00:11:53,840
for example, explore whether engagement in arts activities supports wellbeing in adults.

110
00:11:54,320 --> 00:12:00,380
So we might start with a national survey to older adults looking at whether arts engagement is related to wellbeing.

111
00:12:01,190 --> 00:12:06,709
But we might want to then do some qualitative interviews to explore how engagement in the arts supports wellbeing.

112
00:12:06,710 --> 00:12:13,550
So really looking at what some of those mechanisms might be and applying the associations we might find within a survey.

113
00:12:14,960 --> 00:12:17,210
In terms of the exploratory sequential,

114
00:12:17,300 --> 00:12:24,890
we may find in the literature that there's not been very much around wild and adults may or may not be engaging in the arts.

115
00:12:25,400 --> 00:12:29,870
So we may want to start by doing some qualitative work and using focus groups,

116
00:12:29,870 --> 00:12:34,370
for example, within the local area to discuss barriers and facilitators.

117
00:12:34,730 --> 00:12:39,889
And we might then use that to create a national survey to kind of generalise the

118
00:12:39,890 --> 00:12:46,940
findings from the qualitative work and to expand the kind of reach of the the findings.

119
00:12:47,900 --> 00:12:54,889
In terms of the parallel design, I think you've also called that story.

120
00:12:54,890 --> 00:12:59,620
I've just. We could be virgins.

121
00:12:59,950 --> 00:13:02,540
Yeah, yeah, yeah.

122
00:13:02,710 --> 00:13:11,740
So, in terms of the convergent design, um, you may, we may want to look at what coping strategies and support systems are used by older adults.

123
00:13:12,130 --> 00:13:21,310
So again, we may want to collect data at the same time and really triangulate and and look at the data together to think about a broader,

124
00:13:21,310 --> 00:13:25,360
deeper understanding of the coping strategies and support systems available.

125
00:13:26,140 --> 00:13:31,420
And then the final design, which is the big qual, small quant or big quantum small.

126
00:13:31,860 --> 00:13:40,089
So for example, we may want to look at testing an activity group programme without primary aim effectiveness,

127
00:13:40,090 --> 00:13:49,659
so looking at outcomes of wellbeing and depression. But within that, we may want to embed a qualitative study which focuses on user experiences.

128
00:13:49,660 --> 00:13:55,780
So answering a slightly different question to the main question, that date that that question is complementary.

129
00:13:58,320 --> 00:14:08,010
So I'm not going to move on to talk about some work that we have been doing around community singing groups for postnatal depression.

130
00:14:08,700 --> 00:14:17,299
And so. It's now called the Shape a program, but it began as the music and other research projects,

131
00:14:17,300 --> 00:14:21,740
which was led by the Centre for Performance Science, Imperial College, London and UCL.

132
00:14:22,730 --> 00:14:27,170
And this project evaluated the effectiveness of creative interventions,

133
00:14:27,170 --> 00:14:33,140
including singing and play a psychological social tools to reduce postnatal depression symptoms.

134
00:14:35,630 --> 00:14:39,620
So just a bit of background around why this study was conducted.

135
00:14:40,550 --> 00:14:48,620
So postnatal depression is characterised by psychological and behavioural changes and it affects at least 12% of new mothers.

136
00:14:49,850 --> 00:14:56,750
Many women report difficulties accessing pharmacological or psychological treatments to support symptoms,

137
00:14:57,200 --> 00:15:04,310
and barriers to treatment have been identified, which include a lack of awareness that they're experiencing postnatal depression,

138
00:15:05,060 --> 00:15:11,180
a lack of awareness that their services are available to support some women if reported fear or

139
00:15:11,180 --> 00:15:16,570
repercussions if a mental illness is disclosed to healthcare professionals or to professionals,

140
00:15:16,580 --> 00:15:22,520
full stop. And some women also feel a sense of social stigma and feel like they should be

141
00:15:22,520 --> 00:15:27,200
able to cope with new motherhood and don't want to share that they're struggling.

142
00:15:28,520 --> 00:15:33,499
That's also an inadequate treatment and screening pathways for postnatal depression.

