A&HHE Special Issue August 2016AHHELogo-300x300

Health promotion for musicians: Engaging with instrumental and vocal teachers

Naomi C Norton

Royal Northern College of Music

Abstract

Performance-related health problems (PRPs) are prevalent amongst musical communities even though most conditions are preventable. Health promotion initiatives need to mitigate known risk factors by involving qualified professionals and stakeholders in the target environment. Instrumental/vocal teachers are crucial figures in music education and health promotion and research is needed to investigate their health-related experiences, beliefs and behaviours. At present there is only a sparse understanding of who instrumental/vocal teachers in the United Kingdom are and no published research has investigated their personal health, or engaged with their beliefs about responsibility for health, current health-promoting behaviours and engagement with health-related information. This article outlines the rationale for involving instrumental/vocal teachers in health promotion for musicians. Preliminary results from a large-scale survey (N=496) and follow-up interview study (N=12) indicate that, at least to some extent, teachers feel a sense of responsibility for their pupils’ well-being and are already engaging in health-promoting behaviours.

Keywords

Music education, health and well-being, health promotion, prevention, performance-related problems

Introduction

The term “musician” has been defined as ‘a person who practises in the profession of music within one or more specialist fields’ (Bennett, 2008: p.101); e.g. education, performance, composition, therapy, and community music. Musicians’ activities in these fields facilitate engagement with music in settings that confer benefits for individual and community well-being. To continue participating in these activities it is imperative that musicians maintain their own health: there must be a balance between ‘health as a resource for making music and making music as a resource for health’ (Gembris, 2012: p. 371). Performing Arts Medicine (PAM) has advanced considerably as a specialist field and there is now a good understanding of the aetiology, epidemiology and treatment of performance-related problems (PRPs) such as including Performance-Related Musculoskeletal Disorders (PRMDs), Vocal Disability, Noise-Induced Hearing Loss (NIHL), and Music Performance Anxiety (MPA). These problems are prevalent in musical communities; a survey of 551 musicians in the UK reported that 73% of respondents have experienced illness or another physical problem, 73% have experienced MPA, 66% have encountered depression or other psychological issues, and 47% have hearing issues (Musicians’ Health and Wellbeing Survey, March 2014; see Ginsborg et al., 2012 for relevant research). Vocal disability has been found to affect between 30% and 55% of young vocalists (Donahue et al., 2014; Kwak et al., 2014; Zimmer-Nowicka and Januszewska-Stancyzk, 2011) and vocal difficulties continue into professional life for performers (Cammarota et al., 2007) and teachers (Sataloff et al., 2012). Personal accounts and the results of empirical research suggest that PRPs affect musicians physically, emotionally, socially and financially; that disruption of the ability to make music can be devastating; and that PRPs interfere with musicians’ relationship with their instrument and artistic expression (Guptill, 2011; Kenny, 2011; Schoeb and Zosso, 2012). Treatment and management strategies may return musicians to near or fully functional capacity, but there are implications in terms of distress, loss of income, and – in severe cases – cessation of musical activities.

Risk factors for performance-related problems

It is beyond the scope of this article to explore all factors related to the development of PRPs but some of the most commonly cited risk factors for PRMD, MPA, vocal disability and NIHL are outlined below. Risk factors for PRMDs can be divided into two categories; non-modifiable (e.g. race, sex, and flexibility) and modifiable. Modifiable factors include non-musical activities, and change or error in instrumental/vocal technique, posture, practice habits, instrument ergonomics, repertoire, playing time, instrument size or group, and teacher.1 Risk factors for vocal disability include: talking excessively, rapidly, loudly or at a low pitch; frequent throat clearing; inadequate breath support; incorrect body alignment; overuse of pressed phonation; forcing the voice beyond its natural range; poor vocal hygiene; and inefficient vocal production habits (Heman-Ackah et al., 2013; Zimmer-Nowicka and Januszewska-Stanczyk, 2011).2 Hearing damage can be caused by exposure to loud and/or sustained sound levels. A musician’s own instrument contributes most of their sound exposure but proximity to other instruments increases the risk (Schmidt et al., 2011) as do certain venue characteristics (e.g. wall covering, echo, raked staging) and pieces of music (MacDonald et al., 2008; Schmidt et al., 2011). The development of MPA follows an increase in cognitive capacity, self-reflective function, the capacity for understanding others’ perspectives’ and the development of technical skill (Brugués, 2011; Kenny and Osborne, 2006). Orchestral musicians cited excessive physical arousal and not knowing how to manage physical arousal as triggers for MPA (Kenny, 2009a). MPA is more likely to be triggered by performance situations that involve high ego investment, evaluative threat, and a fear of failure (Kenny, 2009b) and an emphasis on perfectionism has been associated with the development of MPA (Patston, 2014). Focusing on mastering the skills necessary for the task is more likely to produce optimal performances compared to focusing on winning or not failing (Lacaille, Whipple and Koestner, 2005).

