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Effects of online choir and mindfulness interventions on auditory perception and well-being in older adults during the COVID-19 pandemic

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Effects of online choir and mindfulness interventions on auditory perception and well-being in older adults during the COVID-19 pandemic

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Content Copyright 2022 Ellen Herschel

EFFECTS OF ONLINE CHOIR AND MINDFULNESS INTERVENTIONS ON AUDITORY
PERCEPTION AND WELL-BEING IN OLDER ADULTS DURING THE COVID-19
PANDEMIC

by

Ellen Herschel

A Thesis Presented to the
FACULTY OF THE USC DORNSIFE COLLEGE OF ARTS AND SCIENCES
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF ARTS
(PSYCHOLOGY)

August 2022

ii
Dedication
I would like to dedicate this work to my partner, Patrick, for his centering soul, without whom I
could not have started down this journey during such an uncertain time, and my puppy, Korra,
who helps me always remember the joy and fun in the everyday.

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Acknowledgements
Many thanks to my collaborators, Sarah Hennessy, Rael Cahn, Raymond Goldsworthy, and
Assal Habibi. I would like to thank Andrew Schultz, our choir director, the team of choir group
section leaders (Shelby Stroud, Hee Seong Lee, Serge Liberovsky, Yen-Hsiang Nieh), and the
accompanist (Barry Tan). We would also like to thank our mindfulness instructor Alex Maizuss.
Additional thanks to our Brain and Music Lab Research Assistants and the research assistants
from Ray Goldworthy’s lab for their help in data collection and class administration. Finally,
much appreciation goes out to Assal Habibi and Jonas Kaplan for their support, humor, and
generosity of spirit.

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TABLE OF CONTENTS
Dedication........................................................................................................................................ii
Acknowledgements........................................................................................................................iii
List of Figures..................................................................................................................................v
Abstract...........................................................................................................................................vi
Chapter 1: Effects of online choir and mindfulness interventions on auditory perception and
well-being in older adults during the COVID-19 pandemic............................................................1
Introduction..........................................................................................................................1
Methods................................................................................................................................8
Results................................................................................................................................21
Discussion..........................................................................................................................30
Conclusion.........................................................................................................................43
References......................................................................................................................................45
Appendices.....................................................................................................................................68
Appendix A: Means and standard deviations for each task by group and time…….……68

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List of Figures
Figure 1. Melodic Contour Identification Task.............................................................................15
Figure 2. Pitch and Rhythm Task performance at pre- and post-test in Choir and Mindfulness
Groups………................................................................................................................................20
Figure 3. Melodic Contour Identification task performance at pre- and post-test in Choir and
Mindfulness groups across interval conditions..............................................................................22
Figure 4. Speech-in-Noise task performance at pre and post-test in Choir and Mindfulness groups
across SNR conditions...................................................................................................................24
Figure 5. State and Trait anxiety scores at pre- and post-test in Choir and Mindfulness
groups.............................................................................................................................................26

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Abstract
Previous work suggests that both choir and mindfulness training may improve well-being and
auditory skills in older adults. As our global population ages and in times of increasing reliance
on virtual and online networks for communication and healthcare, for example, during the
COVID-19 pandemic, more research is needed to determine the efficacy of such interventions in
an online environment. This randomized control trial investigated the effects of a 10-week virtual
choir or mindfulness program on speech-in-noise (SIN) perception, auditory perception and
attention, and socio-emotional well-being in adults (N = 61) aged 50-65. We observed that both
interventions improved SIN perception in high-noise conditions, decreased anxiety and feelings
of alienation, and increased global well-being, self-acceptance, mindfulness, and self-
transcendence. Choir participants, compared to their own performance, showed improvements in
additional noise conditions of the SIN task relative to mindfulness participants. Choir training
produced greater advantages than mindfulness training in reducing state anxiety and improving
melodic interval discrimination. These findings provide evidence for the feasibility of online
singing and mindfulness interventions, and preliminary evidence for associated improvements in
well-being and auditory measures in older adults in the U.S during the COVID-19 pandemic.
Keywords: auditory perception; well-being; speech-in-noise; music training; choir;
mindfulness; COVID-19

Public Significance Statement: As our global population ages, and during times of increased
reliance on virtual and online technology to provide support, we need to better understand the
efficacy of online interventions. This study suggests both online choir and mindfulness programs
are feasible interventions that aid in improving well-being and auditory measures of older adults.

