A qualitative exploration of active ingredients and mechanisms of action of an online singing programme with mothers experiencing postnatal depression during the COVID-19 pandemic: SHAPER-PNDO study.

A qualitative exploration of active ingredients and mechanisms of action of an online singing programme with mothers experiencing postnatal depression during the COVID-19 pandemic: SHAPER-PNDO study. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A qualitative exploration of active ingredients and mechanisms of action of an online singing programme with mothers experiencing postnatal depression during the COVID-19 pandemic: SHAPER-PNDO study. Alexandra Burton, Rebecca H. Bind, Rachel Davis, Lorna Greenwood, and 13 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4177936/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Nov, 2024 Read the published version in BMC Psychology → Version 1 posted 17 You are reading this latest preprint version Abstract Background Social distancing restrictions and the suspension of in-person treatment and support contributed to an increase in postnatal depression during the coronavirus disease 2019 (COVID-19) pandemic. Creative health interventions can help to alleviate anxiety and depression, with studies showing that singing is particularly effective for supporting the mental health of new mothers. We adapted an in-person group singing programme (Breathe Melodies for Mums (M4M)) to online delivery during the COVID-19 pandemic to support the mental health of new mothers, and, in a feasibility study, found improvements in postnatal depression (PND) symptoms at 6-month follow up. The current qualitative study aimed to explore how and why M4M-online impacted the mental health of those taking part. Methods We took a theory-based approach using the Ingredients in Arts in Health (INNATE) Framework of ‘active ingredients’ and the Multi-level Leisure Mechanisms Framework of ‘mechanisms of action’ to identify and categorise intervention components and change mechanisms. Iterative consensus building between three researchers were complemented by qualitative semi-structured online interviews with 24 women experiencing PND symptoms who took part in M4M-online. Data were analysed inductively using reflexive thematic analysis. Results Consistency was found between the online and in-person interventions in active ingredients relating to project design, content, programme management and the composition of the group. Key differences were in the social and contextual ingredients. Psychological, social and behavioural mechanisms for improved mental health and wellbeing included: 1) Increased self-confidence as a mother, 2) Increased positive emotional responses, 3) A supported change in identity, 4) Reduced loneliness and isolation, 5) Increased social bonding and connections with family and 6) Enhanced sense of time through new routines. Conclusions Participating in online group singing can support new mothers experiencing PND by triggering psychological, social and behavioural responses that lead to improved mental health. Key programme features are identified which can be used to design future online creative health interventions or tailor in-person activities for remote delivery to support populations who may face practical and social barriers to attending in-person. Depression postpartum postnatal depression qualitative research COVID-19 creative health singing intervention online delivery Figures Figure 1 Introduction Postnatal depression (PND) affects approximately 10–15% of mothers within the first year after childbirth ( 1 ). It is characterized by low mood, anxiety, sleep disruptions, irritability, anhedonia, fatigue, and suicidal thoughts in severe cases ( 2 ). Risk factors for PND include low perceived social support from partners and family, and social isolation during and after pregnancy ( 3 – 5 ). If left untreated, PND may predispose mothers to poorer psychological well-being, chronic depression, and difficulties in bonding ( 6 , 7 ), which can disrupt infants’ emotional, cognitive and behavioural adjustment into adolescence ( 8 , 9 ). Yet, PND is widely under-reported due to barriers to help-seeking arising from the stigma, shame and guilt associated with mental health disorders ( 10 , 11 ). Because of the potentially long-lasting impacts of PND, it is vital that appropriate support and treatment is offered and that the mechanisms underlying effective interventions are understood. The postnatal period is widely accepted as a “vulnerable time” where mothers are susceptible to changes in social circumstances and thus require higher levels of social support ( 12 ). The coronavirus disease 2019 (COVID-19) pandemic led to an increased PND prevalence in the UK due to unprecedented COVID-19 social distancing restrictions, fear of the virus, and uncertainty about the future ( 13 , 14 ). An English population-based maternity survey study found that PND prevalence doubled to 23.9% at the height of the pandemic ( 3 ). The lockdown restrictions also increased anxiety and loneliness experienced by expectant mothers and new mothers alike ( 15 , 16 ), exacerbating existing PND risk factors such as social isolation and lack of social support. In addition to these changes, many mothers experiencing PND struggled to receive timely treatment due to not being able to access in-person healthcare during the pandemic ( 16 ). There is a growing evidence base demonstrating that engagement in creative activities can improve mental health and wellbeing ( 17 ). Singing has been identified as a particularly powerful tool for supporting the mental health of new mothers by reducing stress and promoting mother-infant bonding ( 18 , 19 ). Previously, participation in an evidence-based 10-week community singing group (Breathe Melodies for Mums (M4M)) was associated with significantly faster recovery in women experiencing moderate to severe PND symptoms compared to women attending play groups and non-intervention controls ( 20 ). These changes were attributed to a range of mechanisms with participants reporting an increased ability to calm their babies through singing, an enhanced sense of achievement, rediscovery of self-identity as a new mother, and enhanced mother-infant bonding ( 21 ). Having established clinical effectiveness, M4M is currently being scaled up and tested in the community as part of a large ‘Scaling-up Health Arts’-research programme (SHAPER) ( 22 ). The COVID-19 Pandemic led to the suspension of in-person community activities, with group singing deemed as a high-risk activity due to the greater potential for virus transmission via respiratory droplets ( 23 ). During this time, many in-person arts activities moved online ( 24 ) and M4M was adapted into a six-week online intervention which aimed to replicate as closely as possible its face-to-face counterpart ( 25 ). Online delivery enabled participants to be recruited from across the UK and mitigated COVID-19 related obstacles to participating in group activities such as fear of contracting COVID-19 at a time when access to services and support were severely restricted ( 25 , 26 ). M4M-online was associated with significant reductions in PND symptoms, anxiety and stress with positive effects observed at weeks three and six that were maintained at 6-month follow-up, however no impact of M4M-online was observed on quantitative measures of social support or loneliness ( 27 ). Having identified the positive impact of M4M-online on mental health outcomes, it is important to understand how and why these effects occurred so that new online interventions can be developed or tailored to meet the needs of this group. Theoretical work on arts interventions and health have conceptualised the component parts of arts interventions as ‘active ingredients’, comprising elements of the activity people engage in and the broader social and contextual environment in which engagement occurs ( 28 ). Online engagement has clear differences in all three of these categories of ingredients. For example, previous research on virtual choirs has shown that participants engaging virtually report lower and more variable social presence than participants of in-person choirs ( 29 ). Yet in the M4M-online intervention, the outcome findings suggested comparable benefits to mental health in the in-person intervention ( 20 , 27 ). This raises the question as to whether the ‘core’ ingredients most responsible for effects were nonetheless still present, even if there were changes to other ingredients that may have been more peripheral. Active ingredients can in turn trigger causal processes or “mechanisms of action” that lead to health outcomes. The Multi-Level Leisure Mechanisms Framework derived from a multi-disciplinary review of over 600 potential mechanisms that are triggered by arts and leisure engagement theorised these mechanisms to be biological, social, psychological and behavioural ( 30 ). Again, it is important to understand whether the mechanisms activated for M4M-online differed from the in-person intervention, to inform future adaptations. Research aim To identify the (i) active ingredients and (ii) mechanisms of action of an online singing intervention (M4M-online) that contributed to improvements in mental health and wellbeing among mothers experiencing postnatal depression. Methods To identify the active ingredients , we used the INNATE (Ingredients iN Arts and healTh intErventions) framework. INNATE is a theoretical model for identifying the ‘active ingredients’ in arts in health interventions ( 28 ). The concept ‘active ingredients’ has its origins in pharmacological research for describing the elements of a pharmacological intervention responsible for its therapeutic action (i.e. the ‘intervention components’ or ‘interacting components’) ( 31 ). However, the approach has become increasingly prominent in behavioural interventions to map how different mechanisms of action are triggered and to compare similar interventions to understand why some are more effective than others ( 32 , 33 ). INNATE provides a bespoke model and checklist for mapping the ingredients in arts in health intervention and is designed to support the design and implementation of interventions, their evaluation and their replication, scalability and sustainability ( 28 ). Ingredients are categorised as relating to the project or content of the activity, the people including how people interact and who is involved in the activity and the context or environment in which the activity is delivered. AB, DF and LG completed a comprehensive mapping of the key project, people and contextual details for both the M4M-online and previous M4M in-person programme ( 20 ), using an iterative approach to the identification of each ingredient until full consensus on each ingredient was achieved. To identify the mechanisms of action (the processes that causally relate ingredients to intervention outcomes ( 30 )), individual semi-structured qualitative interviews were conducted with M4M-online participants after they had completed the singing programme by AB, a female senior research fellow with expertise in conducting qualitative research with people experiencing mental health problems and on the impact of the COVID-19 pandemic on mental health and wellbeing. The intervention M4M-online consisted of six weekly one hour online singing sessions with 3–7 participants in each group. The groups were held via Zoom and facilitated by a professional singing lead and supported by a Breathe Arts Health Research co-facilitator who assisted with technological support and troubleshooted any in-session issues, as well as being the main point of contact for participants from recruitment to completion of the programme with responsibility for safeguarding. Participants sang from their homes while being muted at certain times from each other but were able to hear and follow the singing lead throughout. The singing lead also used pre-recorded backing tracks containing vocals in multiple parts and harmonies to support delivery and amplify the experience of singing with others. Participants were signposted to a WhatsApp group to connect with one another outside of the singing sessions and given unstructured time at the beginning and end of each session to talk to the singing lead, co-facilitator and/or other participants. Participants Participants were eligible for the trial if they were aged 18 years or older, were able to understand English, had internet access, capacity to consent, a child between 0 and 9 months old and reported PND symptoms defined as a minimum score of 10 on the Edinburgh Postnatal Depression Scale (EPDS) ( 34 ). Participants were recruited to the trial via different routes including social media, posters and