This mixed methods research focused on the health-related quality of life (HRQOL) of
participants who sing in neurological choirs (social singing groups offering choral
singing therapy [CST]) and community choirs in New Zealand. The mixed methods paradigm
values both quantitative and qualitative methods and aligns well with the holistic
philosophies that underpin several approaches to music therapy (
The authors of the present research are influenced through their research backgrounds in psychology, speech science, and music therapy. Authors Jordyn Thompson and Brieonie Jenkins were psychology honours students at the time the present research was carried out; author Alison Talmage is a registered music therapist with more than ten years’ experience leading neurological choirs; author Suzanne Purdy has a background in neuropsychology and communication disorders and has collaborated with author Alison Talmage for over ten years.
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
(
Research shows that diagnosis with a neurological condition is associated with worse
HRQOL outcomes compared to well people (
There is growing interest in the outcomes of music-based approaches to
neurorehabilitation (
However, growing evidence supports additional psychosocial and QOL benefits (
In a review paper, Gick (
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 (
A mixed methods feasibility study carried out with The CeleBRation Choir identified
several therapeutic benefits of choral singing.
The present research aims to build on the findings from
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.
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 (
The NZ WHOQOL-BREF is the New Zealand version of the WHOQOL-BREF, which is a
condensed version of the original WHOQOL-100. The WHOQOL tools measure HRQOL on
four domains: physical, psychological, social relationships, and environmental
(
NZ WHOQOL-BREF Items and Respective Domains/ Facets
Domain | Item | Facet |
---|---|---|
1 | Overall QOL | |
2 | Overall physical health | |
Physical | 3 | Pain |
4 | Medication | |
10 | Energy | |
15 | Mobility | |
16 | Sleep | |
17 | Ability to perform daily activities | |
18 | Work | |
Psychological | 5 | Positive feelings |
6 | Spirituality | |
7 | Concentration | |
11 | Body image | |
19 | Self-esteem | |
26 | Negative feelings | |
Social Relationships | 20 | Personal relationships |
21 | Sex life | |
22 | Friendships | |
Environmental | 8 | Safety |
9 | Physical environment | |
12 | Finances | |
13 | Access to information | |
14 | Leisure opportunities | |
23 | Living conditions | |
24 | Access to health services | |
25 | Access to transport | |
New Zealand National Questions | 27 | Meets expectations |
28 | Respected by others | |
29 | Manages personal difficulties | |
30 | Feelings of belonging | |
31 | Control over life |
The CPQ is a 16-item questionnaire, which explores choir involvement perspectives. The CPQ includes three demographic questions, eight questions scored on a visual analogue scale (VAS), and five open-ended questions (see Table 2). The CPQ is a non-standardised questionnaire that was developed for the present research based on earlier studies carried out with the CeleBRation Choir. To score the VAS questions, a visual scale is presented after each question as a 10-centimetre line (on A4 paper). For bipolar questions (Q5, Q6, and Q10), centre-oriented responses indicate higher satisfaction, and left- or right-oriented responses indicate lower satisfaction (either “not enough” or “too much” of something). For unipolar questions (Q4, Q7, Q9, Q11, and Q12), left-oriented responses indicate lower satisfaction and right-oriented responses indicate higher satisfaction. Each VAS response is scored from 0 to 1 with a higher score indicating higher satisfaction. The CPQ was presented in English.