143
00:15:33,500 --> 00:15:38,210
So there's a need to identify alternative ways to support the mental health of new mothers.

144
00:15:40,950 --> 00:15:47,340
So the evidence base is growing, so community arts based programs to support mental health and wellbeing.

145
00:15:48,090 --> 00:15:53,520
And there's a lot of evidence around group singing, particularly in mental health.

146
00:15:53,910 --> 00:15:58,650
So it's been found to support recovery and it's associated with social bonding.

147
00:15:59,580 --> 00:16:07,680
And a systematic review conducted by Perkins Attell found that singing helps people to manage and express their emotions.

148
00:16:08,070 --> 00:16:16,680
It helps them to facilitate self-development, provides respite, so distraction and absorption, and it facilitates social connection.

149
00:16:18,630 --> 00:16:24,720
And there's also been growing evidence base around singing to infants,

150
00:16:25,620 --> 00:16:32,519
which has shown that singing to infants improves mother infant interactions as well as reduces biological markers of stress,

151
00:16:32,520 --> 00:16:42,190
both in mothers and in the infants. So this was a randomised controlled trial.

152
00:16:42,280 --> 00:16:47,799
So it was an embedded study with the the big quantitative and the small qualitative

153
00:16:47,800 --> 00:16:51,310
because the primary aim was to establish effectiveness of the singing groups.

154
00:16:51,910 --> 00:17:01,150
And so a trial was conducted with 134 mothers experiencing postnatal depression who were allocated to one of 310 week programmes.

155
00:17:02,050 --> 00:17:07,030
So the group singing programmes are run by an organisation called Brief Arts Health

156
00:17:08,080 --> 00:17:12,670
and the program is delivered to groups of 8 to 12 mothers in weekly sessions,

157
00:17:12,670 --> 00:17:21,250
which last an hour and the mothers all start a block of sessions together and they continue with the same group leader for the duration of the course.

158
00:17:21,760 --> 00:17:30,669
The classes are free and they take place in children's centres or the community venues in London and mothers attend with their babies and classes.

159
00:17:30,670 --> 00:17:35,559
They start with welcome songs, they introduce the babies and mothers to one another,

160
00:17:35,560 --> 00:17:41,470
and then the classes involve a range of singing and music activities, including simple instruments.

161
00:17:41,890 --> 00:17:49,480
And the mothers and babies can play these instruments together. Another aspect is that mothers can write some of their own songs over the weeks,

162
00:17:49,480 --> 00:17:54,760
and they can develop their own lyrics together, either about their babies or experiences of motherhood.

163
00:17:55,120 --> 00:18:02,410
And they can also create simple melodies. And recordings of the songs are also made available online for the mothers to listen to at home.

164
00:18:03,790 --> 00:18:12,759
And the classes are led by professional workshop leaders trained by free thoughts house and they're supported by facilitators and times.

165
00:18:12,760 --> 00:18:19,239
It's a creative play intervention. These workshops involving mothers engaging in sensory play with babies,

166
00:18:19,240 --> 00:18:23,770
with their babies, doing arts and crafts activities and playing simple games together.

167
00:18:24,430 --> 00:18:30,370
And those randomised to routine care didn't receive any workshops above and beyond usual care,

168
00:18:30,370 --> 00:18:35,290
but they were provided with the singing groups at the end of the research study.

169
00:18:36,970 --> 00:18:41,440
So as I mentioned, it's an embedded study, so there are some secondary aims there.

170
00:18:41,440 --> 00:18:47,200
So again, thinking about those mechanisms, why might singing support people's mental health?

171
00:18:47,200 --> 00:18:51,189
So the qualitative work which was done through focus groups and interviews,

172
00:18:51,190 --> 00:18:58,690
was around what features of the singing groups support recovery and a process evaluation was also conducted.

173
00:18:58,690 --> 00:19:05,380
So thinking about whether the groups were feasible, whether they were acceptable, and whether they were delivered as intended.