leaflets displayed in community centres, signposting via health and social care professionals and a local National Childbirth Trust (NCT) group. For this qualitative study, all participants who attended one or more online singing sessions as part of the trial and who had consented to take part in an interview were invited to participate. Procedures The study was approved by the King’s College London (KCL) Research Ethics Office (KCL Ethics Reference: HR-20/21–19659). Participants were invited to take part in an interview via email by AB. All participants were given the opportunity to ask questions in the initial email exchange and again before the interview commenced. Interviews followed a semi-structured topic guide (see Supplementary Material) developed by AB, DF, and RD to explore i) experiences, highlights, and challenges of taking part in the sessions, and ii) how and why, if at all, the singing groups impacted mental health, wellbeing, thoughts, and behaviours around motherhood. Interviews took place remotely via video call and were audio-recorded. Interviews lasted between 22 and 56 minutes (average 40 minutes). Audio-recordings were transcribed verbatim by an external company (TP Transcription) and any identifiable information such as names or locations were subsequently removed from the transcripts. Transcripts and recordings were stored within the University College London (UCL) Data Safe Haven, a certified secure data storage system. Data analysis Interview data were analysed inductively using reflexive thematic analysis ( 35 , 36 ). Our research methodology was informed by critical realist ontology whereby, we sought to understand mother’s views of participating in online singing groups and how the groups supported them through in-depth exploration of their personal accounts, stories and experiences. Transcripts were imported into NVivo 12 software to enable data management and coding. DF and AB independently coded three transcripts and met to discuss emerging mechanisms of action as well as active ingredients of the singing intervention that triggered general points of interest that aligned with the research aim. AB then coded all remaining transcripts using language and words closely aligned with participant accounts. Codes were then grouped into similar topics and used to inform the development of themes. A preliminary list of themes was shared and discussed with DF and RD for comment, interpretation, and reflection before the themes were finalised. Themes were then categorised as either psychological, social, or behavioural as defined by the Multi-Level Leisure Mechanisms Framework ( 30 ). Results 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 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 (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 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, 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 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). Discussion To our knowledge this is the first qualitative study exploring how a group singing programme (M4M) adapted to run online during the COVID-19 pandemic supported the mental health of women with postnatal depression. The online format was implemented directly in response to the suspension of in-person groups due to social distancing restrictions and provided an opportunity to explore whether similar ingredients and mechanisms to improved mental health might be observed by participating online as in person. Our study helps interpret the findings of the feasibility trial ( 27 ) by mapping out programme ingredients that seemed to trigger mechanisms which then impacted PND symptoms, as well as identifying ingredients unique to online delivery such as being able to sing on mute at home which led to increased confidence in singing. A key feature of the outcome findings previously reported on the M4M-online intervention was the similarity in the reduction in EPDS scores over six weeks to the original M4M-in-person intervention ( 20 , 27 ). Notably, this was found despite the mode of delivery (online vs in person) being quite different. In this study, by mapping the active ingredients in the trial using a theory-informed approach, we were able to differentiate which ingredients were ‘peripheral’, in that changes in them did not materially affect the ability of the intervention to achieve the primary outcome, vs which ingredients were potentially ‘core’ for such similarities in the primary outcome to be achieved. The key differences between the formats were the environments in which the programmes were delivered, the atmosphere of a virtual rather than in-person setting, and the dominance of singing on mute, using backing tracks and being unable to hear other participants sing online. These ingredients were largely context-based or related to the technical delivery of the project. This suggests that modification of such elements can occur without diluting the psychological benefits of the programme. That said, participant feedback on the online experience was not always positive. Similar to other studies in populations with chronic health conditions ( 37 ), participants acknowledged the ease of taking part from home and the benefits during an unprecedented time of social change. But many expressed a preference for attending M4M in-person if given the option. We also identified several shared or “core” ingredients across the online and in-person ( 20 ) formats which may be key to supporting the mental health of new mothers. This included the frequency and duration of sessions and the artistic and emotional content of the songs and singing activities. Participants had similar levels of previous engagement with group singing across both formats and shared experiences of motherhood and postnatal depression. Previous research has identified that shared experience of health problems among online creative health programme participants are important for engagement and feeling supported ( 38 , 39 ). The artists and facilitators delivering the online and in-person programmes shared similar skills and previous experience of delivering community singing programmes. Key contextual similarities were the resources including staffing used to deliver, recruit to and manage the programme and the creation of a safe and inclusive environment within both the online and in-person spaces. It is likely that some or all these ingredients are core to achieving intervention outcomes. That said, further research would be needed to confirm if modifications to these ingredients could still be made without adversely influencing outcomes. Our study also demonstrated that M4M-online targeted a range of psychological, social and behavioural mechanisms including increased participant confidence in interacting with their babies, supported a change in identity, improved social bonding with their babies and families and reduced feelings of loneliness and social isolation. Attending the groups also provided participants with new routines and increased their experience of positive emotional responses. Importantly, these effects were felt both during and outside of the singing sessions as participants implemented what they had learned into their daily lives and routines. These findings help us to understand why participating in M4M-online led to reductions in stress, anxiety and PND symptoms in the feasibility trial ( 27 ). Most of the mechanisms identified in the present study also mirrored those produced by the in-person M4M groups including increased bonding between mothers and their babies, supporting mothers to establish new routines, an enhanced sense of identity and singing as a tool for mothers to calm their babies ( 21 ). These same mechanisms have also been reported in research into other online creative health programmes including increased positive emotional response ( 38 , 40 , 41 ), increased confidence in communicating with others ( 38 ) and reduced loneliness and isolation ( 38 , 41 , 42 ). One study evaluating online group dance sessions for young people with anxiety and depression identified increased feelings of social connectedness to others as key for supporting their mental health ( 39 ). We did however identify an additional mechanism around increased self-confidence as a mother, which was not reported in the original M4M-in-person trial. However, this encompassed being able to calm their babies, which was a mechanism of the original trial, and the mothers in the original trial described an increase in achievement, which suggests similar mechanisms. This study also allowed for an understanding of how the ingredients and mechanisms in the intervention interacted to impact outcomes. While participants in our study qualitatively reported feeling less lonely and socially isolated due to meeting other mothers with PND and being able to share the challenges of motherhood, many expressed a dilution of impact through the online format because participants were geographically spread and unable to meet socially after the sessions (alterations in the active ingredients of informal social exchanges and environment). Many of the participants in our study expressed a preference for in-person sessions in their local area to promote lasting social connections with other participants. These experiences help us to understand the lack of effect on social support and feelings of loneliness observed in the feasibility trial ( 27 ). It is also important to acknowledge that the absence of social support from friends and family due to social distancing restrictions and resulting increases in loneliness and social isolation among new parents during the COVID-19 pandemic ( 15 , 26 ) may have limited the impact that M4M-online was able to have on social outcomes. Challenges to social engagement have also been identified in online singing interventions with other populations with a key barrier being technological limitations to social interactions and connectedness ( 37 , 41 ). A study comparing experiences of moving from in-person to online choir sessions during the pandemic also identified limited opportunities for group and social bonding through the lack of real-time singing, harmonising and the act of singing together as a group within a shared physical space ( 43 ). For mothers in our study and in studies with people experiencing chronic health problems ( 37 , 41 ), however, the focus on singing whilst muted allowed some participants to express themselves more openly, particularly those who lacked confidence in their singing abilities. This highlights that different considerations might be needed for adapting and promoting engagement with online creative health interventions compared to creative activities for those who are already actively engaged in creative pursuits. Strengths and limitations This study builds on and helps to interpret the findings from a feasibility trial on the impact of online singing groups for new mothers experiencing PND. It provides an in-depth understanding of how and why online singing groups helped reduce PND, stress and anxiety symptoms in new mothers during the COVID-19 pandemic as well as why social support and loneliness outcomes were not strongly impacted. It also formalises the identification and comparison of active ingredients of a creative health programme delivered across different formats with a theory-based approach. The study is not without limitations. Whilst attempts were made to include all women who participated in the feasibility trial, 11 women did not respond to the invitation to take part. The current study sample, while being of a similar age to the overall trial sample, was less heterogeneous and contained fewer women from ethnic minority groups, those who were single, and those with fewer educational qualifications. Their experiences may have been less positive or different to the views and experiences expressed here. Conclusions We identified key programme features (‘active ingredients’) of an online group singing programme that helped to support new mothers experiencing postnatal depression. These features triggered a range of psychological, social and behavioural responses (‘mechanisms of action’) that led to improved mental health. We also compared online and in-person delivery formats to determine the likely “core ingredients” of the M4M programme. These findings can be used to i) inform the design of future online creative health interventions to support mental health and maximise engagement and impact and ii) tailor in-person activities for remote delivery to extend geographical reach and support populations who may struggle to attend in-person. List of abbreviations Breathe Melodies for Mums M4M Coronavirus disease 2019 COVID-19 EPDS Edinburgh Postnatal