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 (
Choir Participation Questionnaire
Item | Question |
---|---|
Q1 | Please tick a box to indicate your age |
Q2 | Health (tick as many as you need) |
Q3 | Which choir do you attend? |
Q4 | How would you rate the time of day of the choir sessions, from inconvenient, to perfectly timed? |
Q5 | How would you rate the length of the choir sessions, from too long, to too short? |
Q6 | The choir currently runs weekly. How would you would rate the frequency of the weekly sessions, from too infrequent, to too often? |
Q7 | How would you rate the location of the choir sessions, from inconvenient, to perfectly located? |
Q9 | How would you rate the choir overall, from boring to very enjoyable? |
Q10 | How would you rate the difficulty of the music sung at the choir, from too hard to too easy? |
Q11 | How would you rate the choir for your mood, from having no benefit to a huge improvement? |
Q12 | If you have a neurological condition, how would you rate the impact of the choir on your condition, from being no benefit to a huge improvement? If you do not have a neurological condition, skip to the next question. |
Q8 | Please include here any comments you may have about how we can improve the timing, location and frequency of the choir sessions. |
Q13 | If you have felt any changes as a result of the choir, what do you think they are? |
Q14 | Please tell us what makes an excellent choir session for you. |
Q15 | Please tell us anything else you like about the choir. |
Q16 | Please let us know any other comments or suggestions for improving the choir in the future. |
Demographic Information
Participants | Neurological Choirs | Community Choirs | |||
---|---|---|---|---|---|
Number | % of Sample | Number | % of Sample | ||
48 | 53.3% | 42 | 46.7% | ||
30-44 | 3 | 6.3% | 1 | 2.4% | |
45-59 | 7 | 14.6% | 20 | 47.6% | |
60+ | 38 | 38.0% | 21 | 50.0% | |
Male | 28 | 58.3% | 7 | 16.7% | |
Female | 17 | 35.4% | 35 | 83.3% | |
New Zealand European | 39 | 81.3% | 32 | 76.2% | |
Māori | 1 | 2.1% | 0 | 0% | |
Asian | 2 | 4.2% | 1 | 2.4% | |
Other European | 4 | 8.3% | 7 | 16.7% | |
Other New Zealander | 2 | 4.2% | 2 | 4.8% | |
Primary | 2 | 4.2% | 0 | 0% | |
Secondary | 21 | 43.8% | 5 | 11.9% | |
Tertiary | 25 | 52.1% | 37 | 88.1% | |
Full-time | 0 | 0% | 8 | 19.0% | |
Part-time | 3 | 6.3% | 18 | 42.9% | |
Retired | 35 | 72.9% | 9 | 21.4% | |
Unemployed | 7 | 14.6% | 2 | 4.8% | |
Other | 3 | 6.3% | 4 | 9.5% | |
Parkinson’s disease | 18 | 37.5% | 0 | 0% | |
Stroke | 13 | 27.1% | 2 | 4.8% | |
Other medical condition | 9 | 18.8% | 15 | 35.7% | |
No medical condition | 1 | 2.1% | 22 | 52.4% | |
Carer | 7 | 14.6% | 2 | 4.8% | |
Single | 4 | 8.3% | 2 | 4.8% | |
Married | 31 | 64.6% | 10 | 23.8% | |
Living as married | 4 | 8.3% | 17 | 40.5% | |
Separated | 2 | 4.2% | 0 | 0% | |
Divorced | 6 | 12.5% | 6 | 14.3% | |
Widowed | 1 | 2.1% | 6 | 14.3% |
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 (
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 (
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.
Data collection for choir groups NC 1 and NC 2 occurred in 2016 (
Kolmogorov-Smirnov tests (
Process for Recruitment, Procedure, and Data Analysis.
As mentioned, in the earlier phase of this research (
There were no significant differences between the two choir groups for Q1 and Q2,
indicating that overall QOL and overall physical health satisfaction were similar
(
Four individual HRQOL items showed significant differences between the two choir
groups after Bonferroni corrections for multiple comparisons (see Table 4). Three
items, Q4 (“medication”,
Significant Group Differences in NZ WHOQOL-BREF Scores
Item | Domain/ Facet | U | Std. Test Statistic | Effect Size, |
---|---|---|---|---|
4 | Medication | 1,603.50 | 4.99 | .53 |
15 | Mobility | 1,385.00 | 3.32 | .35 |
18 | Work | 1,481.50 | 4.72 | .50 |
7 | Concentration | 1,423.00 | 3.65 | .38 |
1,521.00 | 4.40 | .47 |
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 (
Visual Comparison of HRQOL for the Current Sample and the World Disabilities Sample.
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,
(
CPQ Bipolar Questions: Median VAS Scores.
CPQ Unipolar Questions: Median VAS Scores.
Coding of manifest content from the CPQ open-ended responses is summarised in Tables 5 to 10. To explore agreement between the NZ WHOQOL-BREF and the CPQ, manifest content from the CPQ was mapped under NZ WHOQOL-BREF HRQOL domains where possible. Most manifest content (94.1%) was consistent with the HRQOL domains and is presented in Tables 5 to 9 with individual examples provided to illustrate this mapping of content. Content not consistent with the HRQOL domains (5.9%) is organised as “other” and is presented in Table 10. Participant responses to Q16 accounted for most of the content not consistent with the HRQOL domains (84.6%).
