Quality of Life for People who Sing :

Stroke and Parkinson’s Disease: Prevalence and Prognosis

A growing ageing population in New Zealand and worldwide poses a number of challenges, including the predicted strain on public health services due to a consequential increase in neurological conditions, which tend to occur later in life (Statistics New Zealand, 2020). A stroke is a serious health condition and is caused through a blocked or burst blood vessel that interrupts blood flow to the brain and can result in brain damage or death (World Health Organization, 2021). Risk of stroke increases with age with 75% of all strokes occurring after age 65. Stroke is the third leading cause of death in New Zealand and a leading cause of serious adult disability (New Zealand Institute of Economic Research, 2020). The most common intervention following a stroke is a combination of occupational, physio- and speech-language therapies (Hoffmann et al., 2010; Kelly et al., 2010). Parkinson’s disease (Parkinson’s) is a progressive neurodegenerative disorder, which affects neurons within the brain’s basal ganglia and substantia nigra (World Health Organization, 2006). The onset of Parkinson’s is slow and difficult to diagnose as there are no detectable symptoms until after significant deterioration has occurred. Parkinson’s results in a gradual deterioration of motor functioning, including slowed movement, frozen gait, rest tremor, and impaired balance, posture, and coordination (Jankovic, 2008). Speech and swallowing difficulties, sleep disturbances, and mood changes are also common. Risk of Parkinson’s increases with age, with the average age at diagnosis in New Zealand being 59 years (Parkinson’s New Zealand, 2021). Parkinson’s is the second leading neurodegenerative disease worldwide after Alzheimer’s disease (Bertram & Tanzi, 2005). While there is no cure, pharmaceutical interventions can help to slow progression (Connolly & Lang, 2014).

Life After Diagnosis

Research shows that diagnosis with a neurological condition is associated with worse HRQOL outcomes compared to well people (Carod-Artal & Egido, 2009; Mutai et al., 2016; Rahman et al., 2008) and mental health issues can be comorbid (Campbell Burton et al., 2013; Dissanayaka et al., 2010; Dissanayaka et al., 2011; Haddad, 2009; Jasinska-Myga et al., 2010; Jørgensen et al., 2016). HRQOL refers to a person’s physical, psychological, social, and environmental functioning. It focuses on the impact of a person’s health status on their quality of life (QOL). Wellbeing, which explores the positive aspects of a person’s life, is also linked to QOL (Office of Disease Prevention and Health Promotion, 2010). HRQOL measures are ideal to use within unwell populations due to their holistic approach to explore wellbeing in light of a person’s health condition. An important demographic factor associated with the onset of neurological conditions is ageing (Anderson et al., 2005; Ascherio & Schwarzschild, 2016), which is also associated with a number of negative psychosocial and QOL outcomes (World Health Organization, 2017). Stressful life events such as the loss of a significant other, a perceived loss of purpose (due to retirement), and a loss of social support can have harmful effects on wellbeing, including depression (Patel & Prince, 2001; Unützer, 2007; Valvanne et al., 1996) and loneliness (Golden et al., 2009). There is evidence to suggest that diagnosis with a neurological condition intensifies existing challenges for older adults (Hornsten et al., 2012).

Singing for Health and in Neurorehabilitation

There is growing interest in the outcomes of music-based approaches to neurorehabilitation (Kern & Tague, 2017; Schlaug et al., 2010; Thaut et al., 2015; Wan et al., 2010). Community music therapy (CoMT) provides opportunities for groups and communities to partake in musical activities designed to benefit the group as a whole. CoMT approaches take inspiration from communities and seek to address issues of social exclusion and disadvantage where present (Ansdell, 2002). One CoMT approach thought to be beneficial for people with neurological conditions is choral singing therapy (CST), which is an eclectic, music-centred approach to addressing some of the negative outcomes associated with a neurological condition diagnosis, including acquired communication challenges, and social isolation (Talmage, 2022; Talmage et al., 2013; Talmage & Purdy, 2021). The aim of CST is to be an inclusive rather than diagnostic-specific approach, which often results in a diverse choir group. There is a social aspect to choral singing (Fogg & Talmage, 2011), which can help with feelings of social isolation sometimes experienced in older adults and those with neurological and other health conditions. Research in this area tends to focus on the relationship between CST and physical symptoms (Matthews, 2018; Tamplin et al., 2019).