1

Chapter 1: Effects of online choir and mindfulness interventions on auditory perception
and well-being in older adults during the COVID-19 pandemic

Introduction
As the US population of adults over 50 continues to increase (Jacobsen et al., 2011), more care
needs to be invested in maintaining the health and well-being of individuals in this demographic.
Two areas of concern, of many, to this population's healthy aging are hearing (Pichora-Fuller et
al., 2015) and socio-emotional well-being (Gerino et al., 2017). Hearing difficulties are
associated with loneliness (Littlejohn et al., 2022) depression (Li et al., 2014) and impaired
social activity (M. Yoo et al., 2019). One such difficulty is hearing speech in noisy
environments, which is particularly important for social functioning. Relatedly, socioemotional
well-being is essential for health and cognitive functioning in aging. Loneliness is a strong
predictor of dementia (Kuiper et al., 2015; Lara et al., 2019) and related cognitive decline
(Gilmour, 2011; Gow et al., 2007). Anxiety (Gulpers et al., 2016) and depression (Köhler et al.,
2011) also predict cognitive impairment and dementia. In addition to these concerns, the
COVID-19 pandemic increased concerns regarding the well-being of older adults (De Pue et al.,
2021; Krendl & Perry, 2021). Many enrichment programs may benefit older adults in terms of
auditory skills and socioemotional well-being. Auditory training programs (Ferguson &
Henshaw, 2015; Heidari et al., 2020; Humes et al., 2014) have shown to improve auditory
abilities in older adults, which may positively impact social wellbeing by increasing ease of
communication and social activities. Relatedly, interventions aimed at improving well-being and
reducing anxiety specifically have been shown to be effective, including those implementing
physical activities (Inoue et al., 2020; Pedersen et al., 2017; Stathi et al., 2002) and art classes

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(Bennington et al., 2016; Johnson et al., 2021). However, due to the COVID-19 pandemic, there
has been an increased need to utilize interventions that are low-cost and adaptable to a virtual
environment. Choir training has previously been explored as an intervention for auditory skills
and wellness. Yet, to explore the impact of choir training effectively, a comparison intervention
that is community-based, socially engaging, and accessible to novices is necessary. Mindfulness
training is a compelling candidate for comparison, as it is low-cost, socially engaging, and has
also been studied for its impact on general attentional skills and well-being making it a suitable
activity for comparison. Similar to choir training it can be learned in a relatively short period,
practiced in a group, does not require a lot of prompts, and has been shown to benefit both
speech in noise perception and well-being. Importantly, both choir and mindfulness training
programs are adaptable to a virtual format, a necessity during the COVID-19 pandemic.

Choir Training on Speech in Noise in Older Adults
Choir training is a low-cost, socially engaging activity that is accessible to individuals from a
range of musical abilities, making it a good candidate for a community-based implementable
music intervention. Choir training is hypothesized to improve auditory abilities, such as speech-
in-noise perception, through repetitive practice discriminating acoustic features such as pitch,
rhythm, and timbre. The OPERA hypothesis (Patel, 2011, 2014) posits that speech processing
specifically may be enhanced in musicians due to Overlap, Precision, Emotion, Repetition, and
Attention. In this conception, music training places demands on neural networks and sensory
processes that overlap with speech processing. Practicing music requires precise discrimination
of sound and attentional focus, and repetitive engagement of these skills and networks are
encouraged through the emotionally rewarding nature of music playing. Additionally, singing

3
may provide near-transfer benefits to speech perception, given that most singing involves the
integration of language and music through lyrics.

Musicians demonstrate advantages in perceiving speech-in-noise across various contexts
(Hennessy et al., 2022). Cross-sectional research indicates that musicians, as compared to non-
musicians, have improved abilities to perceive sentences (Başkent & Gaudrain, 2016; Escobar et
al., 2020; Parbery-Clark et al., 2009; Slater & Kraus, 2016; J. Yoo & Bidelman, 2019; Zendel et
al., 2015), words (Escobar et al., 2020; Parbery-Clark et al., 2009; Slater & Kraus, 2016; J. Yoo
& Bidelman, 2019; Zendel et al., 2015), and syllables (Du & Zatorre, 2017) in noisy
environments. Older adult musicians show less age-related hearing decline and auditory
degradation than age-matched non-musician counterparts (Fostick, 2019; Parbery-Clark et al.,
2011, 2012; Zendel & Alain, 2012), suggesting that music training may play a role in preserving
auditory function in later decades of life. This finding is supported by a recent randomized-
control trial conducted by (Zendel et al., 2019) in which older adults placed in six months of
piano training outperformed passive controls and a video-game group on a speech-in-noise task
and showed improved neural auditory encoding as measured by event-related potentials. Specific
to choir training, Dubinsky et al., (2019) observed that older adults randomly assigned to group
singing for ten weeks performed better than a passive control group in a sentence-in-noise task,
and Hennessy et al., (2021) observed that 12 weeks of choir training as compared to passive
music listening resulted in enhanced early auditory encoding in a syllables in noise task.