Health promotion and the prevention of performance-related problems

The best form of treatment is prevention or – as Ralph Manchester quipped – ‘a sixteenth note of prevention is worth a whole note of cure’ (2006: p.1). Encouragingly, the majority of problems that affect musicians’ health are preventable as long as appropriate education and support are available (Chan and Ackermann, 2014). Potter (2012) identifies two forms of prevention: Primary Prevention refers to avoiding the onset of preventable impairments that result from exposure to risk factors whereas Secondary Prevention involves raising awareness of PRPs so that they can be identified quickly and dealt with appropriately. Bennett (2008: p.51) identified seven foci for PRP prevention amongst musicians:

  1. The role of conservatoires in promoting healthy work practices for students and in providing suitable professional development for instrumental staff;
  2. The role of professional organisations in promoting healthy workplaces;
  3. The need for proactive measures such as the development of a fitness regime;
  4. Availability and affordability of treatment and advice;
  5. The necessity for musicians to become more physically and psychologically aware;
  6. Increased physiological and psychological awareness from earliest stages of musical development;
  7. A general lack of pedagogical training amongst instrument tutors at every level, and the potential role of tutors in reducing incidence of playing-related injury;

The first three foci relate to secondary prevention whereas the final four focus on primary prevention. Given the high prevalence of PRPs it is perhaps right that the initial focus should be on secondary prevention, especially because those who will ultimately be involved in primary prevention may initially need help with their own health.

Da Costa and Vieira (2010) carried out a review of risk factors for work-related musculoskeletal-disorders and concluded that health promotion programmes should mitigate known risk factors by calling on the expertise of qualified professionals and the educated opinion of stakeholders. Although more research is needed, there is a general understanding of which risk factors are associated with the development of PRPs. Medical professionals are already engaged in the treatment of PRPs and the development and maintenance of health promotion programmes;3 however, they are rarely involved in the initial stages of musical education and are unlikely to play a formative role in the development of musicians’ beliefs and approaches to musical activities. To date, the majority of PAM research has been designed, conducted, reported and read by medical professionals; research that investigates and represents the current beliefs, attitudes and practices of relevant stakeholders is sparse.

Stakeholders in health promotion

Stakeholders in musical environments include parents/carers, other musicians, educational institutions, classroom and instrumental/vocal music teachers. Parents are unlikely to be experts on their child’s instrument and will almost certainly be advised by their child’s teacher regarding how to guide musical development. Other musicians (e.g. famous musicians, peers or colleagues) may influence musical development but the strongest bond tends to be between teacher and student. Educational and professional organisations have begun to improve the availability of treatment and address injury prevention.4 A large proportion of the education and support available in tertiary education institutions is delivered by instrumental/vocal teachers. Many children studying classical music in the Western world start before puberty and one-to-one tuition forms the central part of their musical education (Gaunt et al., 2012; Welch et al., 2010). The relationship between an instrumental/vocal teacher and their student is complex and influential; Gaunt (2011) described these relationships having potential to reflect ‘parent-child’ or ‘doctor-patient’ relationships (p.165) indicating the inherent responsibility and power involved. Instrumental/vocal teachers are often seen as role models (Jorgenson, 2000) and can use this influence positively by modelling healthy behaviour for their students (Patston, 2014; Steele, 2010; Trollinger, 2007). Aside from the considerable benefits drawn from healthy teacher-student relationships there are potential difficulties relating to abuse of these relationships (Burwell, 2005; Purser, 2005). A famous quotation from Henry Adams (1973) suggests that ‘a teacher affects eternity: he can never tell where his influence stops’ (p.300); this oft-used truism carries cautionary overtones when read in its original context.5 Chesky commented that ‘the ability to make changes and the responsibility for doing so belong to the person who holds the baton’ (2008: p.41); many people hold the (metaphorical) baton in terms of conducting musicians’ development, but instrumental/vocal teachers are particularly influential.