However, growing evidence supports additional psychosocial and QOL benefits (Irons et al., 2021; Johnson et al., 2013; Moss et al., 2018). Mixed methods research investigating the “Sing to Beat Parkinson’s” programme identified significant improvements on several HRQOL domains for participants, and self-report data identified both physical (speech, voice, and breathing) and psychosocial benefits, including a sense of wellbeing, improved mood, and peer support (Irons et al., 2021). Moss et al. (2018) identified six themes as contributing to the relationship between choral singing and wellbeing: social connection, physical and psychological benefits, cognitive stimulation, improved mental health, enjoyment, and transcendence. Female participants rated physical, emotional, and social factors higher than male participants, and participants who were also professional singers reported greater physical, spiritual, and social experiences following choral singing. Johnson et al. (2013) used the WHOQOL-BREF (a QOL instrument developed through the World Health Organization) to explore HRQOL in older adult choir singers in Finland (N = 117). Each WHOQOL-BREF question corresponds to HRQOL on one of four domains: physical, psychological, social relationships, or environmental. Johnson et al.’s findings showed that choral singing was associated with higher HRQOL on three out of four HRQOL domains (psychological, social relationships, and environmental). Both Moss et al. (2018) and Johnson et al. (2013) acknowledged the limitations of their research designs, including the use of a convenience sample and self-report data (Moss et al., 2018). Meanwhile, Johnson et al. (2013) acknowledged the cross-sectional nature of their research and noted that cause and effect cannot be established as the research design was not a randomised controlled trial.

In a review paper, Gick (2011) found evidence in support of group singing and highlighted a need for more robust research designs (that include both quantitative and qualitative research methods) to investigate potential benefits (and potential contraindications) for singing interventions within a biopsychosocial context. Similar positive findings and recommendations for more rigorous methodologies were found in research exploring singing interventions for people with stroke (Hurkmans et al., 2012; Tamplin et al., 2013) and Parkinson’s (Di Benedetto et al., 2009; Elefant et al., 2012,, Yinger & Lapointe, 2012). Research from an inter-professional research group (Dingle et al., 2019) identified several limitations of the current literature and recommended that future studies consider negative voice and psychosocial outcomes, increase participant diversity, strengthen research designs, investigate choir leader perspectives, and encourage inter-professional collaboration. Consistent with these recommendations, Pongan et al. (2017) compared a musical intervention against a painting intervention for French Alzheimer’s disease patients, while Zumbansen et al. (2017) compared a choir group, a drama group, and a waitlist group for Canadian stroke patients. Both studies were randomised controlled trials and found therapeutic benefits as a direct result of choral singing.

Neurological Choirs in New Zealand

While the literature highlights choir or group singing for wellbeing within both general and discrete clinical populations, New Zealand has witnessed an evolution of neurological choirs catering to a mixed clinical population of people with communication difficulties resulting from a number of conditions including post-stroke aphasia and Parkinson’s. The first such choir, the music therapist-led CeleBRation Choir was established in 2009 with The University of Auckland’s Centre for Brain Research (CBR). The CeleBRation Choir sessions are music therapist-led and include vocal warm-ups and singing a range of new and familiar songs. The CeleBRation Choir aims to improve physical symptoms (posture, breathing, and oromotor skills) for choir members as well as psychosocial and QOL outcomes. Choir member’s families and carers are also invited to attend choir sessions (Talmage et al., 2013).

