Singing for Lung Health: a qualitative assessment of a British Lung Foundation programme for group leaders

Introduction

Singing for Lung Health (SLH) is a new but rapidly expanding approach where people with lung disease take part in a group activity that can improve breathing control and posture, without directly focusing on their respiratory limitations.1 Participants in SLH groups report that singing helps them to manage their breathlessness, improving quality of life, mood, activities of daily living and participation in meaningful social and physical activity.2–5 Moreover, SLH group attendance remains high over months up to a year suggesting that is perceived as worthwhile.2 3 Quantitative data also suggest that SLH improves health-related quality of life.5 6 Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide7 with estimated direct National Health Service costs in the UK of £1.8 billion/year.8 Pharmacological treatment of COPD can improve quality of life and lung function, but only to a limited extent,9 as can surgical and bronchoscopic treatments.10 11 Pulmonary rehabilitation (PR) is a key aspect of high-value12 evidence-based care for COPD patients with functional limitation, but access to programmes is variable and adherence and completion is suboptimal.13 Furthermore, a defined optimal package for long-term self-management does not yet exist.14 In this context, a recent consensus statement and systematic review of SLH has highlighted future research questions, including what aspects of singing training are most important to run an effective group and how singing leaders can best be supported in this role.1

Since 2015, The British Lung Foundation (BLF) has provided training and funding to singing leaders to set up and run SLH groups. BLF financial support lasts for the initial 12 weeks of group set up. The BLF training programme has developed since 2015, where 1 day of training was provided for singing leaders. Now, leaders receive an initial 2 days of training, a further peer-to-peer training day and a financial stipend for setting up groups and mentoring with an SLH trainer. The BLF training enables leaders to learn the basics of vocal and respiratory anatomy and physiology as well as the pathophysiology of common respiratory diseases. Leaders learn about posture and the use of the whole body in singing and breathing. Leaders learn how to run specific elements of a group, such as physical and vocal warm ups, rhythm and pitch warm ups, breathing exercises, appropriate repertoire and relaxation exercises.

No data exist on the effectiveness of SLH training and how this is reflected in the actual delivery of SLH groups. Furthermore, the experiences of SLH leaders running groups have not previously been researched. By understanding these experiences, technical aspects of running SLH groups may be understood, and differences and similarities can be established in comparison with other generic community choirs. This information is important for establishing the intervention fidelity of SLH during future clinical trials and for future decisions about commissioning SLH as a healthcare intervention.

Methods

Ethical approval

This paper includes results from an internal service evaluation for BLF. No institutional ethical committee approval was required for the service evaluation.

Recruitment

Between June and August 2016, a convenience sample of 19 singing leaders trained by the BLF were contacted by AL and PC via email and 15 of these agreed to participate and provided written consent. The singing leaders had a range of backgrounds. They were choir leaders, adult education teachers, speech and language therapy trained, community musicians, vocal coaches and music teachers. They were interviewed by AL about their experiences undergoing BLF training and running groups. Some groups had stopped running due to funding difficulties or paused over the summer.

Data collection

SLH group leaders completed a questionnaire prior to their interview with AL to provide some background about their experiences (online supplementary file 1).

Fifteen singing leaders were female and one was male. Semistructured interviews took place in the venue where the singing group ran, or at the leader's home, depending on how long the leader was able to use the singing venue. Leaders were asked about their experience of setting up and running a SLH group and their experience of BLF training and resources. Interviews lasted between 26 min and 44 min. The semistructured interview schedule is included as online supplementary file 2. No repeat interviews were performed.

Singing groups were observed to judge the extent to which singing leaders used the techniques from BLF training and the class resources (eg, ‘Singing for Breathing’ CD). In order for AL to gain sufficient understanding of the BLF SLH training, he first observed all singing leader weekend training sessions that were video-recorded. Six aspects of the singing groups were scored independently by AL and PC:physical warm-up, breathing exercises, vocal warm-ups, rhythm and pitch games, repertoire and relaxation. These were graded from 0 to 10, with a score of 10 representing best practice. Scores were recorded immediately at the end of the SLH session. Leaders were not informed of the content of the observation scoring system. The six section scores were then added together, and a total of 60 given for each session was observed. A score of 60 meant that the leader displayed practice exactly in accordance with the principles and practice set out in the BLF training. A score of 0 for a component meant that no such component was observed in that group, for example, the absence of a physical warm-up. On each scoring sheet, observation notes were also made by PC and AL. As part of the SLH training, each leader was offered mentoring sessions with PC. Two singing leaders received one of their mentoring sessions on the same day after the group observation, and independent scoring had been completed. After each singing group observation and interview, PC and AL then met to compile group scores and have a debriefing session to discuss observations in order to develop recommendations for the BLF to improve its future service delivery of SLH.