174
00:19:08,750 --> 00:19:17,930
So in terms of the effectiveness, the primary outcome was the Edinburgh postnatal depression scale and as you can see from these graphs,

175
00:19:18,410 --> 00:19:22,820
there was a significant decrease across time in postnatal depression scores

176
00:19:23,180 --> 00:19:28,100
indicating that women in all three groups experienced improvements in the symptoms.

177
00:19:28,670 --> 00:19:34,040
But if you look at the bottom line, which is the singing group, the dark blue group,

178
00:19:34,490 --> 00:19:38,450
you can see that sometimes with moderate to severe symptoms of postnatal depression,

179
00:19:38,450 --> 00:19:44,390
the group singing program led to a significantly faster recovery and care as normal.

180
00:19:45,440 --> 00:19:47,419
So after just six weeks of singing,

181
00:19:47,420 --> 00:19:57,110
moms experienced a decrease of 35% in their postnatal depression symptoms and 65% of mums no longer had the moderate to severe symptoms.

182
00:19:57,470 --> 00:20:01,640
So when we took the group as a whole we didn't find any significant differences.

183
00:20:01,640 --> 00:20:10,640
But when we looked at the mums who had the most severe symptoms, we found that singing seemed to be more effective in treatment as usual.

184
00:20:13,420 --> 00:20:21,880
In terms of the findings from the focus groups and the interviews, we found that there were social, psychological and behavioural mechanisms at work.

185
00:20:23,290 --> 00:20:30,040
And while there were many similar features that supported the mental health of new mums across the play groups as well as the singing groups,

186
00:20:30,460 --> 00:20:34,240
these five features were distinctive to the singing groups.

187
00:20:35,110 --> 00:20:44,320
So mums told the researchers that the singing groups supported them because it was conducted in an inclusive and safe environment.

188
00:20:44,620 --> 00:20:51,850
And just to say that the quotes next to each of those mechanisms are from the mums themselves.

189
00:20:52,520 --> 00:21:01,330
And it promoted a sense of achievement in learnings of feeling like that, that mums were achieving something for that day.

190
00:21:02,460 --> 00:21:13,420
It provided me time to focus and immerse. So not just focusing on the baby and being a mum, but it was about time for the mothers themselves.

191
00:21:14,350 --> 00:21:22,520
It also helped with bonding with the baby, as well as providing a new tool to calm their babies.

192
00:21:22,540 --> 00:21:27,310
So when the babies were crying, they could use singing to really calm the babies down.

193
00:21:30,600 --> 00:21:38,790
So in terms of the process evaluation, this was both quantitative and qualitative data collection.

194
00:21:39,300 --> 00:21:48,240
So evaluation forms were used using like us like, but also free text responses could be given to give feedback.

195
00:21:48,930 --> 00:21:56,010
Focus groups again, the focus groups asked people about some of the, the acceptability around the singing groups.

196
00:21:56,460 --> 00:22:01,110
Interviews were conducted with the program leaders and attendance data was collected.

197
00:22:01,980 --> 00:22:07,470
So terms of the findings, 88% of members felt that the classes were well tailored to them.

198
00:22:09,060 --> 00:22:16,350
The singing groups were better attended than the play groups. So an average of seven sessions is 5.76 sessions.

199
00:22:16,980 --> 00:22:23,820
Face to face recruitment was far more successful than social media, and there was a 10% withdrawal rate.

200
00:22:23,830 --> 00:22:27,600
Some lost follow up at the outcome assessment stage.

201
00:22:27,600 --> 00:22:35,339
So we lost 13 members at the end of the study in terms of not being contactable or moving away from

202
00:22:35,340 --> 00:22:41,850
where the singing groups were being held were some challenges to delivery identified in the groups.

203
00:22:41,850 --> 00:22:48,389
So some of them said that space was a bit of an issue. It could be quite cramped in the sessions and some members did struggle to

204
00:22:48,390 --> 00:22:54,000
fit in the sessions around the babies routines of sleeping or feeding times.

205
00:22:55,710 --> 00:23:02,040
So all of that kind of ground work was brought together and the team was successful

206
00:23:02,040 --> 00:23:07,710
in receiving funding to conduct a hybrid type two effectiveness implementation trial.