Depression Scale INNATE Framework Ingredients in Arts in health Framework KCL Kings College London NCT National Childbirth Trust PND Postnatal depression SHAPER Scaling-up Health-Arts Programme UCL University College London Declarations Ethics approval and consent to participate This study was approved by the King’s College London Research Ethics Office (KCL Ethics Ref: HR-20/21–19659). Any protocol amendments were submitted to the King’s College London Research Ethics Office for approval. The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. Written informed consent was obtained by researchers from all participants involved in the study. Consent for publication Not applicable Availability of data and materials The datasets used during the current study are available from the corresponding author upon reasonable request. Competing interests From 2016 to 2022 DF was a non-executive board director for Breathe Arts Health Research but she received no financial compensation for her involvement. CMP has received grants from European Commission (IMI2 853966). Additional funding has been provided by UK National Institute of Health Research (NIHR) Biomedical Research Centre at South London and Maudsley NHS Trust and King’s College London. He is also funded by a NIHR Senior Investigator Award. He has received research or consultation funding from Johnson & Johnson and Boehringer Ingelheim, as well as research funding from the Medical Research Council (UK) and the Wellcome Trust for research on depression and inflammation as part of two large consortia that also include Johnson & Johnson, GSK and Lundbeck. The work presented in this paper is unrelated to this funding. The other authors have no competing interests to declare. Funding This study is part of the SHAPER programme, a Scaling-up Health-Arts Programme to scale up arts interventions funded by the Wellcome Trust (award reference 219425/Z/19/Z). This work is additionally supported by the National Institute for Health Research (NIHR) Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King’s College London and by an NIHR Senior Investigator Award (CMP). RD was supported by the National Institute for Health Research (NIHR) Applied Research Collaboration: South London, at King’s College Hospital NHS Foundation Trust. The views expressed in this publication are those of the authors and not necessarily those of the Wellcome Trust, the NIHR, or the Department of Health and Social Care. Author Contributions AB: Data Curation, Formal Analysis, Investigation, Methodology, Writing - Original Draft, RHB: Data Collection, Project administration, Writing – Reviewing and Editing, RD: Formal Analysis, Methodology, Writing – Reviewing and Editing, LG: Formal analysis, Project administration, Supervision, Writing – Reviewing and Editing, CYL: Writing - Original Draft, CE: Project administration, Writing – Reviewing and Editing, KH: Data Collection, Writing – Reviewing and Editing, CM: Data Collection, Writing – Reviewing and Editing, KP: Data Collection, Writing – Reviewing and Editing, LR: Data Collection, Writing – Reviewing and Editing, TO: Project administration, Writing – Reviewing and Editing, HD: Project administration, Writing – Reviewing and Editing, PD: Writing – Reviewing and Editing, AW: Project administration, Writing – Reviewing and Editing, NC: Writing – Reviewing and Editing, CMP: Conceptualization, Funding Acquisition, Methodology, Writing – Reviewing and Editing , DF: Conceptualization, Formal Analysis, Funding Acquisition, Methodology, Writing – Reviewing and Editing, Supervision. 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Moving singing for lung health online in response to COVID-19: experience from a randomised controlled trial. BMJ Open Respiratory Research. 2020;7(1):e000737. Taylor ER, Estevao C, Jarrett L, Woods A, Crane N, Fancourt D, et al. Experiences of acquired brain injury survivors participating in online and hybrid performance arts programmes: an ethnographic study. Arts & Health.1-17. Finn S, Wright LHV, Mak HW, Åström E, Nicholls L, Dingle GA, Warran K. Expanding the social cure: a mixed-methods approach exploring the role of online group dance as support for young people (aged 16–24) living with anxiety. Frontiers in Psychology. 2023;14. Tamplin J, Haines SJ, Baker FA, Sousa TV, Thompson Z, Crouch H, et al. ParkinSong Online: Feasibility of Telehealth Delivery and Remote Data Collection for a Therapeutic Group Singing Study in Parkinson's. Neurorehabil Neural Repair. 2023:15459683231219269. Dowson B, Schneider J, McDermott O, Orrell M. Online Singing Groups for People With Dementia: Adaptation and Resilience in the Face of the COVID-19 Pandemic. Dementia (London). 2023;22(7):1348-71. Bek J, Leventhal D, Groves M, Growcott C, Poliakoff E. Moving online: Experiences and potential benefits of digital dance for older adults and people with Parkinson's disease. PLoS One. 2022;17(11):e0277645. Daffern H, Balmer K, Brereton J. Singing Together, Yet Apart: The Experience of UK Choir Members and Facilitators During the Covid-19 Pandemic. Front Psychol. 2021;12:624474. Additional Declarations Competing interest reported. From 2016 to 2022 DF was a non-executive board director for Breathe Arts Health Research but she received no financial compensation for her involvement. CMP has received grants from European Commission (IMI2 853966). Additional funding has been provided by UK National Institute of Health Research (NIHR) Biomedical Research Centre at South London and Maudsley NHS Trust and King’s College London. He is also funded by a NIHR Senior Investigator Award. He has received research or consultation funding from Johnson & Johnson and Boehringer Ingelheim, as well as research funding from the Medical Research Council (UK) and the Wellcome Trust for research on depression and inflammation as part of two large consortia that also include Johnson & Johnson, GSK and Lundbeck. The work presented in this paper is unrelated to this funding. The other authors have no competing interests to declare. Supplementary Files InterviewtopicguideFINAL.docx M4MapplicationoftheworksheetFINAL.docx Cite Share Download PDF Status: Published Journal Publication published 30 Nov, 2024 Read the published version in BMC Psychology → Version 1 posted Editorial decision: Revision requested 13 Oct, 2024 Reviews received at journal 27 Sep, 2024 Reviews received at journal 23 Sep, 2024 Reviews received at journal 19 Sep, 2024 Reviewers agreed at journal 17 Sep, 2024 Reviewers agreed at journal 17 Sep, 2024 Reviews received at journal 17 Sep, 2024 Reviewers agreed at journal 16 Sep, 2024 Reviewers agreed at journal 16 Sep, 2024 Reviewers agreed at journal 16 Sep, 2024 Reviewers agreed at journal 14 Sep, 2024 Reviewers agreed at journal 21 Jun, 2024 Reviewers invited by journal 29 May, 2024 Editor invited by journal 11 Apr, 2024 Editor assigned by journal 05 Apr, 2024 Submission checks completed at journal 05 Apr, 2024 First submitted to journal 27 Mar, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4177936","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":287853622,"identity":"7443817a-4b22-4bce-b945-ff09e7a0db38","order_by":0,"name":"Alexandra Burton","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxElEQVRIiWNgGAWjYFACHgjFz8DAeABZgICWBAYGyQYGBhK1GBwgVgt/A+8x6cofNnnGN5IfHGCosWMwOHMAvxaJA3xpkmcS0orNbqQBLTqWzGBwtoGANQd4zCQbEg4nbruRA3QY2wEGg/MEdMjDtGyeAdLyjwgtBjAtGySAWhjbDhB2mOFhvmTLhrS0xBlnnhkcSOxL5pEk5H25470HbzbY2CT2tyc/fPDhm50c35kEAi5jRuYkEBORo2AUjIJRMAoIAwDr0UObFWu8YwAAAABJRU5ErkJggg==","orcid":"","institution":"Department of Behavioural Science and Health, University College London","correspondingAuthor":true,"prefix":"","firstName":"Alexandra","middleName":"","lastName":"Burton","suffix":""},{"id":287853623,"identity":"9f5023de-c97d-46dc-bf72-51d0157e2103","order_by":1,"name":"Rebecca H. Bind","email":"","orcid":"","institution":"Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London","correspondingAuthor":false,"prefix":"","firstName":"Rebecca","middleName":"H.","lastName":"Bind","suffix":""},{"id":287853624,"identity":"a647b716-d6c6-456c-930a-9449e680c179","order_by":2,"name":"Rachel Davis","email":"","orcid":"","institution":"Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology \u0026 Neuroscience, King's College London","correspondingAuthor":false,"prefix":"","firstName":"Rachel","middleName":"","lastName":"Davis","suffix":""},{"id":287853625,"identity":"5bf22b57-647e-4b07-911a-71302756cb7b","order_by":3,"name":"Lorna Greenwood","email":"","orcid":"","institution":"Breathe Arts Health Research","correspondingAuthor":false,"prefix":"","firstName":"Lorna","middleName":"","lastName":"Greenwood","suffix":""},{"id":287853626,"identity":"31d043b6-3a82-41eb-beaa-00760a61cf2e","order_by":4,"name":"Ching Yin Lee","email":"","orcid":"","institution":"Department of Behavioural Science and Health, University College London","correspondingAuthor":false,"prefix":"","firstName":"Ching","middleName":"Yin","lastName":"Lee","suffix":""},{"id":287853627,"identity":"41141cfe-e541-4e62-8ad8-64a4b08c86ef","order_by":5,"name":"Carolina Estevao","email":"","orcid":"","institution":"Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London","correspondingAuthor":false,"prefix":"","firstName":"Carolina","middleName":"","lastName":"Estevao","suffix":""},{"id":287853628,"identity":"79dad5aa-a8cf-491d-ad1f-08fd3c42ce75","order_by":6,"name":"Katie Hazelgrove","email":"","orcid":"","institution":"Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London","correspondingAuthor":false,"prefix":"","firstName":"Katie","middleName":"","lastName":"Hazelgrove","suffix":""},{"id":287853629,"identity":"58e98527-46e8-4e53-9b45-cbff8a4d8b1d","order_by":7,"name":"Celeste Miller","email":"","orcid":"","institution":"Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London","correspondingAuthor":false,"prefix":"","firstName":"Celeste","middleName":"","lastName":"Miller","suffix":""},{"id":287853630,"identity":"26dfdfe7-61be-4a50-a114-0f897eae56fd","order_by":8,"name":"Kristi Priestley","email":"","orcid":"","institution":"Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London","correspondingAuthor":false,"prefix":"","firstName":"Kristi","middleName":"","lastName":"Priestley","suffix":""},{"id":287853633,"identity":"a1faf243-6cb9-461e-ad01-cf6c168ba12a","order_by":9,"name":"Lavinia Rebecchini","email":"","orcid":"","institution":"Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London","correspondingAuthor":false,"prefix":"","firstName":"Lavinia","middleName":"","lastName":"Rebecchini","suffix":""},{"id":287853635,"identity":"f6542423-d840-4186-8736-90007ac2db9f","order_by":10,"name":"Tim Osborn","email":"","orcid":"","institution":"Breathe Arts Health Research","correspondingAuthor":false,"prefix":"","firstName":"Tim","middleName":"","lastName":"Osborn","suffix":""},{"id":287853636,"identity":"7e997ddc-2e87-4217-85c0-bd56181fbbfd","order_by":11,"name":"Hannah Dye","email":"","orcid":"","institution":"Breathe Arts Health Research","correspondingAuthor":false,"prefix":"","firstName":"Hannah","middleName":"","lastName":"Dye","suffix":""},{"id":287853637,"identity":"ba944dff-8940-434a-9845-164a7d08d2dd","order_by":12,"name":"Paola Dazzan","email":"","orcid":"","institution":"Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London","correspondingAuthor":false,"prefix":"","firstName":"Paola","middleName":"","lastName":"Dazzan","suffix":""},{"id":287853639,"identity":"73acad77-9eef-4880-b6f1-df1d715dbacc","order_by":13,"name":"Anthony Woods","email":"","orcid":"","institution":"Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London","correspondingAuthor":false,"prefix":"","firstName":"Anthony","middleName":"","lastName":"Woods","suffix":""},{"id":287853641,"identity":"bf86a828-176c-4fe3-a5c5-b6792fa412b6","order_by":14,"name":"Nikki Crane","email":"","orcid":"","institution":"Culture Team, King’s College London","correspondingAuthor":false,"prefix":"","firstName":"Nikki","middleName":"","lastName":"Crane","suffix":""},{"id":287853643,"identity":"784353ad-7b8b-47d5-b471-8ba82a9ca6b6","order_by":15,"name":"Carmine M. Pariante","email":"","orcid":"","institution":"Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London","correspondingAuthor":false,"prefix":"","firstName":"Carmine","middleName":"M.","lastName":"Pariante","suffix":""},{"id":287853649,"identity":"00726834-7261-4388-a3e6-4da966aae7b7","order_by":16,"name":"Daisy Fancourt","email":"","orcid":"","institution":"Department of Behavioural Science and Health, University College London","correspondingAuthor":false,"prefix":"","firstName":"Daisy","middleName":"","lastName":"Fancourt","suffix":""}],"badges":[],"createdAt":"2024-03-27 