A mixed methods feasibility study carried out with The CeleBRation Choir identified several therapeutic benefits of choral singing. Fogg-Rogers et al. (2015) met with members of The CeleBRation Choir who had Parkinson’s or stroke (N = 23) and asked them about their experience with a neurological condition as well as their thoughts on choral singing and its perceived therapeutic benefits. Participants identified the following therapeutic benefits of choral singing: voice, breath, movement, language, and mood improvements, new abilities and connections, and a shared interest with others. In a separate paper, the experience of one participant from the same sample was highlighted. Talmage et al. (2014) observed the physical, psychosocial, and HRQOL changes for Don, a 69-year-old man diagnosed with Parkinson’s as he participated in choral singing with The CeleBRation Choir. Don observed physical improvements (voice and speech) and his voice-related quality of life (V-RQOL) and HRQOL was higher than members of a comparison sample of people with disabilities.

The Present Research

The present research aims to build on the findings from Jenkins et al. (2017) and other studies that have found benefits of CST for people with neurological conditions, including physical (Lee et al., 2018), psychosocial (Lee et al., 2018; Moss et al., 2018), and QOL (Johnson et al., 2013). The present research aims to explore HRQOL among New Zealanders who sing in choirs to find out whether their choir involvement perspectives reflect benefits of group singing similar to those identified in the literature, and to explore whether neurological and community choir members report similar experiences of group singing. The present research combines historical data from an earlier phase of HRQOL research (Jenkins et al., 2017) with current data. In the earlier phase, the researchers explored HRQOL using the NZ WHOQOL-BREF (a version of the WHOQOL-100, a QOL instrument developed through the World Health Organization) (World Health Organization, 1994). In the earlier phase, all of the participants (N = 38) were neurological choir members and their HRQOL scores were compared against an existing sample of baseline HRQOL data called the world disabilities sample (Power et al., 2010), obtained through the WHOQOL-DIS Group. The WHOQOL-DIS Group were interested in whether the WHOQOL-BREF would be a suitable HRQOL tool for people with disabilities and in their research recruited 1,400 adult participants with intellectual or physical disabilities from 15 World Health Organization collaborating centres worldwide. Participants completed the WHOQOL-BREF to provide baseline HRQOL data for people with disabilities.

In the earlier phase of the present research, the researchers felt that the world disabilities sample would be a good comparison sample for their participants, all of whom had an acquired neurological condition. Research outputs from the earlier phase showed that HRQOL for neurological choir members was higher than for members of the world disabilities sample. The researchers also explored choir involvement perspectives using a choir participation questionnaire (CPQ) and found that neurological choir members perceived a number of positive benefits of choir involvement. While the earlier phase was open for neurological choir members to participate, the current phase invited community choir members to participate as well. In the present research, raw data from the earlier phase is combined with current data to compare the benefits of choral singing for people with neurological conditions and for the general population.

Design

Quantitative and qualitative data were collected from participants using two written questionnaires (the NZ WHOQOL-BREF and the CPQ). The researchers utilised a convergent, parallel, mixed methods design to examine participants’ HRQOL and choir involvement perspectives (Creswell & Poth, 2018). Whilst the researchers conducted separate analyses for the quantitative data (obtained from the NZ WHOQOL-BREF and the CPQ VAS responses) and the qualitative data (obtained from the CPQ open-ended responses), the quantitative and qualitative findings are intended to complement each other and confirm the HRQOL benefits of choral singing.

Materials

Participants

Members of four neurological choirs (NC 1, NC 2, NC 3, and NC 4) and two secular community choirs (CC 1 and CC2) throughout New Zealand were invited to participate in the present research. To differentiate between the two choir categories, the term NC refers to the four neurological choirs in this sample and the term CC refers to the two community choirs in this sample. Music therapists and choir leaders were sent an initial email inviting their choir members to participate in the present research. For NC members, companions supporting their choir attendance (for instance, professional/ personal carers or partners) were also invited to participate. Choir members expressed initial interest in the research with their music therapist or choir leader. The researchers then visited the choirs to explain the research project in greater detail, observe a choir session, and hand out consent forms and questionnaire packs to interested choir members. The researchers did not control the choir programmes, which continued as usual practice. Two of the NCs in this sample were led by the same music therapist (who is also one of the co-authors) (NC 1 and NC 4), one was co-led by two music therapists (NC 3), and the other was co-led by a music therapist and a speech-language therapist (NC 2). Both of the CCs in this sample were led by the same choir leader (CC 1 and CC 2).

