So over to you, Alex. Fantastic.
Thank you so much, Stephanie. And again, apologies for not being there in person.
So, yeah, I'm Alex Burton. I'm a senior research fellow based within the Social Biobehavioral Research Group here at University College London,
and the teams led by Dr. Daisy Fancourt.
And we're really interested in studying the role of social factors on health, and this includes social deficits.
So things like loneliness, social isolation, social restrictions, for example, during the pandemic as well as social assets.
So thinking about social connections, arts, cultural and community engagement, nature engagement and social prescribing,
and more specifically, we want to unpick the effects of social factors on health outcomes.
We look at the psychological, biological, social and behavioural mechanisms underlying these effects.
We also look for differential patterns, barriers and enablers of social behaviours.
So including thinking about engagement in the arts is a big focus among different groups of people.
And my research is particularly interested in studying the impact of these activities,
these deficits and assets on mental health, and particularly among people with severe mental illnesses.
And I'm predominately a qualitative researcher,
but I also have managed clinical trials and I think when we talk through understandably a lot of these methods complement one another.
So let's see if I can get the slide to move.
There we go. So I'm just going to give a very broad overview of arts and health and briefly describe
some of the methodologies that we frequently used to conduct research in this area.
I'll then move on to talk about the history and the development of the shape of
Postnatal Depression project as a case study example of a mixed message design.
And I'll finish with some thoughts around how we might evaluate mixed methods research.
But I won't go into too much detail on that because I think that's already been covered in your previous lectures.
So it may seem pretty straightforward, but I think it's always useful to begin by defining the broader concepts that we're
interested in exploring within our research and defining what art is and what it is not.
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,
who's receiving them, as well as people who are involved in funding these types of interventions.
However, despite these complexities, several characteristics have been recognised as fundamental to a definition of art.
And there's a really, really good resource outlines this debate,
which is the World Health Organisation evidence synthesis written by Foucault and Sydney in 2019.
So in this report the key characteristics outlined include firstly that as an art objects be that physical or experiential,
which is meaningful for those who engage in it.
Secondly, that imaginative experiences often accompany these meaningful engagements in art for both those who create the objects,
as well as those who receive those objects. And they normally comprise or provoke some sort of emotional response.
So within this frame of understanding in relation to health research,
engagement with the arts is being proposed as consisting of five broad categories.
So we look at performing arts activities such as singing in a choir,
which is one of the interventions I'll be talking about digital arts activities, including animation and filmmaking.
Visual arts participation including crafts and design.
Cultural engagement such as visiting a museum or going to a concert or gallery of literature.
Engagement such as reading or writing. And within these categories, there's a diverse range of different types of engagement.
And that includes both active engagement, such as participatory arts program.
So taking part in a drama group or a dance group as well as receptive engagement.
As I've talked about though, with audience viewing objects or objects and similarly defining what health is can also be a difficult task.
And I think it's really important with within arts and health research to consider the complexities of this and what
we mean by health and the World Health Organisation back in 1948 defined health as a state of complete physical,
mental and social wellbeing and not merely the absence of disease or infirmity.
And I think this is really important for the research that we do because it situates health firmly within society and within culture,
such as how health is shaped by the cultural constructs within which it is situated.
And that helps us to consider health at different levels of analysis, including the individual, the group, the community and the societal perspective.
So some examples of the societal perspective include whether you see an integrated or that you're contributing to society,
as well as if you feel accepted and whether you trusted or trust others within social groups.
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
to shift and change and it depends on the disciplines that also are studying health interventions that help to improve health.
And but I think one of the key things is that we need to recognise that complete health may
not be as antibodies go and rather concepts of supporting people to live well for example,
with a chronic condition or a life limiting illness are becoming more common.
And I think arguably this approach also aligns with the more recent biopsychosocial model of health,
which considers the importance of biological, psychological and social factors and the complex interactions to understanding health and illness.
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.
So arts and culture, understandably,
combine lots of different components that we know are probably beneficial for our health for example sensory activation,
cognitive stimulation and social interactions.
And again, these components can prompt psychological, biological, social or behavioural responses.
So, for example, if an arts intervention involves some sort of cognitive stimulation that may help people living with dementia,
it may help manage symptoms of cognitive decline, or it may even help prevent or lower the risk of dementia.