CPQ Q8: Participant Responses
Response Topic | n | Examples |
---|---|---|
Timing | 8 | “Time and date is good – 1.30pm” (NC 1, member 11). |
Location | 13 | “There's great parking on campus which is essential” (NC 2, member
6). |
Frequency | 4 | “Good to have a regular, set day as it's a routine part of the weekly
calendar” (NC 2, member 20). |
|
25 |
CPQ Q13: Participant Responses Aligned with the NZ WHOQOL-BREF
Item | Domain/ Facet | n | Examples |
---|---|---|---|
3 | Pain | 6 |
|
10 | Energy | 10 |
|
5 | Positive feelings | 27 |
|
6 | Spirituality | 3 |
|
7 | Concentration | 6 |
|
19 | Self-esteem | 11 |
|
26 | Negative feelings | 3 |
|
22 | Friendships | 17 |
|
14 | Leisure opportunities | 5 |
|
29 | Manages personal difficulties | 16 |
|
30 | Feelings of belonging | 8 |
|
|
112 |
CPQ Q14: Participant Responses Aligned with the NZ WHOQOL-BREF
Item | Domain/Facet | n | Examples |
---|---|---|---|
10 | Energy | 1 |
|
5 | Positive feelings | 37 |
|
7 | Concentration | 1 |
|
22 | Friendships | 37 |
|
14 | Leisure opportunities | 69 |
|
27 | Meets expectations | 22 |
|
28 | Respected by others | 1 |
|
30 | Feelings of belonging | 9 |
|
31 | Control over life | 3 |
|
|
180 |
CPQ Q15: Participant Responses Aligned with the NZ WHOQOL-BREF
Item | Domain/Facet | n | Examples |
---|---|---|---|
10 | Energy | 2 |
|
5 | Positive feelings | 10 |
|
6 | Spirituality | 1 |
|
7 | Concentration | 1 |
|
19 | Self-esteem | 2 |
|
20 | Personal relationships | 2 |
|
22 | Friendships | 49 |
|
14 | Leisure opportunities | 20 |
|
27 | Meets expectations | 1 |
|
28 | Respected by others | 2 |
|
30 | Feelings of belonging | 21 |
|
31 | Control over life | 4 |
|
|
115 |
CPQ Q16: Participant Responses Aligned with the NZ WHOQOL-BREF
Item | Domain/Facet | n | Examples |
---|---|---|---|
22 | Friendships | 1 |
|
14 | Leisure opportunities | 8 |
|
|
9 |
“Other”: Participant Responses not Aligned with the NZ WHOQOL-BREF
CPQ Question | n | Examples |
---|---|---|
Q13 | 1 |
|
Q14 | 3 |
|
Q16 | 22 |
|
|
26 |
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%).
Diagnosis with a neurological condition is associated with negative HRQOL outcomes,
which medical interventions alone are unable to address (
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.
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 (
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.
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 (
There has been limited use of the WHOQOL-BREF tools in research exploring choral
singing and HRQOL. One known example is
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 (
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
(
Jordyn Thompson (she/her) completed her BA (Hons) in Psychology at the University of Auckland – Waipapa Taumata Rau, Aotearoa New Zealand in 2018. Her research explored quality of life for people who sing in neurological and community choirs in Aotearoa, New Zealand. She is currently completing a Master of Arts at the University of Auckland – Waipapa Taumata Rau, Aotearoa New Zealand with research in the field of child and adolescent wellbeing exploring school-wide strategies that support positive mental health outcomes in adulthood and reduce the impact of childhood trauma and adverse childhood experiences. Jordyn has an interest in holistic, person-centred approaches to mental health and wellbeing.
Alison Talmage (she/her) is a music therapist, teacher, and doctoral candidate at the University of Auckland – Waipapa Taumata Rau, Aotearoa New Zealand. She has worked with people with diverse needs across the lifespan. She co-founded the CeleBRation Choir at the University’s Centre for Brain Research (2009), and the Sing Up Rodney community music therapy group (2017). Her current action research study focuses on neurological choirs, that address the social and communication needs of adults with acquired neurogenic communication difficulties.
Brieonie Jenkins (she/her) completed her BA (Hons) in Psychology at the University of Auckland – Waipapa Taumata Rau, Aotearoa New Zealand in 2017. Her research focussed on choir participation for people with neurological conditions. She is currently a doctoral candidate at Massey University – Te Kunenga ki Pūehuroa, Aotearoa New Zealand. Her current research centres on people who care for loved ones with dementia and how aspects of this caregiving role may contribute to quality of life outcomes.
Suzanne Purdy (she/her) is Head of School of Psychology at the University of Auckland – Waipapa Taumata Rau, Aotearoa New Zealand. She has a background in neuroscience, clinical audiology and hearing and speech sciences. Her research interests include community-based therapies for people with neurological conditions and communication disorders. She is a Principal Investigator with the University’s Centre for Brain Research which supports the CeleBRation Choir.
Thank you to the choir leaders, music therapists, and research participants who donated their precious time to take part in this research. We also acknowledge the support of the University of Auckland Centre for Brain Research, led by Distinguished Professor Sir Richard Faull, and the University of Auckland Discipline of Speech Science, particularly Dr Clare McCann, Dr Anna Miles and Ms Adeline Fung.