Instrumental and vocal teachers’ involvement in health promotion

Musicians are frequently compared to athletes and dancers (Chan and Ackerman, 2014; Gaunt, 2011) and research from those disciplines has shown the importance of good teaching in preventing injuries and promoting good health (Hays, 2002; Smith et al., 1995). Music teachers are in a position to influence many of the risk factors outlined previously. In terms of risk factors for PRMDs teachers are often involved in choosing an instrument, ensuring the instrument is in good working order and fitted appropriately to the student. They also teach the student how to interact with their instrument, master various techniques, choose repertoire, and guide practice habits. Vocal teachers are involved in helping students to avoid vocal misuse and can also advise students about the risks associated with vocal abuse.  Poor vocal hygiene habits can predispose vocalists to upper-respiratory tract infections, and individuals who have received vocal training have noticeably better vocal habits and hygiene (Zimmer-Nowicka and Januszewska-Stanczyk, 2011). Many musicians take part in group music activities and the teacher leading these activities is involved in choosing repertoire, ensuring the venue is appropriate, and controlling noise levels. The type of goals that teachers set for beginning students will influence how students subsequently approach performance situations. Performance opportunities are generally facilitated by music teachers and they are also in a position to help their students to prepare for performance.

Where primary prevention of PRPs has been unsuccessful, it may be necessary to engage in secondary prevention. Teachers are often the ‘first port of call’ for music students seeking advice (Kwak et al., 2014; Norton and Greasley, 2014; Petty, 2012). Being supportive of students who are experiencing difficulties, allowing time to discuss problems, and accepting pupils’ need to seek help or modify their musical activities may help to reduce the ‘culture of silence’ that has historically plagued musical environments (Patston, 2014; Wristen, 2013). A trusting student-teacher relationship can result in a teacher noticing, or being told about, early signs and symptoms associated with PRPs (Horvath, 2008; Wristen, 2013); teachers need to know how to react appropriately in this situation. Teachers play a significant role in establishing how, when and where students seek help; awareness of specialist professionals to whom students can be referred could aid this process (Palac, 2008; Wristen, 2013). Music teachers are crucial nodes in musical communities; by working with music teachers it is possible to influence a much larger number of musicians.

Instrumental and vocal teachers as ‘allies of prevention’

Over two decades ago, Spaulding (1988) referred to music teachers as ‘truly appropriate allies of prevention’ and commented that ‘our dependence on teachers in the task of prevention is clear’ (p.135-136). Since this early endorsement numerous researchers have supported the need to involve instrumental and vocal teachers in the prevention of PRPs (e.g. Guptill, 2012; Guptill and Zaza, 2010; Palac, 2008; Petty, 2012; Ranelli et al., 2011). However, these calls for teachers to be involved in PAM mirror a situation in education 40 years ago when Lortie commented that ‘schooling is long on prescription, short on description’ (1975, vii). If instrumental/vocal teachers are to achieve their potential as allies of prevention it is imperative for the PAM community not just to prescribe their involvement but to appreciate their personal and professional experiences, beliefs and needs. Goodson commented that ‘in understanding something so intensely personal as teaching, it is critical we know about the person the teacher is’ (1981: p.69) and stressed the importance of research that seeks to know, listen to and speak with teachers (Goodson, 1982).