Data analysis

PC had trained the leaders and therefore she did not participate in the interview process. However, as part of each debriefing, PC put singing leaders’ experiences in context with the format of BLF training that each trainer had. Interviews were transcribed verbatim by AL. AL and PC independently coded the data and performed a thematic analysis on the data.15 The interview data were put in context with singing group observation field notes (online supplement file 3) and questionnaire data. Codes and themes were discussed with a leader who had received the SLH training but could not be interviewed during the service evaluation. Following this, the results were also shown to a member of a SLH group. Further documentation of the thematic analysis is provided in online supplement file 4. A completed COREQ qualitative research quality criteria checklist is provided in the online supplementary file 5.

Statistical analysis of group observation scores was performed using SAS V.9.4 statistical analysis package. Due to the low number of group observations and different distributions of each observer's observations, weighted kappa coefficient tests were performed to investigate the level of agreement in scores between AL and PC across the six categories of SLH and the overall scoring. Spearman rank correlation was used to analyse differences in the use of BLF training across groups.

Results

The themes from the analysis are provided below. Alternate names have been used so that leaders remain anonymous.

The benefits of SLH

SLH was perceived as a hugely beneficial activity for singers with respiratory disease. Leaders reported that some singers do not want to focus on their lung condition in this setting and simply want to have fun with others in a social setting. The skill of an expert leader enables people to have fun and gain clinical benefit simultaneously.

The thing I really like in this room that I haven't seen in any of the other classes, is that we don't keep talking about our breathing problems, ‘I don't want to, I want to just do, I want to improve my breathing through doing'. —Maureen

SLH leaders create a new culture where individuals feel connected with one another socially within the shared task of singing, experiencing the rhythm and tempo of the breath and body in music.

You are creating a new culture for people. —Julie

I always do the relaxation thing so it feels a bit meditative in a way…it brings people into their bodies and into the room. I could do that in community choirs but often it doesn't feel like it's really the right thing to do but here it really does, it feels really right to bring the group together each week, be in the space, think about the body… —Colin

This ‘new culture’ is one of social bonding in a task with a shared purpose and creative product. These experiences will be novel for many with respiratory disease.

By providing an atmosphere of safety and comfort, people are allowed to focus on themselves and others within a group, as respite from their condition.

Having a bit of a respite where you enjoy something and you're present in the moment and you are not worrying about what's coming next has a real positive impact. —Eileen

Through increased self-awareness, people can learn to cope with the loss of a previous ‘well’ self.

That relationship between who you feel you are and your physical body can kind of come dissociated when you are poorly. —Rachael

When that self-awareness comes, it's really valuable. You know it's the key to change. —Claire

I think there is something powerful in it which goes beyond the practical, physical, it's you know to do with the person-centred, themself and the life within them. —Kirsten

Singing leaders have also reported many health improvements in participants who have sung in their groups.

The nurse had…put it down to the singing that was something that was improving their lung function.—Colin

It's that kind of mental well-being aspect and then actually from singing you get that great rush of endorphins and it makes you more alert. —Toni

SLH's role as a treatment

Singing leaders felt that a patient referral system may reduce the burden of group set up and running a group. Those who received clinical support within groups appreciated this. However, it is not clear whether SLH groups should be funded on the NHS because the intervention offered may be altered as a result. Social prescribing, charitable grants and patient donations were funding routes used following the 12-week BLF funding period.

When things have been taken in house (NHS) they often then come under a number of constraints that aren't running it in a voluntary and community sector setting or a private sector setting, so it would probably end up being a 10 week programme that then people got kicked off.—Eileen

If there's something actually wrong with somebody at that moment (the respiratory nurse) will actually take it and he is actually creating that link now essentially between what's happening in the community and what's happening in the hospital.—Janice

The second quote is an example where a clinician helped when a group member was experiencing an exacerbation. Having healthcare professionals (HCP) attend the group can help singing leaders working independently and at times are not prepared for or feel appropriate within their remit to talk about medical conditions or deal with exacerbations.

Observation scores

Overall, the BLF training has prepared the leaders to run singing groups to an acceptable standard. However, there was significant variation of practice between groups: the ranking of the groups was very well matched (R: 0.91) between observers as shown in figure 1.

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The scores above show good overall consistency of the training that leaders received transferring into their practice during the observations. The bar chart above suggests AL gave higher scores than PC across groups. Further analysis was needed to determine the significance of the differences in independent scoring between observers. Weighted kappa coefficient tests were performed on each of the six group categories (ie, repertoire) comparing scores from each observer. Overall, there is moderate agreement (K=0.42) between PC and AL in individual scores across the six categories shown in figure 2 below. Indeed, PC's lower and more nuanced observations might reflect her music therapy expertise, and greater experience of SLH, because of her involvement in the development of the SLH training.

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The highest level of agreement was in the rhythm and pitch warm ups (K=0.72), and the lowest level of agreement was in the physical warm ups (K=0.21). Consequently, a workshop on physical warm-ups was included in a ‘Train the trainer’ weekend for future rounds of training, and a new standard of practice was agreed between all new trainers.