207
00:23:08,610 --> 00:23:13,440
So really thinking about a much larger study to test the singing groups.

208
00:23:13,860 --> 00:23:15,689
And by hybrid type two,

209
00:23:15,690 --> 00:23:23,400
that means that the implementation of the intervention is being tested alongside and in support of the effectiveness of the intervention and study.

210
00:23:23,700 --> 00:23:30,120
So the effectiveness isn't the primary aim assessing the effectiveness and the implementation.

211
00:23:31,760 --> 00:23:36,720
And we started this work in 2021. So unfortunately we don't have any results from this programme,

212
00:23:37,890 --> 00:23:43,680
but it's ongoing and we're currently delivering the groups and data collection at the moment.

213
00:23:45,030 --> 00:23:50,580
Also just to say that this is a much bigger programme comprising three arts and health interventions.

214
00:23:51,300 --> 00:23:59,400
So for melodies for mums which is the singing groups with postnatal depression, dance for Parkinson's and stroke odysseys, however,

215
00:23:59,400 --> 00:24:04,110
the singing groups at the most kind of developed programme because they have

216
00:24:04,110 --> 00:24:09,250
this evidence base already that's been tested in a small study by residents.

217
00:24:09,270 --> 00:24:14,910
The Parkinson's and Stroke Odyssey is an early stage of implementation and evidence building.

218
00:24:16,290 --> 00:24:28,019
So in terms of the kind of design, so again, we've got a embedded or nested quant called study because we within the effectiveness part of the study,

219
00:24:28,020 --> 00:24:33,480
the primary aim is to look at whether community singing improves symptoms of postnatal depression.

220
00:24:34,020 --> 00:24:39,690
However, it's also a parallel study because the implementation and effectiveness arms are of equal importance.

221
00:24:39,990 --> 00:24:47,310
And one of the the secondary primary objective is to upscale these arts interventions and embed them into clinical pathways.

222
00:24:51,120 --> 00:24:55,109
So in terms of thinking about the outcomes that we're interested in.

223
00:24:55,110 --> 00:25:01,440
So again, our primary outcome remains postnatal depression schools in terms of the quantitative measures.

224
00:25:01,460 --> 00:25:07,350
And we're also collecting data on other mental health skills such as depression and anxiety.

225
00:25:07,710 --> 00:25:13,230
We're looking at social bonding through video recordings of mums interacting with their babies,

226
00:25:14,010 --> 00:25:17,730
also collecting social measures around loneliness and social support.

227
00:25:18,300 --> 00:25:25,740
Biological samples, stress markers and all of these measures are collected at baseline and weeks six, ten, 20 and 36.

228
00:25:27,210 --> 00:25:34,890
Also, just to say, we don't have a third group to randomise women into for this particular study.

229
00:25:35,220 --> 00:25:39,780
We're looking at singing versus control. And the control group is an active control.

230
00:25:40,050 --> 00:25:44,010
So mothers receive details of other non-music classes available,

231
00:25:44,490 --> 00:25:54,330
available to them in the community and the Breathe Out health team kind of prompt women to attend these or encourage them to join these activities.

232
00:25:55,980 --> 00:26:01,470
But everybody obviously receives the outcome assessment appointments.

233
00:26:02,100 --> 00:26:09,510
And in terms of the qualitative data, we are repeating those focus groups at week ten to explore how and why the singing groups support mothers,

234
00:26:10,650 --> 00:26:14,640
mainly because we're going to have much more data to explore this in more detail,

235
00:26:15,060 --> 00:26:22,200
as well as interviews to explore how singing intersects with postnatal depression among women with particular risk factors.

236
00:26:22,200 --> 00:26:26,069
So we're going to speak to women who've experienced a traumatic birth,

237
00:26:26,070 --> 00:26:33,780
who have particular experiences of social isolation and loneliness, as well as adverse childhood experiences.

238
00:26:33,780 --> 00:26:41,640
Just to see because I think we saw in the original study that those with the most severe symptoms seem to improve faster.