Demographic information for the current sample is presented in Table 3. Most participants identified as New Zealand European (81.3%). Just over half identified as female (57.8%). Participant ages ranged from 30 to 60+ with more than half falling into the 60+ age group (65. 6%). Two-thirds of all participants (69.7%) had a tertiary level education. Almost half of all participants were married (45.6%) and this increased to 68.9% when those who identified as “living as married” were included. On average, CC members were younger (M = 60.6, SD = 9.6) than NC members (M = 68.8, SD = 11.7), and while most NC members were retired (72.9%), 61.9% of CC members were working.

Choir Approaches

The NCs in this sample were independent from each other. Whilst two of the NCs were led by the same music therapist (NC 1 and NC 4), the choirs operated independent from each other. This was also true for the two CCs who were led by the same choir leader. For all of the choirs in this sample, the music therapists and/ or choir leaders selected the exercises and repertoire in consultation with choir members. The choir programmes consisted of physical, respiratory, and vocal warm-ups and exercises, followed with song repertoire. For the NCs, more attention was given to exercises related to vowel and consonant production and rhythmic speech (Matthews et al., 2019; Talmage et al., 2013). In selecting, adapting, and leading songs, choir leaders and music therapists consider all music elements, including vocal range, metre, tempo, song structure (repetition, refrains, and cognitive load), and the supportive function of harmonic and rhythmic accompaniment (Buetow et al., 2013; Matthews et al., 2019; Talmage et al., 2013; Thompson et al., 2016). Music resources and materials were either purchased for the choirs or belonged to the music therapists and/ or choir leaders who adapted them for their choirs and printed or projected material for choir members to view. All choir programmes included a refreshment interval.

For the NCs, song repertoire included familiar unison and simple-part songs, with most in English, some in New Zealand Māori, and some simple songs in other languages. Song choices were a range of popular songs (most taken from the 1950s, to 1970s), traditional and cultural songs, show tunes, seasonal material, and songs with a positive or humorous tone. Most singing was done in unison, together with rounds, echo songs and simple harmonies (Matthews et al, 2019; Talmage et al., 2013; Waterhouse & Waterhouse, 2016). For the CCs, song repertoire included varied traditional, world, new composed and popular music, in three- to four-part harmonies, often taught using rote and sometimes incorporating improvisation (Backhouse, 2010; Jansen, 2019) with more challenging part-singing, both in English and in other languages. The CCs in this sample were non-auditioned all-comers choirs with a “natural voice philosophy”.

Ethics Approval

Ethics approval for this research was received on 13 July 2016 from the University of Auckland Human Participants Ethics Committee (approval given for three years, reference number: 01689, 1). Participants were able to request a summarised report of the research findings.

Procedure

Data Collection

Data collection for choir groups NC 1 and NC 2 occurred in 2016 (Jenkins et al., 2017). Data collection for choir groups NC 3, NC 4, CC 1, and CC 2 occurred in 2017. Each participant received an information sheet, a consent form, the two written questionnaires, and a return-addressed, postage-paid envelope at one of their regular choir sessions. The researchers requested that choir members take the documents home, to complete in their own time and return within two weeks. To protect participants and ensure that their data remained confidential, hard copies of participant data were stored in locked cabinets, while digital data was stored within password protected files on a password protected computer. Historical data from Jenkins et al. (2017) were combined with data from the current data collection phase to form the current research sample.

Exclusion Criteria. Participants were required to complete the information sheet and consent form, along with both written questionnaires. Three participants (CEL 5, CEL 15, and CEL 16) completed just one questionnaire, therefore their data was excluded. The WHOQOL-BREF scoring manual requires participants to complete at least 20% of the questionnaire to calculate their HRQOL score (World Health Organization, 1998). All participants met this criterion. In total, 90 choir members participated in this research, 48 from NCs and 42 from CCs.

