Active ingredients
Figure 1 shows the full list of M4M programme ingredients identified by the research team (AB, DF and LG) presented in the INNATE framework and colour-coded according to the similarities between M4M-online and M4M-in-person. The full checklist of ingredients using the comprehensive INNATE worksheet is provided in the Supplementary Material.
In all, there were several key similarities in the project (green), showing shared ingredients. However, other ingredients differed slightly in the online version (orange), while others were very different (yellow).
Figure 1. Colour chart comparing ingredients of M4M-online vs M4M in-person
Project
In the mapping exercise, several project ingredients were identified as being the same across the online and in-person programmes including the frequency and duration of sessions, many of the design features, the artistic, emotional and cognitive content and breathing and stretching warm-up exercises. Project ingredients that shared some similarities included singing together in real time (albeit predominantly on mute in the online programme) and the facilitator sometimes playing a musical instrument (although the use of other props varied as children’s toys, cushions, blankets and mats were supplied in-person however participants in the online group provided their own materials and props including homemade instruments, muslin cloths and scarfs).
Key differences included the number of weeks the programme ran for (M4M-online was a shorter 6-week programme compared to 10 weeks for the in-person programme), the approach to learning the songs, with those online predominantly singing on mute with accompanying backing tracks compared to participant’s directly responding to the singing lead and singing together through harmonies and rounds during the in-person programme and the presentation of song lyrics in the chat function online as opposed to having no access to printed lyrics during the in-person programme.
People
Participants were adult mothers of children aged nine months or younger and experiencing symptoms of postnatal depression. No previous experience of arts activities in healthcare contexts was required to participate but several participants had previous experience of singing in choirs, while others had no formal group singing experience. Mothers engaged in the programmes with their babies and group sizes were similar across both formats. The programme staff were also similar across both formats; the groups were led by a consistent professional singer with experience of leading similar workshops with mothers and babies and co-facilitated by a member of Breath Arts Health Research who provided practical support to both the singing lead and participants. The co-facilitators however were unable to provide hands on support to mothers and their babies during the online programme.
Social interactions were similar across both formats in that participants jointly focused on the singing lead to learn the songs and participants were given time to chat at the beginning and end of the sessions. In the online sessions however, participants could also watch themselves on the screen with their babies. The biggest difference was that participants in the online programme had less opportunity for unstructured face-to-face social time outside of the activity and many were unable to meet in person locally outside of the group sessions because the groups were offered to people across England. They were however signposted to a WhatsApp group and could arrange to meet up with those who were local to them and when pandemic restrictions allowed. Those attending the in-person groups would often go for a coffee together after the sessions or proactively arrange to meet up outside of the sessions.
Context
The main contextual similarities between the online and in-person programmes were the economic resources and management needed to run each programme including sessions being free to attend, “behind the scenes” administrative support, sessions taking place between 10am and 4pm on weekdays and the same range of referral routes and programme advertising including social media, word-of-mouth and formal recommendation from healthcare professionals.
The key difference between M4M-online and the in-person programme occurred in the contexts in which they were delivered. The online space afforded a completely different environment (via Zoom on laptops and mobile phones within the participant’s home) compared to the in-person programme, where participants travelled to Children & Family centres and sang together in a private physical space. While the characteristics of the spaces were different, there were shared elements of comfort, belonging and a welcoming atmosphere created by the different environments. While singing together was an aim of both the online and in-person groups to foster a collaborative and inclusive environment, many participants in the online group reported that singing together off mute did not work well via the online platform.
Participant characteristics
35 of the 37 women who took part in the main trial consented to be contacted for the qualitative interview, of whom 24 women participated. Of the 11 women who did not take part in an interview, ten did not reply to the invitation to participate and one withdrew from the main trial prior to six-week follow up.
Participants were aged 29–44, predominantly White, married, employed/on maternity leave and highly educated. Half of the sample reported a diagnosed mental health problem including anxiety, eating disorders, and mood disorders and just under half had a long-term physical health condition including respiratory, endocrine, cerebrovascular and gynaecological disorders. Singing intervention attendance was high with an average of 5 out of a possible 6 sessions attended. Characteristics of the 24 women who took part are presented in Table 1.