239
00:26:42,060 --> 00:26:46,950
We wondered about the experiences of women who may have had quite significant

240
00:26:46,950 --> 00:26:52,320
trauma in their lives and when the singing has any particular supports for them.

241
00:26:55,410 --> 00:27:00,330
So in terms of the implementation, the primary outcome is acceptability of the intervention,

242
00:27:00,690 --> 00:27:07,500
which is measured both quantitatively through an acceptability implementation measure as well as qualitative interviews.

243
00:27:07,950 --> 00:27:10,919
And the interviews are going to be conducted with lots of different people.

244
00:27:10,920 --> 00:27:17,190
So the participants program leads as well as commissioners and health professionals,

245
00:27:17,520 --> 00:27:23,670
just to see whether and how we can embed these these groups into clinical guidelines in practice.

246
00:27:24,410 --> 00:27:29,640
And there's a thing that this study is interested in that the previous one didn't look at so much as costs,

247
00:27:30,090 --> 00:27:36,600
because that's obviously a huge consideration when implementing interventions into health care settings.

248
00:27:37,890 --> 00:27:44,490
So as I say, we're in the midst of data collection and we're aiming to complete the study 2024.

249
00:27:46,110 --> 00:27:54,870
However, we do have some results from another study that we have done as part of this program.

250
00:27:55,710 --> 00:28:01,800
So like many applied research projects, we were delayed in starting our study because of the pandemic.

251
00:28:02,220 --> 00:28:10,709
And I don't know whether any of you saw on the BBC News or in the newspapers the kind of scenes of people who were in choirs

252
00:28:10,710 --> 00:28:17,340
or singing groups being made to stands outside churches or outside of their community settings to be able to sing together.

253
00:28:17,670 --> 00:28:24,990
Because it was such a risk of spreading COVID 19 by singing with the respiratory kind of power of singing.

254
00:28:25,410 --> 00:28:32,850
And so we were really on tenterhooks about when this and if this study, which would actually be able to happen in person.

255
00:28:33,540 --> 00:28:37,710
So in the meantime, we quickly set up a pre post trial.

256
00:28:38,460 --> 00:28:44,460
We didn't have a control group just to test an online version of the program during the pandemic.

257
00:28:44,460 --> 00:28:52,320
And we were particularly keen to do this because we knew that lockdowns and social distancing restrictions were really highlighting

258
00:28:52,320 --> 00:28:59,940
the importance of adapting these activities to be online to to continue to support women who were having babies during the pandemic.

259
00:29:02,800 --> 00:29:12,700
So as I say, this was sort of a scaled back version, mainly because we haven't tested the program online before.

260
00:29:12,700 --> 00:29:17,920
So we didn't really have that evidence base, but we could adapt the in-person groups to run online.

261
00:29:18,460 --> 00:29:21,880
So the key aim for this one was really the feasibility.

262
00:29:21,970 --> 00:29:25,330
Could we recruit and engage new mums with postnatal depression?

263
00:29:25,780 --> 00:29:29,140
And then the secondary aims were could we get a sense of efficacy?

264
00:29:29,170 --> 00:29:32,410
Could we see if there was any kind of reduction in symptoms?

265
00:29:33,400 --> 00:29:36,130
And also whether it supported women socially.

266
00:29:37,240 --> 00:29:45,640
So this was a slightly urgent six weeks, and it was developed specifically to support mothers during COVID 19 lockdowns.

267
00:29:48,650 --> 00:29:52,370
So these findings haven't been published.

268
00:29:52,400 --> 00:29:56,570
We're currently analysing the data and writing up the results.

269
00:29:56,570 --> 00:30:01,190
So subject to change potentially, but early results show some promise.

270
00:30:01,640 --> 00:30:09,590
And so in terms of feasibility, we did actually aim to recruit 120 women over a 12 month period.

271
00:30:10,010 --> 00:30:10,640
However,

272
00:30:11,000 --> 00:30:20,330
we cut this this recruitment period to six months because social distancing restrictions did start to ease and we had to reprioritize the main trial.