18:44:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4177936/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4177936/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s40359-024-02213-7","type":"published","date":"2024-11-30T15:58:07+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":54437316,"identity":"7ebb79cc-f348-4587-b448-e36e4af5c586","added_by":"auto","created_at":"2024-04-10 13:53:05","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1171052,"visible":true,"origin":"","legend":"\u003cp\u003eColour chart comparing ingredients of M4M-online vs M4M in-person\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4177936/v1/b023753c094da5a8443bb952.jpg"},{"id":70390972,"identity":"f51b171b-62ae-47d1-b38e-3d0dcd5fcbf3","added_by":"auto","created_at":"2024-12-02 17:30:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1822279,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4177936/v1/bb717a36-caf8-433f-aee1-0c62f40ae986.pdf"},{"id":54437317,"identity":"602832d0-85f4-4cde-a3af-f9b4694bcbea","added_by":"auto","created_at":"2024-04-10 13:53:05","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":28138,"visible":true,"origin":"","legend":"","description":"","filename":"InterviewtopicguideFINAL.docx","url":"https://assets-eu.researchsquare.com/files/rs-4177936/v1/a3d12a513cb1eaa86eb3cdfb.docx"},{"id":54437318,"identity":"c8c3c504-44ff-4cb7-b882-304b1be49395","added_by":"auto","created_at":"2024-04-10 13:53:06","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":71993,"visible":true,"origin":"","legend":"","description":"","filename":"M4MapplicationoftheworksheetFINAL.docx","url":"https://assets-eu.researchsquare.com/files/rs-4177936/v1/a3c6bd5c4c525bae1576e019.docx"}],"financialInterests":"Competing interest reported. From 2016 to 2022 DF was a non-executive board director for Breathe Arts Health Research but she received no financial compensation for her involvement. CMP has received grants from European Commission (IMI2 853966). Additional funding has been provided by UK National Institute of Health Research (NIHR) Biomedical Research Centre at South London and Maudsley NHS Trust and King’s College London. He is also funded by a NIHR Senior Investigator Award. He has received research or consultation funding from Johnson \u0026 Johnson and Boehringer Ingelheim, as well as research funding from the Medical Research Council (UK) and the Wellcome Trust for research on depression and inflammation as part of two large consortia that also include Johnson \u0026 Johnson, GSK and Lundbeck. The work presented in this paper is unrelated to this funding. The other authors have no competing interests to declare.","formattedTitle":"A qualitative exploration of active ingredients and mechanisms of action of an online singing programme with mothers experiencing postnatal depression during the COVID-19 pandemic: SHAPER-PNDO study.","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePostnatal depression (PND) affects approximately 10–15% of mothers within the first year after childbirth (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). It is characterized by low mood, anxiety, sleep disruptions, irritability, anhedonia, fatigue, and suicidal thoughts in severe cases (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Risk factors for PND include low perceived social support from partners and family, and social isolation during and after pregnancy (\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e–\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). If left untreated, PND may predispose mothers to poorer psychological well-being, chronic depression, and difficulties in bonding (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), which can disrupt infants’ emotional, cognitive and behavioural adjustment into adolescence (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Yet, PND is widely under-reported due to barriers to help-seeking arising from the stigma, shame and guilt associated with mental health disorders (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Because of the potentially long-lasting impacts of PND, it is vital that appropriate support and treatment is offered and that the mechanisms underlying effective interventions are understood.\u003c/p\u003e \u003cp\u003eThe postnatal period is widely accepted as a “vulnerable time” where mothers are susceptible to changes in social circumstances and thus require higher levels of social support (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The coronavirus disease 2019 (COVID-19) pandemic led to an increased PND prevalence in the UK due to unprecedented COVID-19 social distancing restrictions, fear of the virus, and uncertainty about the future (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). An English population-based maternity survey study found that PND prevalence doubled to 23.9% at the height of the pandemic (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The lockdown restrictions also increased anxiety and loneliness experienced by expectant mothers and new mothers alike (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), exacerbating existing PND risk factors such as social isolation and lack of social support. In addition to these changes, many mothers experiencing PND struggled to receive timely treatment due to not being able to access in-person healthcare during the pandemic (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThere is a growing evidence base demonstrating that engagement in creative activities can improve mental health and wellbeing (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Singing has been identified as a particularly powerful tool for supporting the mental health of new mothers by reducing stress and promoting mother-infant bonding (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Previously, participation in an evidence-based 10-week community singing group (Breathe Melodies for Mums (M4M)) was associated with significantly faster recovery in women experiencing moderate to severe PND symptoms compared to women attending play groups and non-intervention controls (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). These changes were attributed to a range of mechanisms with participants reporting an increased ability to calm their babies through singing, an enhanced sense of achievement, rediscovery of self-identity as a new mother, and enhanced mother-infant bonding (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Having established clinical effectiveness, M4M is currently being scaled up and tested in the community as part of a large ‘Scaling-up Health Arts’-research programme (SHAPER) (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe COVID-19 Pandemic led to the suspension of in-person community activities, with group singing deemed as a high-risk activity due to the greater potential for virus transmission via respiratory droplets (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). During this time, many in-person arts activities moved online (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) and M4M was adapted into a six-week online intervention which aimed to replicate as closely as possible its face-to-face counterpart (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Online delivery enabled participants to be recruited from across the UK and mitigated COVID-19 related obstacles to participating in group activities such as fear of contracting COVID-19 at a time when access to services and support were severely restricted (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). M4M-online was associated with significant reductions in PND symptoms, anxiety and stress with positive effects observed at weeks three and six that were maintained at 6-month follow-up, however no impact of M4M-online was observed on quantitative measures of social support or loneliness (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHaving identified the positive impact of M4M-online on mental health outcomes, it is important to understand how and why these effects occurred so that new online interventions can be developed or tailored to meet the needs of this group. Theoretical work on arts interventions and health have conceptualised the component parts of arts interventions as ‘active ingredients’, comprising elements of the activity people engage in and the broader social and contextual environment in which engagement occurs (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Online engagement has clear differences in all three of these categories of ingredients. For example, previous research on virtual choirs has shown that participants engaging virtually report lower and more variable social presence than participants of in-person choirs (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Yet in the M4M-online intervention, the outcome findings suggested comparable benefits to mental health in the in-person intervention (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). This raises the question as to whether the ‘core’ ingredients most responsible for effects were nonetheless still present, even if there were changes to other ingredients that may have been more peripheral. Active ingredients can in turn trigger causal processes or “mechanisms of action” that lead to health outcomes. The Multi-Level Leisure Mechanisms Framework derived from a multi-disciplinary review of over 600 potential mechanisms that are triggered by arts and leisure engagement theorised these mechanisms to be biological, social, psychological and behavioural (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Again, it is important to understand whether the mechanisms activated for M4M-online differed from the in-person intervention, to inform future adaptations.\u003c/p\u003e \u003cp\u003eResearch aim\u003c/p\u003e \u003cp\u003eTo identify the (i) active ingredients and (ii) mechanisms of action of an online singing intervention (M4M-online) that contributed to improvements in mental health and wellbeing among mothers experiencing postnatal depression.\u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003e \u003cb\u003eTo identify the active ingredients\u003c/b\u003e, we used the INNATE (Ingredients iN Arts and healTh intErventions) framework. INNATE is a theoretical model for identifying the ‘active ingredients’ in arts in health interventions (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). The concept ‘active ingredients’ has its origins in pharmacological research for describing the elements of a pharmacological intervention responsible for its therapeutic action (i.e. the ‘intervention components’ or ‘interacting components’) (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). However, the approach has become increasingly prominent in behavioural interventions to map how different mechanisms of action are triggered and to compare similar interventions to understand why some are more effective than others (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). INNATE provides a bespoke model and checklist for mapping the ingredients in arts in health intervention and is designed to support the design and implementation of interventions, their evaluation and their replication, scalability and sustainability (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Ingredients are categorised as relating to the \u003cem\u003eproject\u003c/em\u003e or content of the activity, the \u003cem\u003epeople\u003c/em\u003e including how people interact and who is involved in the activity and the \u003cem\u003econtext\u003c/em\u003e or environment in which the activity is delivered. AB, DF and LG completed a comprehensive mapping of the key project, people and contextual details for both the M4M-online and previous M4M in-person programme (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), using an iterative approach to the identification of each ingredient until full consensus on each ingredient was achieved.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTo identify the mechanisms of action\u003c/b\u003e (the processes that causally relate ingredients to intervention outcomes (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e)), individual semi-structured qualitative interviews were conducted with M4M-online participants after they had completed the singing programme by AB, a female senior research fellow with expertise in conducting qualitative research with people experiencing mental health problems and on the impact of the COVID-19 pandemic on mental health and wellbeing.