Critical thinking in musicians' health education. Findings from four workshops with experts (Part I).

Health education encompasses building health knowledge, but also training skills such as critical thinking, that guide individuals' ability to access, understand and use health information to take care of their own health (WHO, 1998). This study aimed to document expert discussions on the content of an ideal health education curriculum for higher music education (HME) students in the UK, integrating critical thinking. Four interdisciplinary workshops were conducted, where 67 experts in relevant fields discussed the content of four lists created based on literature reviews (cognitive biases, logical fallacies, critical appraisal tools and health topics). Notes taken during the discussions were thematically analysed. Most of the participants thought that the topics and tools were relevant. Two of four identified themes are reported in this paper, which represents the first of a two-part series: (1) critical thinking applied to health; and (2) misconceptions. This is the first attempt to document conversations aimed at using the applied knowledge of key stakeholders to discuss the content of an ideal health education curriculum integrating critical thinking, for conservatoire students.

Professional classical musicians struggle with a range of occupational health issues, but clear guidelines around health education in HME are still missing. This paper reports the first attempt to document a series of four interdisciplinary discussions between 67 experts on (1) the ideal health education content for music students, and (2) the integration of critical thinking as part of music students' health education. Discussions were facilitated by comprehensive lists based on literature reviews. Notes were taken during discussions and were thematically analysed. Four themes were identified, two of which are discussed here: (1) critical thinking applied to health; and (2) misconceptions.

Health education in conservatoires: what should it consist of? Findings from workshops with experts (Part II).

Although health education programmes have been implemented in higher music education (HME) and their evaluations published in peer-reviewed journals, guidelines as to what ought to be included in these programmes are still missing. This study aimed to document expert discussions on the content of an ideal health education curriculum for HME students in the UK, integrating critical thinking. Four interdisciplinary workshops were conducted, where 67 experts in relevant fields took part, and were asked to discuss four lists of topics and concepts created based on literature reviews (cognitive biases, logical fallacies, critical appraisal tools and health topics). Only the list on health topics is relevant here. Notes taken by the participants and ourselves were thematically analysed. Four themes were identified, two of which are reported in this paper: (i) The health education curriculum and (ii) A settings-based approach to health. Part I of this project (published elsewhere) is focussed on the critical thinking content of health education for conservatoire students. The present paper focusses on the ideal health education curriculum and its implications for the wider context of health promotion.

Health education programmes are constantly embedded as part of the higher music education curricula. However, clear guidelines as to what ought to be included in these courses are still missing. This paper reports the first attempt to document a series of four interdisciplinary discussions with 67 experts on the ideal health education content for music students, and its implications for the wider context of health promotion. Discussions were facilitated by comprehensive lists created on the basis of literature reviews. Notes taken by both the participants and ourselves during discussions were thematically analysed. Two of four themes are discussed here: (i) The health education curriculum and (ii) A settings-based approach to health.

Returning to clinical work and doctors' personal, social and organisational needs: a systematic review.

OBJECTIVE: This systematic review aims to synthesise existing evidence on doctors' personal, social and organisational needs when returning to clinical work after an absence. DESIGN: Systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. DATA SOURCES: AMED, BNI, CINAHL, EMBASE, EMCARE, HMIC, Medline, PsycINFO and PubMed were searched up to 4 June 2020. Non-database searches included references and citations of identified articles and pages 1-10 of Google and Google Scholar. ELIGIBILITY CRITERIA: Included studies presented quantitative or qualitative data collected from doctors returning to work, with findings relating to personal, social or organisational needs. DATA EXTRACTION AND SYNTHESIS: Data were extracted using a piloted template. Risk of bias assessment used the Medical Education Research Study Quality Instrument or Critical Appraisal Skills Programme Qualitative Checklist. Data were not suitable for meta-analyses and underwent narrative synthesis due to varied study designs and mixed methods. RESULTS: Twenty-four included studies (14 quantitative, 10 qualitative) presented data from 92 692 doctors in the UK (n=13), US (n=4), Norway (n=3), Japan (n=2), Spain (n=1), Canada (n=1). All studies identified personal needs, categorised as work-life balance, emotional regulation, self-perception and identity, and engagement with return process. Seventeen studies highlighted social needs relating to professional culture, personal and professional relationships, and illness stigma. Organisational needs found in 22 studies were flexibility and job control, work design, Occupational Health services and organisational culture. Emerging resources and recommendations were highlighted. Variable quality and high risk of biases in data collection and analysis suggest cautious interpretation. CONCLUSIONS: This review posits a foundational framework of returning doctors' needs, requiring further developed through methodologically robust studies that assess the impact of length and reason for absence, before developing and evaluating tailored interventions. Organisations, training programmes and professional bodies should refine support for returning doctors based on evidence.