The most up-to-date information about the demographic characteristics, educational routes and career decisions of UK instrumental/vocal teachers is the result of industry-based studies rather than empirical research. No published research has explored the health of UK instrumental/vocal teachers or the effect that personal experiences have on teachers’ perceptions of healthcare and health promotion. The research community must listen to and speak with instrumental and vocal teachers by encouraging exploration of their current health-related practices and beliefs. Only six studies have investigated music teachers’ health-related knowledge and practices (Barrowcliffe, 1999; Brandfonbrener, 1989/1990; McKechnie and Jacobs, 2011; Quarrier, 1995; Redmond and Tiernan, 2001; Rogers, 1999). These studies are nearly all at least a decade out of date, were conducted almost entirely using quantitative methods, did not involve a full range of instrumental and vocal teachers, and did not take place in the UK. Only one study has provided teachers with health promotion training to assess whether this is effective; Hildebrandt and Nübling (2004) delivered a 17-week course that encouraged teachers to use physiology-related content in their teaching. This research is, as noted by the researchers, a ‘starting point for further development and investigation’ (p.69); instrumental and vocal teachers voluntarily engaged in PAM-orientated training, perceived an improvement in their own teaching, and were perceived to have changed by their students. A criticism of this study is the lack of participant voice and information regarding teachers’ existing strategies and beliefs; this research does not seek to know, listen to, or speak with teachers – it is an experiment conducted ‘on’ them to determine the effectiveness of an externally applied intervention.

Current research

To address the lack of research identified above a research project was designed to address the following questions:

  1. What were the characteristics of those delivering instrumental and vocal teaching in the UK in terms of their demographic characteristics, educational backgrounds, and performance-related health?
  2. To what extent did teachers report promoting their pupils’ health? How did they report doing so?
  3. What influenced teachers’ health-promoting behaviours?
  4. To what extent would teachers like to access health-related information so as to promote their own and their pupils’ health more effectively? What would they like to learn and how?

This research involved an online survey of 496 musicians currently teaching in the UK (recruited purposively and via snowball sampling) and semi-structured interviews with 12 survey respondents.6 The survey template and interview schedules were developed based on previous literature and research. Most survey questions yielded categorical data that was most appropriately analysed using descriptive statistics. Open-ended survey responses were analysed using quasi-statistics: i.e. the responses were coded, counted, and presented as sub-categories. Some data was recoded based on criteria that were applied after data collection, for example: respondents were not asked to indicate the highest Qualifications and Credit Framework (QCF) level they have achieved but responses regarding qualifications were recoded to reflect these levels based on published criteria.

Survey respondents were predominantly female (n=343, 69%), ranged in age from 18-90 years, and self-identified primarily as an ‘instrumental/vocal teacher’ or ‘musician who performs and teaches’. Respondents included musicians who participate in musical activities from classical, contemporary, jazz, folk and other genres and who play and teach instruments from keyboard, voice, bowed string, woodwind, plucked string, brass, and percussion families. Just over 45% of respondents (n=225) have received at least one QCF Level 6 qualification, with a further 35% having progressed to Level 7 (n=172) and 5% holding Level 8 qualifications.7 Nearly two-thirds (66%, n=328) of respondents have experienced physical symptoms that interfere with their ability to play/sing and just under 30% (N=141) were experiencing these symptoms at the time of the study. Over half (52%, n=260) of respondents have experienced MPA symptoms and 27% (n=133) were experiencing symptoms at the time of the study. The majority (65%, n=320) of respondents do not believe they have hearing problems; however, 27 participants have been diagnosed with NIHL, seven reported ‘Other’ symptoms (e.g. tinnitus and hyperacusis), and 60 participants believe they may have NIHL (undiagnosed). A further 27 participants have hearing problems that were not caused by noise and 32 participants have experienced hearing problems but are unsure what caused those problems.