\u003c/p\u003e\u003cp\u003eThe intervention\u003c/p\u003e\u003cp\u003eM4M-online consisted of six weekly one hour online singing sessions with 3–7 participants in each group. The groups were held via Zoom and facilitated by a professional singing lead and supported by a Breathe Arts Health Research co-facilitator who assisted with technological support and troubleshooted any in-session issues, as well as being the main point of contact for participants from recruitment to completion of the programme with responsibility for safeguarding. Participants sang from their homes while being muted at certain times from each other but were able to hear and follow the singing lead throughout. The singing lead also used pre-recorded backing tracks containing vocals in multiple parts and harmonies to support delivery and amplify the experience of singing with others. Participants were signposted to a WhatsApp group to connect with one another outside of the singing sessions and given unstructured time at the beginning and end of each session to talk to the singing lead, co-facilitator and/or other participants.\u003c/p\u003e\u003cp\u003eParticipants\u003c/p\u003e\u003cp\u003eParticipants were eligible for the trial if they were aged 18 years or older, were able to understand English, had internet access, capacity to consent, a child between 0 and 9 months old and reported PND symptoms defined as a minimum score of 10 on the Edinburgh Postnatal Depression Scale (EPDS) (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Participants were recruited to the trial via different routes including social media, posters and leaflets displayed in community centres, signposting via health and social care professionals and a local National Childbirth Trust (NCT) group. For this qualitative study, all participants who attended one or more online singing sessions as part of the trial and who had consented to take part in an interview were invited to participate.\u003c/p\u003e\u003cp\u003eProcedures\u003c/p\u003e\u003cp\u003e The study was approved by the King’s College London (KCL) Research Ethics Office (KCL Ethics Reference: HR-20/21–19659). Participants were invited to take part in an interview via email by AB. All participants were given the opportunity to ask questions in the initial email exchange and again before the interview commenced. Interviews followed a semi-structured topic guide (see Supplementary Material) developed by AB, DF, and RD to explore i) experiences, highlights, and challenges of taking part in the sessions, and ii) how and why, if at all, the singing groups impacted mental health, wellbeing, thoughts, and behaviours around motherhood. Interviews took place remotely via video call and were audio-recorded. Interviews lasted between 22 and 56 minutes (average 40 minutes). Audio-recordings were transcribed verbatim by an external company (TP Transcription) and any identifiable information such as names or locations were subsequently removed from the transcripts. Transcripts and recordings were stored within the University College London (UCL) Data Safe Haven, a certified secure data storage system.\u003c/p\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eInterview data were analysed inductively using reflexive thematic analysis (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Our research methodology was informed by critical realist ontology whereby, we sought to understand mother’s views of participating in online singing groups and how the groups supported them through in-depth exploration of their personal accounts, stories and experiences. Transcripts were imported into NVivo 12 software to enable data management and coding. DF and AB independently coded three transcripts and met to discuss emerging mechanisms of action as well as active ingredients of the singing intervention that triggered general points of interest that aligned with the research aim. AB then coded all remaining transcripts using language and words closely aligned with participant accounts. Codes were then grouped into similar topics and used to inform the development of themes. A preliminary list of themes was shared and discussed with DF and RD for comment, interpretation, and reflection before the themes were finalised. Themes were then categorised as either psychological, social, or behavioural as defined by the Multi-Level Leisure Mechanisms Framework (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eActive ingredients\u003c/p\u003e\n\u003cp\u003eFigure \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e 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.\u003c/p\u003e\n\u003cp\u003eIn 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).\u003c/p\u003e\n\u003cp\u003eFigure \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. Colour chart comparing ingredients of M4M-online vs M4M in-person\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eProject\u003c/p\u003e\n\u003cp\u003eIn 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\u0026rsquo;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).\u003c/p\u003e\n\u003cp\u003eKey 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\u0026rsquo;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.\u003c/p\u003e\n\u003cp\u003ePeople\u003c/p\u003e\n\u003cp\u003eParticipants 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.\u003c/p\u003e\n\u003cp\u003eSocial 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.\u003c/p\u003e\n\u003cp\u003eContext\u003c/p\u003e\n\u003cp\u003eThe 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, \u0026ldquo;behind the scenes\u0026rdquo; 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.\u003c/p\u003e\n\u003cp\u003eThe 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\u0026rsquo;s home) compared to the in-person programme, where participants travelled to Children \u0026amp; 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.\u003c/p\u003e\n\u003cp\u003eParticipant characteristics\u003c/p\u003e\n\u003cp\u003e35 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.\u003c/p\u003e\n\u003cp\u003eParticipants were aged 29\u0026ndash;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\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eParticipant characteristics\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCharacteristic\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eN\u0026thinsp;=\u0026thinsp;24 (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAge (Mean, range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e36 (29\u0026ndash;44)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEthnicity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWhite\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e20 (83%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eIndian\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMixed ethnicity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOther ethnicity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEnglish as first language\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e21 (88%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMarital/living status\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMarried/cohabiting\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23 (96%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSingle (no partner)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEducational qualifications\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHigher education (degree/diploma)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23 (96%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGCSEs/O levels\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEmployment status\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEmployed/maternity leave\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e21 (88%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUnemployed/student\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (13%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDiagnosed health conditions\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMental health condition\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12 (50%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePhysical health condition\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11 (46%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNumber of sessions attended (Mean, range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eMechanisms of action\u003c/p\u003e\n\u003cp\u003eWe 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.\u003c/p\u003e\n\u003cp\u003ePsychological mechanisms\u003c/p\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n\u003ch2\u003eIncreased self-confidence as a mother\u003c/h2\u003e\n\u003cp\u003eParticipants described being given \u003cem\u003e\u0026ldquo;a toolkit of things that I can use\u0026rdquo;\u003c/em\u003e 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\u0026rsquo;s behaviour which in turn increased their confidence in parenting, improving their own mood and ability to cope:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI think that you\u0026rsquo;re very delicate and you\u0026rsquo;re probably at your most fragile after you\u0026rsquo;ve had a baby both in terms of physical health and mental health, and it\u0026rsquo;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)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eObserving 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\u0026rsquo;s mood and increased their confidence when taking their child out in public:\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003e\u003cem\u003eIt\u0026rsquo;s increased my repertoire and confidence\u0026hellip;and if I\u0026rsquo;m out and about sometimes I\u0026rsquo;m singing away to her, and you know sometimes I\u0026rsquo;ll scat to \u0026lt;\u0026thinsp;baby\u0026thinsp;\u0026gt;\u0026thinsp;which is funny. Yes, so it\u0026rsquo;s given me that confidence just to be like, do you know what I don\u0026rsquo;t care because she enjoys it and it calms her as well, it does calm\u0026thinsp;\u0026lt;\u0026thinsp;baby\u0026gt; (O21)\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eMany 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:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI think it made me braver about going to do things with people I don\u0026rsquo;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\u0026rsquo;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).\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n\u003ch2\u003eIncreased experience of positive emotional responses\u003c/h2\u003e\n\u003cp\u003eParticipants 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:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIf I\u0026rsquo;m feeling a bit low- I don\u0026rsquo;t know, just any time of day, I\u0026rsquo;ll put on sound cloud and we\u0026rsquo;ll sing away to Boats Go Home or one of them, and it will just brighten- I think it\u0026rsquo;s like an endorphin hit isn\u0026rsquo;t it, singing. It\u0026rsquo;s like exercise and stuff like that. Eating chocolate. So, it just gives you a hit of just feeling nice (R07).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMany 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:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe sessions were just fun whether it was singing as a group or \u0026lt;\u0026thinsp;Name of facilitator\u0026thinsp;\u0026gt;\u0026thinsp;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\u0026rsquo;m almost deaf but I love singing and after a couple of weeks I didn\u0026rsquo;t even think twice about doing that (N17).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAs 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:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIt\u0026rsquo;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\u0026rsquo;m not getting so het up with like, \u0026ldquo;must do this, must do this\u0026rdquo;. And then all we need to do is just sit back and just, \u0026ldquo;okay what\u0026rsquo;s going on\u0026rdquo;. Evaluate and then move forward (O21).\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n\u003ch2\u003eA supported change in identity\u003c/h2\u003e\n\u003cp\u003eMost 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:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eOnce 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).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHaving 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:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eJust having space that\u0026rsquo;s for me, where I\u0026rsquo;m not just mum for five minutes. Because I think that\u0026rsquo;s one of the things becoming a mum, it\u0026rsquo;s actually really lonely. And I found this with my daughter a bit, but you just lose yourself, and you feel like you don\u0026rsquo;t exist anymore, and you\u0026rsquo;re just mum. So having something where it was like, yes, it\u0026rsquo;s a mums\u0026rsquo; singing group. But it\u0026rsquo;s not all about baby. Having that head space just for a bit of fun for me, baby will be there, he doesn\u0026rsquo;t have to be there, it\u0026rsquo;s fine (N14).