Health education for musicians in the UK: a qualitative evaluation.

Musical training in higher education music institutions (e.g. conservatoires) has been associated with health-related issues among musicians. The Health Promotion in Schools of Music project in the USA and the Healthy Conservatoires project in the UK have therefore recommended health promotion at conservatoires. Few health education courses have been evaluated to date, however. A 5-month health education programme for first-year undergraduate students at a British conservatoire was introduced as part of the core curriculum in September 2016. The programme, which involved both lectures and seminars, was evaluated using quantitative and qualitative approaches. This article reports only the qualitative evaluation. Twenty semi-structured individual interviews were conducted either face-to-face or via Skype in April 2017. The data were transcribed verbatim and analysed thematically. Five themes were identified: (i) the programme as a catalyst for engagement with health; (ii) behavioural changes; (iii) barriers to engaging with the programme material and initiating changes; (iv) suggestions for improvement; and (v) misinformation. Generally, participants viewed the programme as relevant and informative, particularly appreciating the intimate nature of the seminars. They reported that the programme helped them take a broader perspective on musicianship and that they would welcome sessions that are more practical than theoretical. They also reported instances of change in their behaviours relating to both lifestyle and management of music practice. In conclusion, undergraduate music students viewed this health education programme positively. Their feedback illustrates the complex nature of health promotion in the conservatoire setting.

Professional classical musicians struggle with a range of occupational health issues. It has therefore been recommended that health education be integrated as part of their higher education training. Although some programmes of this nature have been implemented in recent years, very few were evaluated, so it is often unclear if they work and if so, how. This paper reports the evaluation of one such programme that lasted 5 months and was delivered to first-year undergraduate music students in the UK. Although the evaluation of the programme was complex and involved many measurements, this article reports only the analysis of themes arising from interviews with 20 participants that were audio-recorded and transcribed verbatim. The results of the analysis show that participants viewed the course positively. Specifically, they viewed the programme as relevant and informative, and appreciated the intimate nature of the seminars. The programme seemed to widen their perspective on musicianship and they reported changes in their behaviours related to preventative health and music practice, although they also expressed a preference for an even more practical and thus less theoretical approach.

'I Have Had to Stop Singing Because I Can't Take the Pain': Experiences of Voice, Ability, and Loss in Singers With Hypermobility Spectrum Disorders.

OBJECTIVE: This study explored the voice experience, singing ability, and wellbeing of singers diagnosed with Hypermobility Spectrum Disorder (HSD) or hypermobile Ehlers-Danlos Syndrome (h-EDS). STUDY DESIGN: This was a mixed-method study. A purposive sampling strategy was used. Data were collected via an online survey, using written closed and open-ended questions. METHODS: 276 adults completed the survey. This study focuses on a subset of professionally-trained singers (n=71). Responses elicited information about participants' voice health and function, symptoms of hypermobility, singing experiences and training. Data were analysed using template analysis. RESULTS: Many participants reported wide vocal ranges and enjoyment of singing but 74.6% of participants across all age groups (18-60 years) experienced voice difficulties. Three common themes were identified: (1) 'My unreliable voice': The ups and downs; (2) Wider effects of HSD/h-EDS on singers, and (3) Need for acknowledgment and support. CONCLUSIONS: Voice difficulties and hypermobility-related health conditions affected the participants' abilities to sing and perform; this impacted their professional and personal opportunities, communication, relationships, and wellbeing. Our results indicate that symptoms of voice disorder worsen over time. We suggest practical strategies that singers and training providers could implement to support hypermobile singers. More research is needed to fully understand voice difficulties in singers with HSD/H-EDS and to inform tuition and support.

Physical Activity, Sedentary Behavior, Anxiety, and Pain Among Musicians in the United Kingdom.