Table 1
Participant characteristics
Characteristic
|
N = 24 (%)
|
Age (Mean, range)
|
36 (29–44)
|
Ethnicity
|
|
White
|
20 (83%)
|
Indian
|
2 (8%)
|
Mixed ethnicity
|
1 (4%)
|
Other ethnicity
|
1 (4%)
|
English as first language
|
21 (88%)
|
Marital/living status
|
|
Married/cohabiting
|
23 (96%)
|
Single (no partner)
|
1 (4%)
|
Educational qualifications
|
|
Higher education (degree/diploma)
|
23 (96%)
|
GCSEs/O levels
|
1 (4%)
|
Employment status
|
|
Employed/maternity leave
|
21 (88%)
|
Unemployed/student
|
3 (13%)
|
Diagnosed health conditions
|
|
Mental health condition
|
12 (50%)
|
Physical health condition
|
11 (46%)
|
Number of sessions attended (Mean, range)
|
5 (1–6)
|
Mechanisms of action
We identified six key psychological, social and behavioural mechanisms by which M4M-online positively impacted the mental health and wellbeing of participants. Psychological mechanisms included i) increased self-confidence as a mother, ii) increased experience of positive emotional responses and iii) a supported change in identity. Social mechanisms were iv) reduced loneliness and isolation and v) Increased social bonding and connection with family. One behavioural mechanism was identified: vi) enhancing a sense of time through providing new routines. These mechanisms are described alongside the active ingredients responsible for each mechanism with accompanying quotations from participants below. All participant names have been replaced with an anonymised ID number after each quote.
Psychological mechanisms
Increased self-confidence as a mother
Participants described being given “a toolkit of things that I can use” to help them calm and soothe their baby before bedtime, to energise and engage during playtime and to distract during nappy changing, feeding or during times when they were unable to fully engage with their baby due to competing household activities. This was achieved through learning a range of songs with different styles and tempos that could be harnessed in different situations. This enabled participants to build their psychological strength and feel more in control of their baby’s behaviour which in turn increased their confidence in parenting, improving their own mood and ability to cope:
I think that you’re very delicate and you’re probably at your most fragile after you’ve had a baby both in terms of physical health and mental health, and it’s easy to not have confidence. I think that I suffered from a lack of confidence and an inability to know what to do when my baby was upset and it just sort of stimulated this memory that actually sing, you know, you can sing, you know songs, so just sing! And it works. (P04)
Observing the positive impact that singing had on their baby whilst participating in the group sessions also helped participants to feel more confident in singing to their baby both within the home but also in front of other people, which helped them to feel more in control of their baby’s mood and increased their confidence when taking their child out in public:
It’s increased my repertoire and confidence…and if I’m out and about sometimes I’m singing away to her, and you know sometimes I’ll scat to < baby > which is funny. Yes, so it’s given me that confidence just to be like, do you know what I don’t care because she enjoys it and it calms her as well, it does calm < baby> (O21)
Many participants also described being able to access the singing group in an online format during the pandemic as a catalyst for feeling more confident in seeking out opportunities for in-person social interactions and activities once COVID-19 pandemic restrictions were lifted. The welcoming and safe environment created by the artists and facilitators delivering the programme contributed to this:
I think it made me braver about going to do things with people I don’t know, specifically mother and baby classes. As we said, like it was a safe space and it was all really fun and really worthwhile, so actually being able to do that as a starter has meant that I’ve gone to other baby classes and not worried about not knowing anybody and going there for the first time. I think it was the stepping stone to feeling like I could achieve things as a mum and doing things like that with my son (P04).
Increased experience of positive emotional responses
Participants attributed a range of positive emotions to the online singing programme and reported feeling energised and euphoric both during and after the sessions. Participants described their anticipation and excitement to take part in future sessions and reported being able to return to the songs they had learned in their own time to help improve their mood:
If I’m feeling a bit low- I don’t know, just any time of day, I’ll put on sound cloud and we’ll sing away to Boats Go Home or one of them, and it will just brighten- I think it’s like an endorphin hit isn’t it, singing. It’s like exercise and stuff like that. Eating chocolate. So, it just gives you a hit of just feeling nice (R07).