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis 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:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIt\u0026rsquo;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\u0026rsquo;s been so long now. It\u0026rsquo;s hard to remember sometimes the things that you like to do, that haven\u0026rsquo;t been a possibility for so long (P19).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSocial Mechanisms\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n\u003ch2\u003eReduced loneliness and isolation\u003c/h2\u003e\n\u003cp\u003eParticipants experienced the groups as friendly, supportive and some described feeling part of \u003cem\u003e\u0026ldquo;a community through singing together\u0026rdquo;\u003c/em\u003e. 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:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI 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\u0026ndash; it's not like we logged in and talked about our feelings, no, \u0026lt;facilitator\u0026thinsp;\u0026gt;\u0026thinsp;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\u0026ndash; yes, it was just nice and easy (P12)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome 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:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIt 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\u0026rsquo;m not a terrible mum because my son cries sometimes because this lady also has those feelings, she\u0026rsquo;s not a terrible mum (N09).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOthers 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 \u003cem\u003e\u0026ldquo;comforting\u0026rdquo;, \u0026ldquo;healing\u0026rdquo;\u003c/em\u003e and made participants feel \u003cem\u003e\u0026ldquo;normal\u0026rdquo;\u003c/em\u003e:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI think just connection. It\u0026rsquo;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)\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003eReceiving positive feedback about their own baby\u0026rsquo;s behaviour from group members \u003cem\u003e\u0026ldquo;people would say his smile has made my day and I\u0026rsquo;d think, oh that\u0026rsquo;s nice\u0026hellip;to feel proud of them\u0026rdquo;\u003c/em\u003e and observing other mums interacting with their babies also helped participants to feel less alone and normalised their own difficult experiences:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI 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\u0026rsquo;t know whether they had colic\u0026hellip; I was kind of like, oh, this is normal, and it made me feel less self-conscious (R01).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWhile 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:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAnd 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\u0026rsquo;t work to do it too often (M22).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome 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:\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003eI think, you know\u0026thinsp;\u0026lt;\u0026thinsp;Name of facilitator\u0026thinsp;\u0026gt;\u0026thinsp;was always very good at facilitating a bit of, \u0026ldquo;Hey how are you and what\u0026rsquo;s going on?\u0026rdquo; It\u0026rsquo;s nice but it\u0026rsquo;s also a bit difficult as well because there\u0026rsquo;s not really\u0026hellip;a connection with the other people apart from having a baby. I think that\u0026rsquo;s the difficulty with Zoom is, it\u0026rsquo;s all right if you have a connection with people in real life beforehand and then you have a web interface, but otherwise it\u0026rsquo;s quite hard to really get a sense of who people are and whether or not, you want to have further conversations (O12).\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n\u003ch2\u003eIncreased social bonding and connection with family\u003c/h2\u003e\n\u003cp\u003eParticipants 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, \u003cem\u003e\u0026ldquo;from just sort of waiting for her to fall asleep so that I can do something I want to do\u0026hellip;to feeling more like I'm a mum who wants to do things with her child\u0026rdquo;\u003c/em\u003e which in turn improved their mood:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI was feeling that I attended to his needs but may be mechanically, or doing this while feeling that I wasn\u0026rsquo;t functioning properly. So, a fa\u0026ccedil;ade of everything is going well so that the baby isn\u0026rsquo;t affected but feeling anxious inside. And during or after the sessions I attended to his needs and I enjoyed it, a real fa\u0026ccedil;ade wasn\u0026rsquo;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).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome 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:\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n\u003cp\u003e\u003cem\u003eMy daughter, my husband, they\u0026rsquo;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, \u0026ldquo;I want someone to buy me a pony.\u0026rdquo; 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).\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eBehavioural Mechanisms\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n\u003ch2\u003eEnhancing a sense of time through providing new routines\u003c/h2\u003e\n\u003cp\u003eParticipants described sometimes feeling in a \u0026ldquo;rut\u0026rdquo; 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:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe 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\u0026rsquo;t been - well I had been busy but busy purely feeding on a constant basis with a baby that wasn\u0026rsquo;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).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome 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:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI 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\u0026rsquo;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\u0026rsquo;m going to do, I think it has helped reignite a bit of creativity when it comes to that (R12).\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo our knowledge this is the first qualitative study exploring how a group singing programme (M4M) adapted to run online during the COVID-19 pandemic supported the mental health of women with postnatal depression. The online format was implemented directly in response to the suspension of in-person groups due to social distancing restrictions and provided an opportunity to explore whether similar ingredients and mechanisms to improved mental health might be observed by participating online as in person. Our study helps interpret the findings of the feasibility trial (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) by mapping out programme ingredients that seemed to trigger mechanisms which then impacted PND symptoms, as well as identifying ingredients unique to online delivery such as being able to sing on mute at home which led to increased confidence in singing.\u003c/p\u003e \u003cp\u003eA key feature of the outcome findings previously reported on the M4M-online intervention was the similarity in the reduction in EPDS scores over six weeks to the original M4M-in-person intervention (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Notably, this was found despite the mode of delivery (online vs in person) being quite different. In this study, by mapping the active ingredients in the trial using a theory-informed approach, we were able to differentiate which ingredients were \u0026lsquo;peripheral\u0026rsquo;, in that changes in them did not materially affect the ability of the intervention to achieve the primary outcome, vs which ingredients were potentially \u0026lsquo;core\u0026rsquo; for such similarities in the primary outcome to be achieved. The key differences between the formats were the environments in which the programmes were delivered, the atmosphere of a virtual rather than in-person setting, and the dominance of singing on mute, using backing tracks and being unable to hear other participants sing online. These ingredients were largely context-based or related to the technical delivery of the project. This suggests that modification of such elements can occur without diluting the psychological benefits of the programme. That said, participant feedback on the online experience was not always positive. Similar to other studies in populations with chronic health conditions (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e), participants acknowledged the ease of taking part from home and the benefits during an unprecedented time of social change. But many expressed a preference for attending M4M in-person if given the option.\u003c/p\u003e \u003cp\u003eWe also identified several shared or \u0026ldquo;core\u0026rdquo; ingredients across the online and in-person (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) formats which may be key to supporting the mental health of new mothers. This included the frequency and duration of sessions and the artistic and emotional content of the songs and singing activities. Participants had similar levels of previous engagement with group singing across both formats and shared experiences of motherhood and postnatal depression. Previous research has identified that shared experience of health problems among online creative health programme participants are important for engagement and feeling supported (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). The artists and facilitators delivering the online and in-person programmes shared similar skills and previous experience of delivering community singing programmes. Key contextual similarities were the resources including staffing used to deliver, recruit to and manage the programme and the creation of a safe and inclusive environment within both the online and in-person spaces. It is likely that some or all these ingredients are core to achieving intervention outcomes. That said, further research would be needed to confirm if modifications to these ingredients could still be made without adversely influencing outcomes.\u003c/p\u003e \u003cp\u003eOur study also demonstrated that M4M-online targeted a range of psychological, social and behavioural mechanisms including increased participant confidence in interacting with their babies, supported a change in identity, improved social bonding with their babies and families and reduced feelings of loneliness and social isolation. Attending the groups also provided participants with new routines and increased their experience of positive emotional responses. Importantly, these effects were felt both during and outside of the singing sessions as participants implemented what they had learned into their daily lives and routines. These findings help us to understand why participating in M4M-online led to reductions in stress, anxiety and PND symptoms in the feasibility trial (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Most of the mechanisms identified in the present study also mirrored those produced by the in-person M4M groups including increased bonding between mothers and their babies, supporting mothers to establish new routines, an enhanced sense of identity and singing as a tool for mothers to calm their babies (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). These same mechanisms have also been reported in research into other online creative health programmes including increased positive emotional response (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e), increased confidence in communicating with others (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e) and reduced loneliness and isolation (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). One study evaluating online group dance sessions for young people with anxiety and depression identified increased feelings of social connectedness to others as key for supporting their mental health (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). We did however identify an additional mechanism around increased self-confidence as a mother, which was not reported in the original M4M-in-person trial. However, this encompassed being able to calm their babies, which was a mechanism of the original trial, and the mothers in the original trial described an increase in achievement, which suggests similar mechanisms.