Developing social interaction may reduce feelings of loneliness, which is a known risk factor for poorer mental and physical health.
And multiple components of arts activities may lead to reduced stress hormonal
responses whereby stress is a known risk factor for many health conditions,
for example, cardiovascular diseases, and that some components of arts activities may include physical activity.
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.
So these are just sort of some of the mechanisms of health.
So the causal processes that these components set in motion and these processes are linked to prevention,
management and treatment of health conditions. And aligning this with the mixed methods approach.
I think, you know, the point is that we might need different methodologies or we might need combined
methodologies to really unpick some of what's going on within arts interventions.
So as I've hopefully presented that at the arts complex interventions,
there are often multiple components involved in their delivery and the Medical
Research Council recognises the complexity of psychosocial interventions.
So more traditional psychological interventions in health care and design defines these interventions as those that have
several interacting components where there's difficulty of standardising the design and delivery of those interventions,
where there's a sensitivity to features of the local context.
So an intervention might need to be adapted, adapted depending on where it's being delivered and where there's complexity around the
causal chains that link the intervention with the outcomes that we're interested in.
And while all of these characteristics fit in with our definition of arts activities,
I think it's this latter point that resonates with some of the challenges we face when we do research in arts and health.
And our team has recently published a theoretical framework called the Multilevel Nature Mechanisms Framework,
which highlights this complexity specifically within leisure and arts activities.
And it's a review of the evidence. The framework was developed as a review of the evidence, looking at different theories,
different disciplines, different methodologies, all the way from basic lab studies to RC cities.
And the review identified over 600 potential mechanisms that link arts and leisure activities to health.
So it's very complex. It's.
And in terms of research methodologies, most of the work that I do is around testing interventions or community activities,
either through feasibility studies, randomised controlled trials or observational studies,
as well as conducting embedded qualitative work to understand experiences of engagement,
how or why they support mental health in particular, as well as barriers to engagement in the arts.
And a core part of the wider team's work is to look at big data.
So we look at longitudinal evidence, thinking about who's engaging, whether there are predictors of engagement,
whether engagement is linked to health outcomes as well as any characteristics that we find people aren't engaging in the arts.
Some of our work has also looked at basic science studies. So thinking about biological sampling, as I mentioned, in the mechanisms model.
So for example, we might measure someone's stress hormone markers before they engage in that arts activity as well as after.
And I think you've covered this hopefully a lot in your mixed methods course.
But I guess just to reiterate that there seems to be four key mixed method designs that are employed in mixed methods research.
And this is taken from a really helpful summary from Shelton and Smith.
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
the research questions you really want to answer and understanding the type of approach you wish to use.
I think the key thing is whether your quantitative and qualitative data will inform, explain or complement one another.
And again, this has an impact on data collection, just applying this to the work that we do and in our team.
So for example, an explanatory sequential design may be the most relevant if we want to,
for example, explore whether engagement in arts activities supports wellbeing in adults.
So we might start with a national survey to older adults looking at whether arts engagement is related to wellbeing.
But we might want to then do some qualitative interviews to explore how engagement in the arts supports wellbeing.
So really looking at what some of those mechanisms might be and applying the associations we might find within a survey.
In terms of the exploratory sequential,
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.
So we may want to start by doing some qualitative work and using focus groups,
for example, within the local area to discuss barriers and facilitators.
And we might then use that to create a national survey to kind of generalise the
findings from the qualitative work and to expand the kind of reach of the the findings.
In terms of the parallel design, I think you've also called that story.
I've just. We could be virgins.
Yeah, yeah, yeah.
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.
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,
deeper understanding of the coping strategies and support systems available.
And then the final design, which is the big qual, small quant or big quantum small.
So for example, we may want to look at testing an activity group programme without primary aim effectiveness,
so looking at outcomes of wellbeing and depression. But within that, we may want to embed a qualitative study which focuses on user experiences.
So answering a slightly different question to the main question, that date that that question is complementary.
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.
And so. It's now called the Shape a program, but it began as the music and other research projects,
which was led by the Centre for Performance Science, Imperial College, London and UCL.
And this project evaluated the effectiveness of creative interventions,
including singing and play a psychological social tools to reduce postnatal depression symptoms.