CONTEXT AND AIMS: Although some exercise-based interventions have been associated with lower levels of pain and performance-related musculoskeletal disorders (PRMDs) among musicians, the evidence is still mixed. Furthermore, little is known about musicians' general engagement in physical activity (PA), their knowledge of PA guidelines, or the relevant training they receive on pain prevention and the sources of such training. Similarly, little is known about the relationship between PA and PRMDs and other risk factors for PRMDs. METHODS: Following a cross-sectional correlational study design, both standardized and ad hoc measurements were used to investigate self-reported PA [International Physical Activity Questionnaire - Short Form (IPAQ-SF)], knowledge of PA guidelines, and barriers to engaging in PA [Centers for Disease Control (CDC); Determinants of Physical Activity Questionnaire (DPAQ)]; sedentary behavior [Sedentary Behavior Questionnaire (SBQ)]; pain [36-Item Short Form Survey Instrument (SF-36)] and PRMDs (frequency and severity); reported physical exertion (RPE); anxiety [Hospital Anxiety and Depression Scale (HADS)]; practice behaviors (e.g., practice time; taking breaks frequency; warming up); and relevant training among conservatoire students in the United Kingdom. The entire set of questionnaires was administered both online and via hard copies between June 2017 and April 2018. RESULTS: Demographic information was obtained from 111 respondents, mostly undergraduate students (UGs) from seven conservatoires. They reported high levels of engagement in PA, despite poor knowledge of PA guidelines. Teachers were the most frequently mentioned source of pain prevention information (by 43% of respondents), and 62% agreed that they had received advice on why they should engage in cardio PA. Sedentary behavior was comparable to normative data. Levels of bodily pain and PRMDs were low, but 43% showed "abnormal" clinical anxiety and found playing their instruments "somewhat hard" (RPE) on average. Bodily pain interfering with practice and performance was positively correlated with frequency and severity of PRMDs, anxiety, and RPE. Frequency and severity of PRMDs were also associated with sedentary behavior at the weekend. Anxiety was associated with RPE. No association was found between PA and PRMDs. CONCLUSION: The relationship between PA and PRMDs and pain remains unclear and needs further investigation. While health education needs to be improved, other pathways may need to be taken. Given the high levels of anxiety, the ideology of Western classical music itself may need to be challenged.

Health Education for Musicians.

Context and aims: Many musicians suffer for their art, and health is often compromised during training. The Health Promotion in Schools of Music (HPSM) project has recommended that health education should be included in core curricula, although few such courses have been evaluated to date. The aim of the study was to design, implement and evaluate a compulsory health education course at a UK conservatoire of music. Methods: The course design was informed by a critical appraisal of the literature on musicians' health problems and their management, existing health education courses for musicians, and the HPSM recommendations. It was delivered by a team of appropriately-qualified tutors over 5 months to 104 first-year undergraduate students, and evaluated by means of questionnaires at the beginning and end of the course. Thirty-three students who had been in their first year the year before the course was introduced served as a control group, completing the questionnaire on one occasion only. Items concerned: hearing and use of hearing protection; primary outcomes including perceived knowledge and importance of the topics taught on the course; and secondary outcomes including physical and psychological health and health-promoting behaviors. The content of the essays written by the first-year students as part of their course assessment served as a guide to the topics they found most interesting and relevant. Results: Comparatively few respondents reported using hearing protection when practicing alone, although there was some evidence of hearing loss, tinnitus, and hyperacusis. Perceived knowledge of the topics on the course, and awareness of the risks to health associated with performing music, increased, as did self-efficacy; otherwise, there were negative effects on secondary outcomes, and few differences between the intervention and control groups. The topics most frequently covered in students' essays were managing music performance anxiety, and life skills and behavior change techniques. Conclusion: There is considerable scope for improving music students' physical and psychological health and health-related behaviors through health education, and persuading senior managers, educators and students themselves that health education can contribute to performance enhancement.

Music performance anxiety in classical musicians - what we know about what works.

When pursued professionally, the demands of musical training and performance can interfere with musicians' well-being and health. Music performance anxiety, while energising at optimal levels, impairs performance quality when excessive. A range of interventions has been explored to address it. However, the poor methodological quality of such studies and the complexity of this issue should mobilise further research resources in this direction.

On Your Feet to Earn Your Seat: pilot RCT of a theory-based sedentary behaviour reduction intervention for older adults.