The majority of respondents (n=416, 84%) believe that they are at least partially responsible for their pupils’ health and well-being. Thematic analysis of open-ended responses (following the principles laid out by Braun and Clarke, 2006) revealed that respondents feel responsible because being a teacher is perceived as a position of responsibility; that this responsibility is shared with others (including the student); that their responsibility includes certain aspects such as performance-related or more general factors (respondents’ views regarding what this did and did not include varied considerably); and that the level of responsibility is limited in certain ways. Many respondents already spend time helping students to adapt their instrument/environment and discussing health-related topics. Respondents’ primary source of health-related information was experience: 221 respondents (44%) cited a mixture of personal, teaching, and performing experience as the source of their knowledge (other sources included musicians, reading materials, training, music or health organisations, medical professionals and body awareness training). Only 71 respondents (14%) indicated that they have never encountered a pupil with a PRP. Nearly three-quarters of respondents (n=312) offer advice to pupils experiencing health problems but refer the pupil onwards (most commonly to a medical professional) if the problem persists or develops. Nearly all respondents were interested in health-related training and the most popular five learning methods were the internet, books, lectures, journal and newspaper articles. Many respondents (n=294, 72%) believe that health education should be available throughout musical development. The 13 interview participants included 9 female and 4 male respondents aged 21-70 years. Preliminary results indicate that interviewees believe that teachers are ideally placed to deliver health-related information, that it is reasonable and appropriate to ask them to do so, but that current training would not adequately equip a teacher to safely and effectively carry out a health promotion role.

Conclusion

Research in the PAM field has begun to focus on prevention of PRPs and instrumental/vocal teachers have been nominated as potential allies of prevention. However, very little research has focused on knowing, listening to or speaking with instrumental and vocal teachers, and teachers are rarely included in the design of health promotion initiatives. Prior to the current research no large-scale empirical studies had investigated UK music teachers’ personal health, beliefs about health education and healthcare, current engagement in health-promoting activities, interest in further training and suggestions for implementing health promotion initiatives. Through listening to and speaking with instrumental and vocal teachers, this research aimed to involve these musicians in the on-going debate regarding the prevention of PRPs. Further analysis of these data and engagement in subsequent research is needed to provide more depth and breadth of understanding of this important area of PAM research; practical application of the results will be vitally important if the research is to have any benefit locally. This research also raises important questions regarding the complexities of the influential relationship between instrumental/vocal teachers and students, the extent to which teachers should be considered responsible for the musical and general development of their students, and the resulting knowledge and awareness that may be deemed necessary for them to carry out their role safely and effectively.

Notes

1 These risk factors are widely accepted by many PAM researchers and practitioners; however, high-quality research investigating the effect of these factors on a variety of musical populations is still relatively sparse (see Wu, 2007 for a review).

2 These behaviours can be categorised as vocal abuse (harmful behaviour) or vocal misuse (inappropriate use of the voice, potentially through deficient vocal techniques); Watson (2009) suggests that the difference between these categories is that vocal misuse is sustainable for longer because the effects are less extreme, but as a result the habits become more ingrained and harder to change.

3 The Association of Medical Advisers to British Orchestras (AMABO) provides orchestral musicians with access to free, confidential advice on conditions that affect their performance from qualified doctors who specialise in PAM. Educational programmes for musicians often include guest lectures delivered by qualified practitioners with experience in PAM[1]  and educational resources are likely to have had editorial and/or authorial input from qualified health care professionals (e.g. Heman-Ackah et al., 2013; Kenny, 2011; Rosset i Llobet and Odam, 2007).

4 See, for example, the Musical Impact Project (see www.musicalimpact.org) and health promotion initiatives led by Help Musicians UK (see www.helpmusicians.org.uk) and the British Association for Performing Arts Medicine (see www.bapam.org.uk).

5 The full quotation reads “A parent gives life, but as parent, gives no more. A murderer takes life, but his deed stops there. A teacher affects eternity: he can never tell where his influence stops” (Adams, 1973, p.300).

6 Respondents who indicated a willingness to participate in further research were invited to take part in the interview study and the final sample was purposively selected to mirror the demographic characteristics of the survey sample.

7 Level 6 of the Qualifications and Credit Framework (QCF) is equivalent to the final year of a bachelor’s degree, Level 7 is equivalent to a master’s degree and Level 8 to a PhD or similar award.

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