\u003c/p\u003e \u003cp\u003eThis study also allowed for an understanding of how the ingredients and mechanisms in the intervention interacted to impact outcomes. While participants in our study qualitatively reported feeling less lonely and socially isolated due to meeting other mothers with PND and being able to share the challenges of motherhood, many expressed a dilution of impact through the online format because participants were geographically spread and unable to meet socially after the sessions (alterations in the active ingredients of informal social exchanges and environment). Many of the participants in our study expressed a preference for in-person sessions in their local area to promote lasting social connections with other participants. These experiences help us to understand the lack of effect on social support and feelings of loneliness observed in the feasibility trial (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). It is also important to acknowledge that the absence of social support from friends and family due to social distancing restrictions and resulting increases in loneliness and social isolation among new parents during the COVID-19 pandemic (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) may have limited the impact that M4M-online was able to have on social outcomes. Challenges to social engagement have also been identified in online singing interventions with other populations with a key barrier being technological limitations to social interactions and connectedness (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). A study comparing experiences of moving from in-person to online choir sessions during the pandemic also identified limited opportunities for group and social bonding through the lack of real-time singing, harmonising and the act of singing together as a group within a shared physical space (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). For mothers in our study and in studies with people experiencing chronic health problems (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e), however, the focus on singing whilst muted allowed some participants to express themselves more openly, particularly those who lacked confidence in their singing abilities. This highlights that different considerations might be needed for adapting and promoting engagement with online creative health interventions compared to creative activities for those who are already actively engaged in creative pursuits.\u003c/p\u003e \u003cp\u003eStrengths and limitations\u003c/p\u003e \u003cp\u003eThis study builds on and helps to interpret the findings from a feasibility trial on the impact of online singing groups for new mothers experiencing PND. It provides an in-depth understanding of how and why online singing groups helped reduce PND, stress and anxiety symptoms in new mothers during the COVID-19 pandemic as well as why social support and loneliness outcomes were not strongly impacted. It also formalises the identification and comparison of active ingredients of a creative health programme delivered across different formats with a theory-based approach.\u003c/p\u003e \u003cp\u003eThe study is not without limitations. Whilst attempts were made to include all women who participated in the feasibility trial, 11 women did not respond to the invitation to take part. The current study sample, while being of a similar age to the overall trial sample, was less heterogeneous and contained fewer women from ethnic minority groups, those who were single, and those with fewer educational qualifications. Their experiences may have been less positive or different to the views and experiences expressed here.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eWe identified key programme features (\u0026lsquo;active ingredients\u0026rsquo;) of an online group singing programme that helped to support new mothers experiencing postnatal depression. These features triggered a range of psychological, social and behavioural responses (\u0026lsquo;mechanisms of action\u0026rsquo;) that led to improved mental health. We also compared online and in-person delivery formats to determine the likely \u0026ldquo;core ingredients\u0026rdquo; of the M4M programme. These findings can be used to i) inform the design of future online creative health interventions to support mental health and maximise engagement and impact and ii) tailor in-person activities for remote delivery to extend geographical reach and support populations who may struggle to attend in-person.\u003c/p\u003e"},{"header":"List of abbreviations","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.10648918469218%\" valign=\"top\"\u003e\n \u003cp\u003eBreathe Melodies for Mums\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"63.89351081530782%\" valign=\"top\"\u003e\n \u003cp\u003eM4M\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.10648918469218%\" valign=\"top\"\u003e\n \u003cp\u003eCoronavirus disease 2019\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"63.89351081530782%\" valign=\"top\"\u003e\n \u003cp\u003eCOVID-19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.10648918469218%\" valign=\"top\"\u003e\n \u003cp\u003eEPDS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"63.89351081530782%\" valign=\"top\"\u003e\n \u003cp\u003eEdinburgh Postnatal Depression Scale\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.10648918469218%\" valign=\"top\"\u003e\n \u003cp\u003eINNATE Framework\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"63.89351081530782%\" valign=\"top\"\u003e\n \u003cp\u003eIngredients in Arts in health Framework\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.10648918469218%\" valign=\"top\"\u003e\n \u003cp\u003eKCL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"63.89351081530782%\" valign=\"top\"\u003e\n \u003cp\u003eKings College London\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.10648918469218%\" valign=\"top\"\u003e\n \u003cp\u003eNCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"63.89351081530782%\" valign=\"top\"\u003e\n \u003cp\u003eNational Childbirth Trust\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.10648918469218%\" valign=\"top\"\u003e\n \u003cp\u003ePND\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"63.89351081530782%\" valign=\"top\"\u003e\n \u003cp\u003ePostnatal depression\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.10648918469218%\" valign=\"top\"\u003e\n \u003cp\u003eSHAPER\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"63.89351081530782%\" valign=\"top\"\u003e\n \u003cp\u003eScaling-up Health-Arts Programme\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.10648918469218%\" valign=\"top\"\u003e\n \u003cp\u003eUCL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"63.89351081530782%\" valign=\"top\"\u003e\n \u003cp\u003eUniversity College London\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eThis study was approved by the King\u0026rsquo;s College London Research Ethics Office (KCL Ethics Ref: HR-20/21\u0026ndash;19659). Any protocol amendments were submitted to the King\u0026rsquo;s College London Research Ethics Office for approval.\u003c/p\u003e\n\u003cp\u003eThe authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained by researchers from all participants involved in the study.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe datasets used during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eFrom 2016 to 2022 DF was a non-executive board director for Breathe Arts Health Research but she received no financial compensation for her involvement. CMP has received grants from European Commission (IMI2 853966). Additional funding has been provided by UK National Institute of Health Research (NIHR) Biomedical Research Centre at South London and Maudsley NHS Trust and King\u0026rsquo;s College London. He is also funded by a NIHR Senior Investigator Award. He has received research or consultation funding from Johnson \u0026amp; Johnson and Boehringer Ingelheim, as well as research funding from the Medical Research Council (UK) and the Wellcome Trust for research on depression and inflammation as part of two large consortia that also include Johnson \u0026amp; Johnson, GSK and Lundbeck. The work presented in this paper is unrelated to this funding. The other authors have no competing interests to declare.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis study is part of the SHAPER programme, a Scaling-up Health-Arts Programme to scale up arts interventions funded by the Wellcome Trust (award reference 219425/Z/19/Z). This work is additionally supported by the National Institute for Health Research (NIHR) Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King\u0026rsquo;s College London and by an NIHR Senior Investigator Award (CMP). RD was supported by the National Institute for Health Research (NIHR) Applied Research Collaboration: South London, at King\u0026rsquo;s College Hospital NHS Foundation Trust. The views expressed in this publication are those of the authors and not necessarily those of the Wellcome Trust, the NIHR, or the Department of Health and Social Care.\u003c/p\u003e\n\u003ch2\u003eAuthor Contributions\u003c/h2\u003e\n\u003cp\u003e\u003cstrong\u003eAB:\u0026nbsp;\u003c/strong\u003eData Curation, Formal Analysis, Investigation, Methodology, Writing - Original Draft, \u003cstrong\u003eRHB:\u003c/strong\u003e Data Collection, Project administration, Writing \u0026ndash; Reviewing and Editing, \u003cstrong\u003eRD:\u0026nbsp;\u003c/strong\u003eFormal Analysis,\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eMethodology, Writing \u0026ndash; Reviewing and Editing, \u003cstrong\u003eLG:\u003c/strong\u003e Formal analysis, Project administration, Supervision, Writing \u0026ndash; Reviewing and Editing, \u003cstrong\u003eCYL:\u0026nbsp;\u003c/strong\u003eWriting - Original Draft,\u003cstrong\u003e\u0026nbsp;CE:\u0026nbsp;\u003c/strong\u003eProject administration, Writing \u0026ndash; Reviewing and Editing, \u003cstrong\u003eKH:\u0026nbsp;\u003c/strong\u003eData Collection, Writing \u0026ndash; Reviewing and Editing, \u003cstrong\u003eCM:\u0026nbsp;\u003c/strong\u003eData Collection, Writing \u0026ndash; Reviewing and Editing, \u003cstrong\u003eKP:\u0026nbsp;\u003c/strong\u003eData Collection, Writing \u0026ndash; Reviewing and Editing, \u003cstrong\u003eLR:\u0026nbsp;\u003c/strong\u003eData Collection, Writing \u0026ndash; Reviewing and Editing, \u003cstrong\u003eTO:\u0026nbsp;\u003c/strong\u003eProject administration, Writing \u0026ndash; Reviewing and Editing, \u003cstrong\u003eHD:\u003c/strong\u003e Project administration, Writing \u0026ndash; Reviewing and Editing, \u003cstrong\u003ePD:\u0026nbsp;\u003c/strong\u003eWriting \u0026ndash; Reviewing and Editing, \u003cstrong\u003eAW:\u003c/strong\u003e Project administration, Writing \u0026ndash; Reviewing and Editing, \u003cstrong\u003eNC:\u0026nbsp;\u003c/strong\u003eWriting \u0026ndash; Reviewing and Editing, \u003cstrong\u003eCMP:\u0026nbsp;\u003c/strong\u003eConceptualization, Funding Acquisition, Methodology, Writing \u0026ndash; Reviewing and Editing\u003cstrong\u003e, DF:\u0026nbsp;\u003c/strong\u003eConceptualization, Formal Analysis, Funding Acquisition, Methodology, Writing \u0026ndash; Reviewing and Editing, Supervision.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eWe would like to thank Breathe Arts Health Research facilitators, administrators and the singing leads who ran the sessions. We would also like to thank the wider SHAPER research team for their support with recruitment and study delivery and all of the mothers and their babies who took part.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eStowe ZN, Hostetter AL, Newport DJ. The onset of postpartum depression: Implications for clinical screening in obstetrical and primary care. American Journal of Obstetrics and Gynecology. 2005;192(2):522-6.\u003c/li\u003e\n\u003cli\u003eBoath E, Henshaw C. The treatment of postnatal depression: A comprehensive literature review. Journal of Reproductive and Infant Psychology. 2001;19(3):215-48.\u003c/li\u003e\n\u003cli\u003eHarrison S, Quigley MA, Fellmeth G, Stein A, Alderdice F. The impact of the Covid-19 pandemic on postnatal depression: analysis of three population-based national maternity surveys in England (2014-2020). Lancet Reg Health Eur. 2023;30:100654.\u003c/li\u003e\n\u003cli\u003eLakey B, Cronin A. 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Int J Environ Res Public Health. 2021;18(9).\u003c/li\u003e\n\u003cli\u003eCooper PJ, Murray L. Postnatal depression. BMJ. 1998;316(7148):1884-6.\u003c/li\u003e\n\u003cli\u003eFeldman R, Granat A, Pariente C, Kanety H, Kuint J, Gilboa-Schechtman E. Maternal depression and anxiety across the postpartum year and infant social engagement, fear regulation, and stress reactivity. J Am Acad Child Adolesc Psychiatry. 2009;48(9):919-27.