BACKGROUND: Of all age groups, older adults spend most of the time sitting and are least physically active. This sequential, mixed-methods feasibility study used a randomised controlled trial design to assess methods for trialling a habit-based intervention to displace older adults' sedentary behaviour with light activity and explore impact on behavioural outcomes. METHODS: Eligibility criteria were age 60-74 years, retired, and ≥6 h/day leisure sitting. Data were collected across four sites in England. The intervention comprised a booklet outlining 15 'tips' for disrupting sedentary habits and integrating activity habits into normally inactive settings, and eight weekly self-monitoring sheets. The control was a non-habit-based factsheet promoting activity and sedentary reduction. A computer-generated 1:1 block-randomisation schedule was used, with participants blinded to allocation. Participants self-reported sedentary behaviour (two indices), sedentary habit, physical activity (walking, moderate, vigorous activity) and activity habit, at pre-treatment baseline, 8- and 12-week follow-ups and were interviewed at 12 weeks. Primary feasibility outcomes were attrition, adverse events and intervention adherence. The secondary outcome was behavioural change. RESULTS: Of 104 participants consented, 103 were randomised (intervention N = 52, control N = 51). Of 98 receiving allocated treatment, 91 (93%; intervention N = 45; control N = 46) completed the trial. One related adverse event was reported in the intervention group. Mean per-tip adherence across 7 weeks was ≥50% for 9/15 tips. Qualitative data suggested acceptability of procedures, and, particularly among intervention recipients, the allocated treatment. Both groups appeared to reduce sedentary behaviour and increase their physical activity, but there were no apparent differences between groups in the extent of change. CONCLUSIONS: Trial methods were acceptable and feasible, but the intervention conferred no apparent advantage over control, though it was not trialled among the most sedentary and inactive population for whom it was developed. Further development of the intervention may be necessary prior to a large-scale definitive trial. One possible refinement would combine elements of the intervention with an informational approach to enhance effectiveness. TRIAL REGISTRATION: ISRCTN47901994 (registration date: 16th January 2014; trial end date 30th April 2015).

Acceptability of a theory-based sedentary behaviour reduction intervention for older adults ('On Your Feet to Earn Your Seat').

BACKGROUND: Adults aged 60 years and over spend most time sedentary and are the least physically active of all age groups. This early-phase study explored acceptability of a theory-based intervention to reduce sitting time and increase activity in older adults, as part of the intervention development process. METHODS: An 8-week uncontrolled trial was run among two independent samples of UK adults aged 60-75 years. Sample 1, recruited from sheltered housing on the assumption that they were sedentary and insufficiently active, participated between December 2013 and March 2014. Sample 2, recruited through community and faith centres and a newsletter, on the basis of self-reported inactivity (<150 weekly minutes of moderate-to-vigorous activity) and sedentary behaviour (≥ 6 h mean daily sitting), participated between March and August 2014. Participants received a booklet offering 16 tips for displacing sitting with light-intensity activity and forming activity habits, and self-monitoring 'tick-sheets'. At baseline, 4-week, and 8-week follow-ups, quantitative measures were taken of physical activity, sedentary behaviour, and habit. At 8 weeks, tick-sheets were collected and a semi-structured interview conducted. Acceptability was assessed for each sample separately, through attrition and adherence to tips, ANOVAs for behaviour and habit changes, and, for both samples combined, thematic analysis of interviews. RESULTS: In Sample 1, 12 of 16 intervention recipients completed the study (25% attrition), mean adherence was 40% (per-tip range: 15-61%), and there were no clear patterns of changes in sedentary or physical activity behaviour or habit. In Sample 2, 23 of 27 intervention recipients completed (15% attrition), and mean adherence was 58% (per-tip range: 39-82%). Sample 2 decreased mean sitting time and sitting habit, and increased walking, moderate activity, and activity habit. Qualitative data indicated that both samples viewed the intervention positively, found the tips easy to follow, and reported health and wellbeing gains. CONCLUSIONS: Low attrition, moderate adherence, and favourability in both samples, and positive changes in Sample 2, indicate the intervention was acceptable. Higher attrition, lower adherence, and no apparent behavioural impact among Sample 1 could perhaps be attributable to seasonal influences. The intervention has been refined to address emergent acceptability problems. An exploratory controlled trial is underway.