Quantitative Data. The WHOQOL-BREF scoring manual (World Health Organization, 1998) was used to calculate domain scores (out of 20) and transformed domain scores (out of 100) for Q3 to Q26 of the NZ WHOQOL-BREF and to reverse-score three negative-coded questions (Q3, Q4, and Q26). Q1, Q2, and the New Zealand national questions did not contribute to the domain scores and were considered on their own. Quantitative data from the NZ WHOQOL-BREF and the CPQ were entered into Microsoft Excel (Office 2013) and checked before being imported into IBM SPSS Statistics Version 23 for analysis.

Kolmogorov-Smirnov tests (Massey, 1951) were used to determine the distributions of NZ WHOQOL-BREF and CPQ VAS responses. Both showed non-normal distributions (p < .001). Therefore, non-parametric statistical tests were used. To explore agreement between the two choir groups, Mann-Whitney U tests (Zimmerman, 1987) were used to test for significant group differences in NZ WHOQOL-BREF and the CPQ VAS responses. Tests were run for individual questions Q1 to Q31 of the NZ WHOQOL-BREF, transformed domain scores, and the CPQ VAS questions, except for Q12, which was excluded as it was relevant to just one of the choir groups (NC members). Due to multiple comparisons being conducted, follow up tests were pairwise comparisons with statistical significance based on Bonferroni-adjusted p-values. Effect sizes (r) were calculated for significant differences (Tomczak & Tomczak, 2014). To explore agreement between the NZ WHOQOL-BREF and the CPQ, Spearman’s correlation coefficients (Zar, 1972) were used to determine associations between Q1 and Q2 of the NZ WHOQOL-BREF and the CPQ VAS questions.

Qualitative Data. For the CPQ open-ended questions (Q8 and Q13 to Q16), manifest content was explored using an open coding process where individual items (participant comments) were mapped under overarching headings. To explore agreement between the NZ WHOQOL-BREF and the CPQ, participant comments were mapped under the NZ WHOQOL-BREF HRQOL domains where possible. The process for recruitment, procedure, and data analysis for the current sample is depicted in Figure 1.

Figure 1

Process for Recruitment, Procedure, and Data Analysis.

NZ WHOQOL-BREF

Comparison with the World Disabilities Sample

Figure 2 shows a visual comparison of HRQOL between the current sample and the world disabilities sample. The visual comparison indicates overall higher HRQOL for participants in the current sample (both NC and CC members) than for participants in the world disabilities sample (Powers et al., 2010). Figure 2 highlights similarities between NC and CC members for individual items 5 (“positive feelings”), 6 (“spirituality”), 11 (“body image”), 22 (“friendships”), 9 (“physical environment”), 14 (“leisure opportunities”), and 24 (“access to health services”). Figure 2 also highlights similarities between NC members and the world disabilities sample for individual items 4 (“medication”), 18 (“work”), 7 (“concentration”), and 21 (“sex life”).

Figure 2

Visual Comparison of HRQOL for the Current Sample and the World Disabilities Sample.

Choir Participation Questionnaire

Visual Analogue Scale Items

Figure 3 shows median VAS scores (%) for bipolar questions in the CPQ for the current sample. One of the three items showed a significant difference between the two choir groups after Bonferroni corrections for multiple comparisons, (U = 576.50, z = -3.60, p < .001, r ≈ -.4). This was Q10 (“difficulty of the music sung at choir”). While the scores were close to 50 percent for both NC members (55%) and CC members (48%), indicating that the difficulty of the music sung at choir was “about right”, the significant difference between the two choir groups indicates that NC members found the music sung at choir to be easier than CC members. Figure 4 shows median VAS scores (%) for unipolar questions in the CPQ for the current sample. None of the items showed a significant difference between the two choir groups. Q12 (“impact of choir on your neurological condition”) was excluded from these comparisons as it was relevant to just one of the choir groups (NC members). For this item, the mean VAS score for NC members was 70% (SD = 23%), indicating that participants felt that choir had a positive impact on their neurological condition.

Figure 3

CPQ Bipolar Questions: Median VAS Scores.

Note. Lower percentages indicate not enough of, while higher percentages indicate too much of, a particular aspect. Percentages close to 50 indicate contentment with a particular aspect.