So just a bit of background around why this study was conducted.
So postnatal depression is characterised by psychological and behavioural changes and it affects at least 12% of new mothers.
Many women report difficulties accessing pharmacological or psychological treatments to support symptoms,
and barriers to treatment have been identified, which include a lack of awareness that they're experiencing postnatal depression,
a lack of awareness that their services are available to support some women if reported fear or
repercussions if a mental illness is disclosed to healthcare professionals or to professionals,
full stop. And some women also feel a sense of social stigma and feel like they should be
able to cope with new motherhood and don't want to share that they're struggling.
That's also an inadequate treatment and screening pathways for postnatal depression.
So there's a need to identify alternative ways to support the mental health of new mothers.
So the evidence base is growing, so community arts based programs to support mental health and wellbeing.
And there's a lot of evidence around group singing, particularly in mental health.
So it's been found to support recovery and it's associated with social bonding.
And a systematic review conducted by Perkins Attell found that singing helps people to manage and express their emotions.
It helps them to facilitate self-development, provides respite, so distraction and absorption, and it facilitates social connection.
And there's also been growing evidence base around singing to infants,
which has shown that singing to infants improves mother infant interactions as well as reduces biological markers of stress,
both in mothers and in the infants. So this was a randomised controlled trial.
So it was an embedded study with the the big quantitative and the small qualitative
because the primary aim was to establish effectiveness of the singing groups.
And so a trial was conducted with 134 mothers experiencing postnatal depression who were allocated to one of 310 week programmes.
So the group singing programmes are run by an organisation called Brief Arts Health
and the program is delivered to groups of 8 to 12 mothers in weekly sessions,
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.
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.
They start with welcome songs, they introduce the babies and mothers to one another,
and then the classes involve a range of singing and music activities, including simple instruments.
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,
and they can develop their own lyrics together, either about their babies or experiences of motherhood.
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.
And the classes are led by professional workshop leaders trained by free thoughts house and they're supported by facilitators and times.
It's a creative play intervention. These workshops involving mothers engaging in sensory play with babies,
with their babies, doing arts and crafts activities and playing simple games together.
And those randomised to routine care didn't receive any workshops above and beyond usual care,
but they were provided with the singing groups at the end of the research study.
So as I mentioned, it's an embedded study, so there are some secondary aims there.
So again, thinking about those mechanisms, why might singing support people's mental health?
So the qualitative work which was done through focus groups and interviews,
was around what features of the singing groups support recovery and a process evaluation was also conducted.
So thinking about whether the groups were feasible, whether they were acceptable, and whether they were delivered as intended.
So in terms of the effectiveness, the primary outcome was the Edinburgh postnatal depression scale and as you can see from these graphs,
there was a significant decrease across time in postnatal depression scores
indicating that women in all three groups experienced improvements in the symptoms.
But if you look at the bottom line, which is the singing group, the dark blue group,
you can see that sometimes with moderate to severe symptoms of postnatal depression,
the group singing program led to a significantly faster recovery and care as normal.
So after just six weeks of singing,
moms experienced a decrease of 35% in their postnatal depression symptoms and 65% of mums no longer had the moderate to severe symptoms.
So when we took the group as a whole we didn't find any significant differences.
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.
In terms of the findings from the focus groups and the interviews, we found that there were social, psychological and behavioural mechanisms at work.
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,
these five features were distinctive to the singing groups.
So mums told the researchers that the singing groups supported them because it was conducted in an inclusive and safe environment.
And just to say that the quotes next to each of those mechanisms are from the mums themselves.
And it promoted a sense of achievement in learnings of feeling like that, that mums were achieving something for that day.
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.
It also helped with bonding with the baby, as well as providing a new tool to calm their babies.
So when the babies were crying, they could use singing to really calm the babies down.
So in terms of the process evaluation, this was both quantitative and qualitative data collection.
So evaluation forms were used using like us like, but also free text responses could be given to give feedback.
Focus groups again, the focus groups asked people about some of the, the acceptability around the singing groups.
Interviews were conducted with the program leaders and attendance data was collected.
So terms of the findings, 88% of members felt that the classes were well tailored to them.
The singing groups were better attended than the play groups. So an average of seven sessions is 5.76 sessions.