273
00:30:21,140 --> 00:30:28,310
So we ended up with 37 participants signing up and 35 completed those outcome assessments at the beginning of the city.

274
00:30:29,060 --> 00:30:36,290
And then we had an 87% follow up point. So at six weeks, 87% of the women completed questionnaires.

275
00:30:37,220 --> 00:30:41,810
The singing groups were well attended, so an average of five out of six sessions,

276
00:30:42,170 --> 00:30:47,749
and we did find a significant reduction in total postnatal depression score at week six.

277
00:30:47,750 --> 00:30:55,340
So women went from an average score of 16.6 indicating probable depression to 11.2 at six week follow up,

278
00:30:55,520 --> 00:30:58,910
which drops you down clinically into possible depression.

279
00:31:00,590 --> 00:31:08,480
We did find, however, that there weren't any differences in schools across time regarding support or social support or loneliness.

280
00:31:10,100 --> 00:31:13,250
And in the qualitative work, we did find women.

281
00:31:14,260 --> 00:31:18,490
Benefited from these groups in lots of different ways and that their mental health benefited.

282
00:31:18,850 --> 00:31:24,400
But one of the things that women came back to was that need for in-person support

283
00:31:25,120 --> 00:31:28,780
and that need to see people in person and to do these activities together.

284
00:31:29,650 --> 00:31:38,650
So that's not really a surprise, but I guess that's just an example of how the qualitative data can really unpack not just the positive results.

285
00:31:38,650 --> 00:31:44,230
You know, why might these groups support mental health, but also where we find the difference?

286
00:31:44,260 --> 00:31:47,290
The qualitative work can really shine a light on why that might be.

287
00:31:49,960 --> 00:31:54,280
So in terms of the qualitative findings to and how do you type, that's good.

288
00:31:54,710 --> 00:32:05,140
And so we again, in the process of analysing the data and again, I'm using quotes from women in the slides there.

289
00:32:05,200 --> 00:32:14,110
So one of the first things that women talked about was that these groups were really helpful in building confidence, the increased confidence,

290
00:32:14,350 --> 00:32:22,510
interacting and singing with the baby, managing the babies behaviours and not just calming but using singing as a tool for lots of other things.

291
00:32:23,170 --> 00:32:31,450
So being able to calm the baby but also distract the baby is like changing in nappy or something as well as just making the baby laugh,

292
00:32:31,450 --> 00:32:38,200
having lots of fun, especially in a time where things were, you know, people were at home and not able to do very much.

293
00:32:38,780 --> 00:32:42,260
It was also seen as a catalyst for going out and trying other groups.

294
00:32:42,280 --> 00:32:48,280
So as things started to open up, this was the first time some women had sort of engaged in a group setting with other moms.

295
00:32:48,280 --> 00:32:53,230
So it was helpful and it felt safe to continue to explore that.

296
00:32:55,320 --> 00:32:59,470
Sometimes talks about the groups supporting a changing identity.

297
00:32:59,490 --> 00:33:03,750
So some of the mums said they felt that they kind of lost themselves,

298
00:33:05,040 --> 00:33:10,619
that they'd obviously become a mum and that there was a disconnect between before being a mum and sort of

299
00:33:10,620 --> 00:33:15,960
afterwards and the groups helped them to be connect with themselves through music and through singing.

300
00:33:16,890 --> 00:33:24,180
It helped with memories of music in the past and bringing that that music into that new experience of being a mother.

301
00:33:27,630 --> 00:33:31,730
So I guess. For me, but maybe not for everyone.

302
00:33:31,940 --> 00:33:35,690
An obvious mechanism was around emotional responses.

303
00:33:35,690 --> 00:33:45,650
So women talked about singing, being something that energised them, that made them quite euphoric while they were engaging in that.

304
00:33:46,160 --> 00:33:55,880
It helped them have more fun and experience more joy, as well as a tool to relax and a sort of release of negative energy as well.

305
00:33:56,930 --> 00:34:01,580
So again, these clips illustrate those kind of emotional responses to singing.

306
00:34:07,430 --> 00:34:11,870
Women also talked about the group supporting kind of social identity building.