Many participants described feelings of joy whilst singing together as a group and described the sessions as enjoyable, playful, and fun. This was credited primarily to the facilitator creating a safe, informal and relaxed space where people did not feel judged by their singing ability, incorporating a mix of popular songs and new songs in different languages and changing lyrics to well-known songs to incorporate humour into the sessions:
The sessions were just fun whether it was singing as a group or < Name of facilitator > often made us sing a line on our own and it was really nice that we were in a group of ladies that were all really confident in doing that or not worried about doing that because it was a safe space. And as I said to you my singing skills you know I’m almost deaf but I love singing and after a couple of weeks I didn’t even think twice about doing that (N17).
As well as feeling uplifted by singing, some participants described using singing within and outside of the sessions to release negative emotions and as a tool to help them relax:
It’s definitely taught me to, because singing relaxes me as well so singing every day has allowed me to relax more so that then opens up many more things that we could be doing. So I’m not getting so het up with like, “must do this, must do this”. And then all we need to do is just sit back and just, “okay what’s going on”. Evaluate and then move forward (O21).
A supported change in identity
Most participants described previously engaging with music, singing or choirs before the birth of their child as a motivating factor for taking part in the singing groups. For some this was an opportunity to reconnect with their identity as a singer, re-engage with their love of music or revisit positive memories triggered by familiar songs:
Once I did Melodies for Mums, I found myself going back through my favourite music, and then singing to her. I still do that now, which is fun for me, because I do really like music, and obviously she enjoys it as well (R01).
Having time and space to engage in something enjoyable for themselves, rather than just participating in an activity for their baby was experienced as an important element of the programme because it enabled participants to reconnect with an identity outside of motherhood and contributed to a reduced loss of self:
Just having space that’s for me, where I’m not just mum for five minutes. Because I think that’s one of the things becoming a mum, it’s actually really lonely. And I found this with my daughter a bit, but you just lose yourself, and you feel like you don’t exist anymore, and you’re just mum. So having something where it was like, yes, it’s a mums’ singing group. But it’s not all about baby. Having that head space just for a bit of fun for me, baby will be there, he doesn’t have to be there, it’s fine (N14).
This led some participants to realise that self-care and engaging in activities without their baby going forward was important for their mental health and for self-restoration:
It’s reminded me that I should prioritise that as, possibly not with the baby, but as something I do for myself, that that is something I might enjoy. Because I think it’s been so long now. It’s hard to remember sometimes the things that you like to do, that haven’t been a possibility for so long (P19).
Social Mechanisms
Reduced loneliness and isolation
Participants experienced the groups as friendly, supportive and some described feeling part of “a community through singing together”. Being in a small group and being able to chat in between singing together and at the end of the sessions helped participants to build connections with one another:
I think the fact it was small groups was really nice because they'd stop and chat part way through and things like that, you know, if there'd been 200 people and you just logged in and it was anonymous– it's not like we logged in and talked about our feelings, no, <facilitator > would just do a bit of chat, like how are you today, it was just small talk chatting, it wasn't sort of how are you feeling today, you know, like that, but it was– yes, it was just nice and easy (P12)
Some participants found it helpful to actively share the challenges associated with parenthood, as well as their experiences of emotional difficulties with others in the group. Sharing these difficulties in turn made them feel validated and less alone:
It was definitely nice to hear other mums say or feel similar things to myself. So, that definitely impacted the way I felt because I knew that, okay, I’m not a terrible mum because my son cries sometimes because this lady also has those feelings, she’s not a terrible mum (N09).
Others felt less isolated just by knowing that other mums were experiencing low mood or anxiety without having to discuss how they were feeling. This shared but unspoken experience was described as “comforting”, “healing” and made participants feel “normal”:
I think just connection. It’s helped me to, like, I guess, deal with perhaps the feelings of isolation, and helped me channel my negative feelings into something a little more positive. It was reassuring to know that other mums were going through similar things, but again, not necessarily having to discuss it (N03).