Discussion

Significance of findings

Setting up singing groups is perceived to be a challenge. The BLF provide a financial stipend for group set up and further payment per session led. However, leaders may require further financial support. Groups being supported by singers’ donations may be a sustainable option. However, this may exclude people from lower socioeconomic backgrounds, leading to inequality in availability for those less well off. Leaders reported pros and cons for SLH groups being embedded within an NHS care pathway for respiratory patients. A referral system may help recruitment and ease the burden of set up. Clinical support is also beneficial to allow singers to focus on running each session effectively and deal with singers who are having an acute exacerbation. However, singers do not necessarily want to be treated as ‘patients’ in this setting and may well not attend groups if exacerbating. Furthermore, singing groups may not operate on a rolling basis with limited funding in the NHS. This could be problematic for patients who feel part of a new culture and engaged in a meaningful community activity.

SLH is complicated and could be viewed as a multicomponent self-management intervention. Leaders require sensitive judgement to adapt repertoire for individuals’ or groups’ levels of breathlessness. Repertoire that works is simple. The use of chant-like formats that stimulate additional physical activity (such as clapping or dancing/swaying) and can easily be taught in a call-and-response format and easily adapted into rounds is recommended.

Anyone in the UK can call themselves a singing teacher, vocal coach or community choir leader. No training is mandated, and there can be a diverse understanding of pedagogy, vocal anatomy as well as physiology and vocal leadership skills. Some trained vocal coaches may not have the skillset to run group singing teaching repertoire ‘by ear’. Some community choir leaders may be intuitively musically adept, but know nothing about how the voice works, and many singing teachers have incorrect assumptions about how we breathe to sing. Some will not know how to plan sessions, others may be inflexible to responding spontaneously when needed. Many singing leaders will have had no information about lung disease from respiratory specialists prior to running the groups. Further discussion on this is provided by Cave.16 The singing leader competencies required to run SLH groups are included in figure 3.

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Figure 3

Singing for Lung Health leader competencies: these competencies are required of any new singing leader in order to run a Singing for Lung Health Group effectively.

SLH enables people to feel part of a new culture where they are not treated as patients but may still benefit clinically. Being in the right space and being cared for has previously been reported.2 These data provide further information that people with respiratory disease benefit from having a space where their condition is not talked about as a disease, and their breathlessness is treated through song. Previous studies have also suggested physical, social and emotional benefits from joining an SLH group.3–5 However, these potential improvements in breathlessness, or the control of breathlessness during a flare up, or a reduction in chest infections have yet to be investigated in large randomised controlled trials.

Our findings highlight that running an SLH group is different from a more generic singing for well-being or general community choir. Specialist training is required to be competent because of the complexities of SLH group set up, fostering personal development in a group of individuals with respiratory disease and technical aspects of running a group effectively. Our data provide technical details on how to run such groups effectively and the importance of creating a specialist approach to delivery. It is not clear whether SLH groups would be best situated within the National Health Service. If SLH were to be adopted more broadly within the UK in the current healthcare climate, more research is required that suggests significant clinical benefits in larger patient cohorts.

SLH is a group intervention. As such it will likely be compared with PR. However, there are significant differences between SLH and PR. Compared with PR, less structured support is available for individuals running SLH groups, and leaders often run groups independently, as freelancers alongside other paid work. Support networks for leaders and singers need to be developed through a needs-led approach, in COPD ‘hotspots’ for example, with locality champions providing expertise and connections between commissioners, healthcare professionals, NHS Trusts and patient-led groups. SLH leaders feel that they would not be able to run such groups competently without the training provided by the BLF. Compared with PR, which only recently completed a nationwide audit of services,17 this service evaluation of SLH is occurring during the foundation years of a developing intervention.

Since this service evaluation began in April 2016, there has been an expansion of SLH groups around the country. Now there are 35 BLF SLH groups in the UK out of a total of 80 groups known to the BLF as shown in figure 4. Further networking between BLF SLH and Breathe Easy groups may increase patient participation in both groups.

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Figure 4

UK Singing for Lung Health groups: the blue points on the map represent groups run by a BLF trained leader. Red points on the map are groups run by non-BLF-affiliated groups. Eleven of these groups are affiliated with Breathe Easy groups. Courtesy of the British Lung Foundation (map data ©2017 GeoBasis-DE/BKG (©2009), Google).

Conclusion

SLH is a developing method of running singing groups for individuals living with respiratory disease, with increasing evidence that patients value the experience. Singing leader accounts of the training provided by the BLF, and the further set up and delivery of SLH highlight the requirements, support and technicalities needed to run a group successfully. The specialised approach to SLH training and delivery distinguishes these groups from generic community singing groups. These data should provide reassurance that it is possible to develop and maintain a best practice standard. This is important for future delivery and expansion of SLH across service providers.

Further large-scale randomised controlled trials are needed prior to SLH groups becoming adopted as an evidence-based self-management option for commissioners to fund more widely.