Figure 4

CPQ Unipolar Questions: Median VAS Scores.

Note. Higher percentages indicate positive responses.

Summarised Results

The NZ WHOQOL-BREF findings show that HRQOL was similar between the two choir groups on the psychological, social relationships, and environmental domains, and lower for NC members on the physical domain. VAS scores from the CPQ show similar responses across participants and that both NC and CC members reported similar satisfaction with the timing, duration, frequency, and location of their choir sessions. NC and CC members also reported similar enjoyment of choir and felt that choir had a positive impact on their mood. Q10 showed a difference between the two choir groups in that NC members found the songs sung at choir to be easier than was reported by CC members. Q12 was only relevant to NC members and indicated that NC members felt that choir had a positive impact on their neurological condition. Mapped manifest content from the CPQ indicated that all participants perceived a range of positive benefits associated with choral singing. Most manifest content was consistent with the HRQOL domains, indicating good mapping of the qualitative data into the HRQOL domains. When asked to reflect on changes felt as a result of choir (Q13), most comments were mapped on the psychological domain (44.6%) where most participants talked about “positive feelings”. When asked to reflect on what makes an excellent choir session (Q14), most comments were mapped on the environmental domain (38.3%) under “leisure opportunities”. When asked to reflect on other positive aspects of choir involvement (Q15), most comments were mapped on the social relationships domain (44.3%) under “friendships”. When asked to provide comments or suggestions for improvement (Q16), most responses were constructive comments about song and music choice (71.0%).

Differences Between the Choir Groups

Transformed domain scores from the NZ WHOQOL-BREF indicate that HRQOL differed between the two choir groups on the physical domain. Individual NZ WHOQOL-BREF item scores indicate that HRQOL for NC members was lower on the “medication”, “mobility”, “work”, and “concentration” facets. This finding is not unexpected given some of the challenges associated with a neurological condition diagnosis, including new medication requirements, impacted cognition and physical functioning, and in some cases impacted work capabilities or loss of job. VAS scores from the CPQ indicate that NC members found their song choices to be easier than CC members. This could have been due to the selection of simpler arrangements for the NCs versus more complex and challenging choir repertoire for the CCs.

Similarities Between the Choir Groups

Transformed domain scores from the NZ WHOQOL-BREF indicate that HRQOL was similar between the two choir groups on the psychological, social relationships, and environmental domains, which is an unexpected finding. Whilst existing research highlights negative HRQOL outcomes for people with neurological conditions (Carod-Artal & Egido, 2009; Rahman et al., 2008), the present research found that HRQOL for NC members is in fact similar to that of well people (CC members). This finding provides a rationale for future research to continue to explore the potential connection between choral singing and HRQOL for people with neurological conditions.

VAS scores from the CPQ indicate that choir members reported similar satisfaction with the timing, duration, frequency, and location of their choir sessions. Choir members also reported similar enjoyment of choir and felt that choir had a positive impact on their mood. Manifest content from the CPQ indicates that choir members perceived a number of positive benefits associated with choral singing, most of which were consistent with the four HRQOL domains. In the psychological domain, most comments were mapped under “positive feelings”; in the social relationships domain, most comments were mapped under “friendships”; and in the environmental domain most comments were mapped under “leisure opportunities”. The outcome of this mapping is consistent with the NZ WHOQOL-BREF findings that HRQOL was similar between the two choir groups on these three domains.

The visual comparison of HRQOL for the current sample and the world disabilities sample (Figure 2) highlights similarities between NC and CC members on several individual facets, including “positive feelings”, spirituality”, “body image”, “friendships”, “physical environment”, “leisure opportunities”, and “access to health services”. The visual depiction also highlights some similarities between NC members and the world disabilities sample on the “medication”, “work”, “concentration”, and “sex life” facets, which as mentioned earlier, is not unexpected given some of the challenges associated with a neurological condition diagnosis.