Receiving positive feedback about their own baby’s behaviour from group members “people would say his smile has made my day and I’d think, oh that’s nice…to feel proud of them” and observing other mums interacting with their babies also helped participants to feel less alone and normalised their own difficult experiences:
I was still finding it quite difficult if I saw friends or family and she was crying a lot, I still found that quite stressful. And also I saw the other babies basically in the same position, I don’t know whether they had colic… I was kind of like, oh, this is normal, and it made me feel less self-conscious (R01).
While most participants described the benefits of socialising and connecting with other mums during the sessions, most reported difficulties connecting and bonding with one another online and described a preference for attending the group in-person. This was attributed in part to multiple functionalities not being supported by the technology, such as not being able to access the lyrics on screen at the same time as viewing the singing lead alongside other participants. Singing together off mute as a group was also described by some as challenging:
And then when we did come off mute occasionally to try to sing altogether, it was kind of, it was really broken up. So it was nice to do occasionally but it definitely wouldn’t work to do it too often (M22).
Some participants had hoped to make lasting connections and meet one another once the groups had finished, but this had not materialised due to living in different locations. Others felt that more time was needed within the sessions to socialise and bond:
I think, you know < Name of facilitator > was always very good at facilitating a bit of, “Hey how are you and what’s going on?” It’s nice but it’s also a bit difficult as well because there’s not really…a connection with the other people apart from having a baby. I think that’s the difficulty with Zoom is, it’s all right if you have a connection with people in real life beforehand and then you have a web interface, but otherwise it’s quite hard to really get a sense of who people are and whether or not, you want to have further conversations (O12).
Increased social bonding and connection with family
Participants experienced a strengthening of bond and connection with their baby through singing. For some participants, singing provided them with the opportunity to feel more present with their baby than they had previously, “from just sort of waiting for her to fall asleep so that I can do something I want to do…to feeling more like I'm a mum who wants to do things with her child” which in turn improved their mood:
I was feeling that I attended to his needs but may be mechanically, or doing this while feeling that I wasn’t functioning properly. So, a façade of everything is going well so that the baby isn’t affected but feeling anxious inside. And during or after the sessions I attended to his needs and I enjoyed it, a real façade wasn’t needed anymore it was me being here with him. So, I liked the being in the moment that music provides, and I took this enjoying the moment into the rest of our everyday life (N10).
Some participants also spoke about the impact of the singing group on the whole family. Having access to songs outside of the sessions helped to reinforce singing at home and shared experiences of singing together which strengthened family bonds and make everyday activities more enjoyable:
My daughter, my husband, they’ve all heard me singing enough that they picked up on some of them. And on Saturday we take my daughter swimming, and just as we were loading everything back in the car to leave swimming, she was singing, “I want someone to buy me a pony.” And then my husband was singing it back to her doing the chick chock chick chock. And it was just lovely... It has a lasting impact beyond just those six weeks (Q18).
Behavioural Mechanisms
Enhancing a sense of time through providing new routines
Participants described sometimes feeling in a “rut” before they joined the online singing programme, spending long periods of time with their babies at home during the pandemic with little variation in routine or activities. For some, attending the singing group added a new structure to their day:
The support came from having something to do every week. I really had very little structure or scheduled going on because of life so it was, you know I think I like to be busy, and I hadn’t been - well I had been busy but busy purely feeding on a constant basis with a baby that wasn’t feeling very well and so I guess for me it was nice to feel I was doing something a bit for myself as well as for him, and to have that regular time in the day to do it (O12).
Some participants continued to introduce new routines into their day once the singing programme had ended, using the songs they had learned and becoming more creative in their interactions with their babies:
I think it has made me sing much more to them, so that has felt really positive and when you start to sing more to them you feel more like playful with them as well. It’s helped in that sense, feeling a bit more creative because sometimes when you have the whole day stretching out, particularly when I have both of them and I sort of wonder what activities I’m going to do, I think it has helped reignite a bit of creativity when it comes to that (R12).