Face to face recruitment was far more successful than social media, and there was a 10% withdrawal rate.
Some lost follow up at the outcome assessment stage.
So we lost 13 members at the end of the study in terms of not being contactable or moving away from
where the singing groups were being held were some challenges to delivery identified in the groups.
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
fit in the sessions around the babies routines of sleeping or feeding times.
So all of that kind of ground work was brought together and the team was successful
in receiving funding to conduct a hybrid type two effectiveness implementation trial.
So really thinking about a much larger study to test the singing groups.
And by hybrid type two,
that means that the implementation of the intervention is being tested alongside and in support of the effectiveness of the intervention and study.
So the effectiveness isn't the primary aim assessing the effectiveness and the implementation.
And we started this work in 2021. So unfortunately we don't have any results from this programme,
but it's ongoing and we're currently delivering the groups and data collection at the moment.
Also just to say that this is a much bigger programme comprising three arts and health interventions.
So for melodies for mums which is the singing groups with postnatal depression, dance for Parkinson's and stroke odysseys, however,
the singing groups at the most kind of developed programme because they have
this evidence base already that's been tested in a small study by residents.
The Parkinson's and Stroke Odyssey is an early stage of implementation and evidence building.
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,
the primary aim is to look at whether community singing improves symptoms of postnatal depression.
However, it's also a parallel study because the implementation and effectiveness arms are of equal importance.
And one of the the secondary primary objective is to upscale these arts interventions and embed them into clinical pathways.
So in terms of thinking about the outcomes that we're interested in.
So again, our primary outcome remains postnatal depression schools in terms of the quantitative measures.
And we're also collecting data on other mental health skills such as depression and anxiety.
We're looking at social bonding through video recordings of mums interacting with their babies,
also collecting social measures around loneliness and social support.
Biological samples, stress markers and all of these measures are collected at baseline and weeks six, ten, 20 and 36.
Also, just to say, we don't have a third group to randomise women into for this particular study.
We're looking at singing versus control. And the control group is an active control.
So mothers receive details of other non-music classes available,
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.
But everybody obviously receives the outcome assessment appointments.
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,
mainly because we're going to have much more data to explore this in more detail,
as well as interviews to explore how singing intersects with postnatal depression among women with particular risk factors.
So we're going to speak to women who've experienced a traumatic birth,
who have particular experiences of social isolation and loneliness, as well as adverse childhood experiences.
Just to see because I think we saw in the original study that those with the most severe symptoms seem to improve faster.
We wondered about the experiences of women who may have had quite significant
trauma in their lives and when the singing has any particular supports for them.
So in terms of the implementation, the primary outcome is acceptability of the intervention,
which is measured both quantitatively through an acceptability implementation measure as well as qualitative interviews.
And the interviews are going to be conducted with lots of different people.
So the participants program leads as well as commissioners and health professionals,
just to see whether and how we can embed these these groups into clinical guidelines in practice.
And there's a thing that this study is interested in that the previous one didn't look at so much as costs,
because that's obviously a huge consideration when implementing interventions into health care settings.
So as I say, we're in the midst of data collection and we're aiming to complete the study 2024.
However, we do have some results from another study that we have done as part of this program.
So like many applied research projects, we were delayed in starting our study because of the pandemic.
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
or singing groups being made to stands outside churches or outside of their community settings to be able to sing together.
Because it was such a risk of spreading COVID 19 by singing with the respiratory kind of power of singing.
And so we were really on tenterhooks about when this and if this study, which would actually be able to happen in person.
So in the meantime, we quickly set up a pre post trial.
We didn't have a control group just to test an online version of the program during the pandemic.
And we were particularly keen to do this because we knew that lockdowns and social distancing restrictions were really highlighting
the importance of adapting these activities to be online to to continue to support women who were having babies during the pandemic.
So as I say, this was sort of a scaled back version, mainly because we haven't tested the program online before.
So we didn't really have that evidence base, but we could adapt the in-person groups to run online.
So the key aim for this one was really the feasibility.
Could we recruit and engage new mums with postnatal depression?
And then the secondary aims were could we get a sense of efficacy?
Could we see if there was any kind of reduction in symptoms?
And also whether it supported women socially.