\u003c/li\u003e\n\u003cli\u003eManso-C\u0026oacute;rdoba S, Pickering S, Ortega MA, As\u0026uacute;nsolo \u0026Aacute;, Romero D. Factors Related to Seeking Help for Postpartum Depression: A Secondary Analysis of New York City PRAMS Data. International Journal of Environmental Research and Public Health. 2020;17(24):9328.\u003c/li\u003e\n\u003cli\u003eSmith MS, Lawrence V, Sadler E, Easter A. Barriers to accessing mental health services for women with perinatal mental illness: systematic review and meta-synthesis of qualitative studies in the UK. BMJ Open. 2019;9(1):e024803.\u003c/li\u003e\n\u003cli\u003eGrote NK, Bridge JA, Gavin AR, Melville JL, Iyengar S, Katon WJ. A meta-analysis of depression during pregnancy and the risk of preterm birth, low birth weight, and intrauterine growth restriction. Arch Gen Psychiatry. 2010;67(10):1012-24.\u003c/li\u003e\n\u003cli\u003eUsmani S, Greca E, Javed S, Sharath M, Sarfraz Z, Sarfraz A, et al. Risk Factors for Postpartum Depression During COVID-19 Pandemic: A Systematic Literature Review. J Prim Care Community Health. 2021;12:21501327211059348.\u003c/li\u003e\n\u003cli\u003eHessami K, Romanelli C, Chiurazzi M, Cozzolino M. COVID-19 pandemic and maternal mental health: a systematic review and meta-analysis. J Matern Fetal Neonatal Med. 2022;35(20):4014-21.\u003c/li\u003e\n\u003cli\u003eDavenport MH, Meyer S, Meah VL, Strynadka MC, Khurana R. Moms Are Not OK: COVID-19 and Maternal Mental Health. Front Glob Womens Health. 2020;1:1.\u003c/li\u003e\n\u003cli\u003eDib S, Rougeaux E, V\u0026aacute;zquez-V\u0026aacute;zquez A, Wells JCK, Fewtrell M. Maternal mental health and coping during the COVID-19 lockdown in the UK: Data from the COVID-19 New Mum Study. International Journal of Gynecology \u0026amp; Obstetrics. 2020;151(3):407-14.\u003c/li\u003e\n\u003cli\u003eFancourt D, S F. What is the evidence on the role of the arts in improving health and well-being? A scoping review. Europe WROf, editor. Copenhagen: WHO; 2019.\u003c/li\u003e\n\u003cli\u003eFancourt D, Perkins R. The effects of mother\u0026ndash;infant singing on emotional closeness, affect, anxiety, and stress hormones. Music \u0026amp; Science. 2018;1:2059204317745746.\u003c/li\u003e\n\u003cli\u003eMualem O, Klein PS. The communicative characteristics of musical interactions compared with play interactions between mothers and their one-year-old infants. Early Child Development and Care. 2013;183(7):899-915.\u003c/li\u003e\n\u003cli\u003eFancourt D, Perkins R. Effect of singing interventions on symptoms of postnatal depression: three-arm randomised controlled trial. Br J Psychiatry. 2018;212(2):119-21.\u003c/li\u003e\n\u003cli\u003ePerkins R, Yorke S, Fancourt D. How group singing facilitates recovery from the symptoms of postnatal depression: a comparative qualitative study. BMC Psychol. 2018;6(1):41.\u003c/li\u003e\n\u003cli\u003eEstevao C, Fancourt D, Dazzan P, Chaudhuri KR, Sevdalis N, Woods A, et al. Scaling-up Health-Arts Programmes: the largest study in the world bringing arts-based mental health interventions into a national health service. BJPsych Bull. 2021;45(1):32-9.\u003c/li\u003e\n\u003cli\u003eVance D, Shah P, Sataloff RT. COVID-19: Impact on the Musician and Returning to Singing; A Literature Review. Journal of Voice. 2023;37(2):292.e1-.e8.\u003c/li\u003e\n\u003cli\u003eBradbury A WK, Mak, H.W, Fancourt, D. The role of the arts during the COVID-19 pandemic. . 2021.\u003c/li\u003e\n\u003cli\u003eBind RH, Estevao C, Fancourt D, Hazelgrove K, Sawyer K, Rebecchini L, et al. Online singing interventions for postnatal depression in times of social isolation: a feasibility study protocol for the SHAPER-PNDO single-arm trial. Pilot and Feasibility Studies. 2022;8(1):148.\u003c/li\u003e\n\u003cli\u003eMcKinlay AR, Fancourt D, Burton A. Factors affecting the mental health of pregnant women using UK maternity services during the COVID-19 pandemic: a qualitative interview study. BMC Pregnancy and Childbirth. 2022;22(1):313.\u003c/li\u003e\n\u003cli\u003eBind RH, Sawyer K, Hazelgrove K, Rebecchini L, Miller C, Ahmed S, et al. Feasibility, clinical efficacy, and well-being outcomes of an online singing intervention for postnatal depression in the UK: SHAPER-PNDO, a single-arm clinical trial. Pilot and Feasibility Studies. 2023;9(1):131.\u003c/li\u003e\n\u003cli\u003eWarran K, Burton A, Fancourt D. What are the active ingredients of \u0026apos;arts in health\u0026apos; activities? Development of the INgredients iN ArTs in hEalth (INNATE) Framework. Wellcome Open Res. 2022;7:10.\u003c/li\u003e\n\u003cli\u003eFancourt D, Steptoe A. Present in Body or Just in Mind: Differences in Social Presence and Emotion Regulation in Live vs. Virtual Singing Experiences. Frontiers in Psychology. 2019;10.\u003c/li\u003e\n\u003cli\u003eFancourt D, Aughterson H, Finn S, Walker E, Steptoe A. How leisure activities affect health: a narrative review and multi-level theoretical framework of mechanisms of action. Lancet Psychiatry. 2021;8(4):329-39.\u003c/li\u003e\n\u003cli\u003eMcCleary N, Duncan EM, Stewart F, Francis JJ. Active ingredients are reported more often for pharmacologic than non-pharmacologic interventions: an illustrative review of reporting practices in titles and abstracts. 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Counselling and Psychotherapy Research. 2021;21(1):37-47.\u003c/li\u003e\n\u003cli\u003eBraun V C, V. Thematic Analysis A Practical Guide: SAGE; 2022.\u003c/li\u003e\n\u003cli\u003ePhilip KE, Lewis A, Jeffery E, Buttery S, Cave P, Cristiano D, et al. Moving singing for lung health online in response to COVID-19: experience from a randomised controlled trial. BMJ Open Respiratory Research. 2020;7(1):e000737.\u003c/li\u003e\n\u003cli\u003eTaylor ER, Estevao C, Jarrett L, Woods A, Crane N, Fancourt D, et al. Experiences of acquired brain injury survivors participating in online and hybrid performance arts programmes: an ethnographic study. Arts \u0026amp; Health.1-17.\u003c/li\u003e\n\u003cli\u003eFinn S, Wright LHV, Mak HW, \u0026Aring;str\u0026ouml;m E, Nicholls L, Dingle GA, Warran K. Expanding the social cure: a mixed-methods approach exploring the role of online group dance as support for young people (aged 16\u0026ndash;24) living with anxiety. Frontiers in Psychology. 2023;14.\u003c/li\u003e\n\u003cli\u003eTamplin J, Haines SJ, Baker FA, Sousa TV, Thompson Z, Crouch H, et al. ParkinSong Online: Feasibility of Telehealth Delivery and Remote Data Collection for a Therapeutic Group Singing Study in Parkinson\u0026apos;s. Neurorehabil Neural Repair. 2023:15459683231219269.\u003c/li\u003e\n\u003cli\u003eDowson B, Schneider J, McDermott O, Orrell M. Online Singing Groups for People With Dementia: Adaptation and Resilience in the Face of the COVID-19 Pandemic. Dementia (London). 2023;22(7):1348-71.\u003c/li\u003e\n\u003cli\u003eBek J, Leventhal D, Groves M, Growcott C, Poliakoff E. Moving online: Experiences and potential benefits of digital dance for older adults and people with Parkinson\u0026apos;s disease. PLoS One. 2022;17(11):e0277645.\u003c/li\u003e\n\u003cli\u003eDaffern H, Balmer K, Brereton J. Singing Together, Yet Apart: The Experience of UK Choir Members and Facilitators During the Covid-19 Pandemic. Front Psychol. 2021;12:624474.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Depression postpartum, postnatal depression, qualitative research, COVID-19, creative health, singing intervention, online delivery","lastPublishedDoi":"10.21203/rs.3.rs-4177936/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4177936/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSocial distancing restrictions and the suspension of in-person treatment and support contributed to an increase in postnatal depression during the coronavirus disease 2019 (COVID-19) pandemic. Creative health interventions can help to alleviate anxiety and depression, with studies showing that singing is particularly effective for supporting the mental health of new mothers. We adapted an in-person group singing programme (Breathe Melodies for Mums (M4M)) to online delivery during the COVID-19 pandemic to support the mental health of new mothers, and, in a feasibility study, found improvements in postnatal depression (PND) symptoms at 6-month follow up. The current qualitative study aimed to explore how and why M4M-online impacted the mental health of those taking part.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe took a theory-based approach using the Ingredients in Arts in Health (INNATE) Framework of \u0026lsquo;active ingredients\u0026rsquo; and the Multi-level Leisure Mechanisms Framework of \u0026lsquo;mechanisms of action\u0026rsquo; to identify and categorise intervention components and change mechanisms. Iterative consensus building between three researchers were complemented by qualitative semi-structured online interviews with 24 women experiencing PND symptoms who took part in M4M-online. Data were analysed inductively using reflexive thematic analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eConsistency was found between the online and in-person interventions in active ingredients relating to project design, content, programme management and the composition of the group. Key differences were in the social and contextual ingredients. Psychological, social and behavioural mechanisms for improved mental health and wellbeing included: 1) Increased self-confidence as a mother, 2) Increased positive emotional responses, 3) A supported change in identity, 4) Reduced loneliness and isolation, 5) Increased social bonding and connections with family and 6) Enhanced sense of time through new routines.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eParticipating in online group singing can support new mothers experiencing PND by triggering psychological, social and behavioural responses that lead to improved mental health. Key programme features are identified which can be used to design future online creative health interventions or tailor in-person activities for remote delivery to support populations who may face practical and social barriers to attending in-person.\u003c/p\u003e","manuscriptTitle":"A qualitative exploration of active ingredients and mechanisms of action of an online singing programme with mothers experiencing postnatal depression during the COVID-19 pandemic: SHAPER-PNDO study.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-10 13:53:01","doi":"10.21203/rs.3.rs-4177936/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-13T08:43:57+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-27T17:12:20+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-24T00:34:44+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-19T10:05:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"328647240003054044216734656809679083357","date":"2024-09-17T16:32:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"259891107254494867364530178314196122219","date":"2024-09-17T09:46:36+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-17T05:35:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"266116491142437986529147408543617569784","date":"2024-09-16T18:54:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"180661050196118075109882678618658602686","date":"2024-09-16T07:37:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"188537265341479147469222607279488130361","date":"2024-09-16T07:05:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"276640835255884446822122851697095116809","date":"2024-09-15T00:02:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"179597172563344058902668233822084831017","date":"2024-06-21T08:32:34+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-05-29T11:59:51+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-04-11T13:38:03+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-04-05T09:33:48+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-04-05T09:33:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychology","date":"2024-03-27T18:42:36+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d3a7602c-0aed-4a81-b9e8-a9a57bb20915","owner":[],"postedDate":"April 10th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-12-02T17:26:21+00:00","versionOfRecord":{"articleIdentity":"rs-4177936","link":"https://doi.org/10.1186/s40359-024-02213-7","journal":{"identity":"bmc-psychology","isVorOnly":false,"title":"BMC Psychology"},"publishedOn":"2024-11-30 15:58:07","publishedOnDateReadable":"November 30th, 2024"},"versionCreatedAt":"2024-04-10 13:53:01","video":"","vorDoi":"10.1186/s40359-024-02213-7","vorDoiUrl":"https://doi.org/10.1186/s40359-024-02213-7","workflowStages":[]},"version":"v1","identity":"rs-4177936","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4177936","identity":"rs-4177936","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}