307
00:34:11,880 --> 00:34:18,860
So again, like I said, some of these moms hadn't really been engaging with other moms very much and having

308
00:34:18,860 --> 00:34:24,259
this space where they could observe the moms with their babies sort of help them feel,

309
00:34:24,260 --> 00:34:27,650
yeah, I'm doing the right thing here, you know? Oh, that mom struggling.

310
00:34:28,580 --> 00:34:31,670
But it's okay and it's normal and it's positive.

311
00:34:31,820 --> 00:34:38,660
Yeah. So it was really validating for their experiences as well as having this sort of social comparison.

312
00:34:39,290 --> 00:34:42,559
And I think testament to the facilitators who lead the groups.

313
00:34:42,560 --> 00:34:51,170
I think there was a lot of, you know, being heard and feeling valued as well coming out of this most social aspects of the group.

314
00:34:53,350 --> 00:35:01,629
And finally, while we found that it didn't really kind of foment bonding between the mothers as a social group,

315
00:35:01,630 --> 00:35:08,480
the community moms did tell us that it did help with increased bonding with the baby as well as with wider family members.

316
00:35:08,480 --> 00:35:15,670
So being able to sing with the family together or family members commenting on the new songs that that the mothers were singing

317
00:35:15,670 --> 00:35:24,640
to their babies and just being able to see the impact that they were having on their babies by using song and music as a tool.

318
00:35:27,830 --> 00:35:33,020
So I'm not sure I need to really talk about the evaluation because she may have already covered this.

319
00:35:33,560 --> 00:35:41,350
So I was just going to briefly talk about the. The MMT, the mixed methods assessment tool.

320
00:35:41,350 --> 00:35:46,930
But Stephanie, you already covered that one. We haven't covered it yet, so we're going to cover it on Friday.

321
00:35:47,230 --> 00:35:50,680
Oh, well, I'll give you a little introduction then, and then you can cover it on Friday.

322
00:35:51,280 --> 00:35:55,810
And so I guess just a whistle stop tour of something you'll cover more in depth.

323
00:35:57,490 --> 00:36:04,660
And especially when I think looking at arts and health intervention or health and arts and health research,

324
00:36:05,020 --> 00:36:11,919
as I say, a lot of it will possibly use mixed methods. So I think it's just really useful to have these six questions in your mind,

325
00:36:11,920 --> 00:36:19,000
which is taken from a critical appraisal tool that has been developed specifically for assessing mixed methods designs.

326
00:36:19,360 --> 00:36:24,700
So it's thinking about, as I said, is that research question justifying the use of mixed methods.

327
00:36:25,150 --> 00:36:30,580
Is the method sequence clearly described? Is it logical and well aligned for the study aims?

328
00:36:31,960 --> 00:36:40,030
Is the data collection and analysis clearly described as one method dominates or limits the other method.

329
00:36:40,480 --> 00:36:46,210
And that data integration, which I think you've covered already, and who's doing it when and by who.

330
00:36:47,680 --> 00:36:55,210
Those are kind of the cool things to be thinking when you're critically appraising your own critically and based on the literature.

331
00:36:57,460 --> 00:37:04,240
Oh, just some useful links that you might find helpful to find out more about the work, specifically if you're interested in arts and health research.

332
00:37:04,240 --> 00:37:09,879
So that's our website that's linked to the shape of study more generally, as well as breathe arts,

333
00:37:09,880 --> 00:37:15,790
health research, community organisation, delivering maladies from singing groups.

334
00:37:16,360 --> 00:37:23,080
And we also have a have an arts health early career research network, which is for anybody,

335
00:37:23,110 --> 00:37:29,110
either post or post-doc who's interested in arts and health research.

336
00:37:29,440 --> 00:37:34,150
So I encourage you to have a look at that and join us if it's something you're interested in getting posted.

337
00:37:36,130 --> 00:37:42,550
Horrible slide, but I did get through quite a lot of references so we can have those after the session.

338
00:37:43,720 --> 00:37:48,970
Thank you. Thank you. Thank you so much, Alex. Really interesting sort of topic.