So this was a slightly urgent six weeks, and it was developed specifically to support mothers during COVID 19 lockdowns.
So these findings haven't been published.
We're currently analysing the data and writing up the results.
So subject to change potentially, but early results show some promise.
And so in terms of feasibility, we did actually aim to recruit 120 women over a 12 month period.
However,
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.
So we ended up with 37 participants signing up and 35 completed those outcome assessments at the beginning of the city.
And then we had an 87% follow up point. So at six weeks, 87% of the women completed questionnaires.
The singing groups were well attended, so an average of five out of six sessions,
and we did find a significant reduction in total postnatal depression score at week six.
So women went from an average score of 16.6 indicating probable depression to 11.2 at six week follow up,
which drops you down clinically into possible depression.
We did find, however, that there weren't any differences in schools across time regarding support or social support or loneliness.
And in the qualitative work, we did find women.
Benefited from these groups in lots of different ways and that their mental health benefited.
But one of the things that women came back to was that need for in-person support
and that need to see people in person and to do these activities together.
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.
You know, why might these groups support mental health, but also where we find the difference?
The qualitative work can really shine a light on why that might be.
So in terms of the qualitative findings to and how do you type, that's good.
And so we again, in the process of analysing the data and again, I'm using quotes from women in the slides there.
So one of the first things that women talked about was that these groups were really helpful in building confidence, the increased confidence,
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.
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,
having lots of fun, especially in a time where things were, you know, people were at home and not able to do very much.
It was also seen as a catalyst for going out and trying other groups.
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.
So it was helpful and it felt safe to continue to explore that.
Sometimes talks about the groups supporting a changing identity.
So some of the mums said they felt that they kind of lost themselves,
that they'd obviously become a mum and that there was a disconnect between before being a mum and sort of
afterwards and the groups helped them to be connect with themselves through music and through singing.
It helped with memories of music in the past and bringing that that music into that new experience of being a mother.
So I guess. For me, but maybe not for everyone.
An obvious mechanism was around emotional responses.
So women talked about singing, being something that energised them, that made them quite euphoric while they were engaging in that.
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.
So again, these clips illustrate those kind of emotional responses to singing.
Women also talked about the group supporting kind of social identity building.
So again, like I said, some of these moms hadn't really been engaging with other moms very much and having
this space where they could observe the moms with their babies sort of help them feel,
yeah, I'm doing the right thing here, you know? Oh, that mom struggling.
But it's okay and it's normal and it's positive.
Yeah. So it was really validating for their experiences as well as having this sort of social comparison.
And I think testament to the facilitators who lead the groups.
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.
And finally, while we found that it didn't really kind of foment bonding between the mothers as a social group,
the community moms did tell us that it did help with increased bonding with the baby as well as with wider family members.
So being able to sing with the family together or family members commenting on the new songs that that the mothers were singing
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.
So I'm not sure I need to really talk about the evaluation because she may have already covered this.
So I was just going to briefly talk about the. The MMT, the mixed methods assessment tool.
But Stephanie, you already covered that one. We haven't covered it yet, so we're going to cover it on Friday.
Oh, well, I'll give you a little introduction then, and then you can cover it on Friday.
And so I guess just a whistle stop tour of something you'll cover more in depth.
And especially when I think looking at arts and health intervention or health and arts and health research,
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,
which is taken from a critical appraisal tool that has been developed specifically for assessing mixed methods designs.
So it's thinking about, as I said, is that research question justifying the use of mixed methods.
Is the method sequence clearly described? Is it logical and well aligned for the study aims?
Is the data collection and analysis clearly described as one method dominates or limits the other method.
And that data integration, which I think you've covered already, and who's doing it when and by who.
Those are kind of the cool things to be thinking when you're critically appraising your own critically and based on the literature.
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.
So that's our website that's linked to the shape of study more generally, as well as breathe arts,
health research, community organisation, delivering maladies from singing groups.
And we also have a have an arts health early career research network, which is for anybody,
either post or post-doc who's interested in arts and health research.
So I encourage you to have a look at that and join us if it's something you're interested in getting posted.
Horrible slide, but I did get through quite a lot of references so we can have those after the session.
Thank you. Thank you. Thank you so much, Alex. Really interesting sort of topic.