Links Between the Present Research and the Existing Literature

The present research suggests that choral singing is associated with positive HRQOL for people with and without neurological conditions. This finding has been documented in other research exploring choral singing and QOL (Irons et al., 2021; Johnson et al., 2013; Moss et al., 2018). Participants in the current sample reported benefits of choral singing that align with earlier randomised controlled trial studies demonstrating therapeutic benefits of choir participation (Pongan et al., 2017; Zumbansen et al., 2017). Also consistent with earlier studies (Fogg-Rogers et al., 2015; Moss et al., 2018; Lee et al., 2018), participants in the current sample reported improved mood, a sense of wellbeing, peer support, social connections, and a shared interest with others.

There has been limited use of the WHOQOL-BREF tools in research exploring choral singing and HRQOL. One known example is Johnson et al. (2013) who found that choral singing was associated with positive HRQOL on three out of the four WHOQOL-BREF domains (psychological, social relationships, and environmental). In the current sample, participants from both choir groups reported similar HRQOL on these three domains, but NC and CC groups differed on the physical domain. Thus, although the results of the present research support HRQOL benefits of choral singing, it is clear that physical challenges remain for people with neurological conditions.

Implications for Neurological Choirs in New Zealand

The findings from the present research suggest that NC members value choir for a number of reasons, including mood improvements, speech, communication, and breathing improvements, friendship and social interaction, the no pressure environment, and the positive challenge that choir provides. At present, NC provision is limited across New Zealand due to a lack of available facilitators and funding issues, although skill-sharing initiatives have encouraged some local musicians to support group singing initiatives for this population (Talmage, 2017). The researchers have also completed interview research with current and potential choir leaders to give a clearer picture of facilitator availability and training needs (Talmage & Purdy, 2021). Further research is required to investigate specific facilitation strategies within different models of neurological choir leadership in New Zealand, including single facilitator versus co-therapist approaches and music therapist, speech-language therapist or other interprofessional approaches observed in the present research, as well as the role of volunteers and partners/ carers. Seven carers who supported NC members participated in the present research and whilst this was not a large enough group from which to obtain sufficient data, future studies should consider exploring partner and carer perspectives in greater detail.

Study Limitations and Future Directions

While the CPQ was able to capture valuable information about the perceived benefits of CST, responses were sometimes repetitive. Future research utilising the CPQ should consider reviewing some of the open-ended questions in order to obtain more diverse responses. For instance, Q14 (“Please tell us what makes an excellent choir session for you”) and Q15 (“Please tell us anything else you like about the choir”) are similar and as a result responses to these two questions were often repetitive. Q14 and Q15 are also positive-framed, which could have resulted in a potential bias towards positive-framed responses. Framing questions in a neutral manner would support more objective responses. In addition, questions about negative aspects of choir as well as other factors in participants’ lives that bring them happiness would also help to achieve a more holistic understanding of their HRQOL. Two of the NCs in this sample were led by the same music therapist (NC 1 and NC 4), and both of the CCs in this sample were led by the same choir leader (CC 1 and CC 2), which could have resulted in skewed responses. Most of the choir members in the current sample identified as New Zealand European. Future research should explore the present findings with choir members from more diverse backgrounds and cultures to provide a more inclusive representation of the benefits of CST in New Zealand.

Choral singing is associated with a number of potential covariates that makes it difficult to distinguish the impact of CST on HRQOL without the use of a randomised controlled trial research design. For instance, given that choral singing is a social occasion, perhaps choral singing provides choir members with opportunities for social connectedness, which is responsible for the positive impact on their HRQOL. If so, then other social activities (not just CST) might also suffice to meet this need. To help control for potential covariates, future studies should aim to explore the association between CST and HRQOL using randomised controlled trials where possible. Researchers should also explore the potential association between CST and other shared activities with HRQOL for people with neurological conditions. A potential covariate in choral singing research that was not considered in the current study is culture. Choral singing in particular is sometimes also tied to religion and culture (Brandt et al., 2012; Conrad, 2010; Cross, 2001; Cross & Morley, 2002). Although this feels important to consider, studies exploring the importance of culture and singing are limited (Gick, 2011). To aid this, future research on this topic should recruit from a range of choirs, including church, cultural, and professional choirs.