Choir Training on Well-being in Older Adults

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Group music-making has been shown to positively impact individuals across the lifespan,
including increased well-being and reduced depression and anxiety (for review see Daykin et al.,
2018). Regular participation in music-making or listening can improve physical and mental well-
being, increase quality of life (Chan et al., 2012; Coulton et al., 2015; Lee et al., 2017), reduce
social isolation and poor mental health (G. D. Cohen et al., 2006), and increase social cohesion,
empowerment, and personal well-being in older adults (Creech et al., 2013).

Significant health benefits have been associated with group choir singing in particular, including
social connection and improvements in physical health, cognitive stimulation, mental health, and
enjoyment (Livesey et al., 2012; Moss et al., 2018). Group choir singing has been repeatedly
shown to have positive impacts on well-being, including a positive impact on affective measures
and the facilitation of social bonding (Bullack et al., 2018), with some studies showing a
concurrent increase of oxytocin, a hormone implicated in intimate social bonding (Kreutz, 2014).
It also fosters recovery in individuals with a history of serious and long-term mental health
problems (Clift & Morrison, 2011). Several studies suggest that women, in particular, seem to
reap the benefits of choir singing on well-being, reporting higher levels of positive emotions
(Sandgren, 2009), higher scores on physical, social, and emotional benefits (Moss et al., 2018),
and an enhanced sense of joy, social inclusion, and self-esteem when compared to men (Batt-
Rawden & Andersen, 2020). Additionally, singing in a choir leads to both short and long-term
improvements in well-being. Participation in a single choir rehearsal was associated with short-
term improvements in mood and stress reduction (Linnemann et al., 2017) and increases in
positive affect, personal growth, and vitality (Busch & Gick, 2012). Longitudinal studies show

5
lasting effects, including improvements in mood and stress reduction (Linnemann et al., 2017),
reduced loneliness, and increased interest in life (Johnson et al., 2020).

Many of the benefits to well-being observed in choir training seen across age groups hold for
older adults when explicitly studied, including the promotion of resilience and social cohesion
(Joseph & Southcott, 2018; Pérez-Aldeguer & Leganés, 2014), and reduction in negative affect
and state anxiety (Sanal & Gorsev, 2014). In a longitudinal study, older adults showed reduced
loneliness and increased interest in life after six months of choir participation (Johnson et al.,
2020). In addition, the health and well-being benefits have been shown to be effective across
different cultures, and the cost-effective nature of choir programs makes their impact especially
appealing on a larger scale (Corvo et al., 2020).

Mindfulness Training on Speech in Noise Perception and Well-being
While there is significantly less research investigating the impact of mindfulness training on
speech-in-noise perception, Kumar et al., (2013) observed that individuals who had been
practicing meditation for at least five years performed better than non-meditators on multiple
speech-in-noise tasks in both younger and older adults. Differences between groups were
hypothesized to be due to changes in attentional processes, where meditation improves attention
(Jha et al., 2007; Tang et al., 2007) which then may improve speech-in-noise abilities through
top-down processes (Getzmann et al., 2015; Price & Bidelman, 2021).

Mindfulness training has also been shown to improve well-being and psychological symptoms,
with the amount of practice time being significantly related to the observed improvements

6
(Carmody & Baer, 2008). A wide range of studies has shown the benefits of mindfulness in
improving a large range of symptoms in younger and older adults (Gu et al., 2015), including
stress (Chiesa & Serretti, 2009; Shapiro et al., 2008), chronic pain (Grossman et al., 2007),
anxiety, depression, and overall wellbeing and quality of life (Godfrin & van Heeringen, 2010;
Green & Bieling, 2012; Strauss et al., 2014).

In studies of older adults specifically, mindfulness training has been shown to lead to reduced
emotional stress, improved mood (Lenze et al., 2014; Splevins et al., 2009; Young & Baime,
2010), decreased loneliness (Creswell et al., 2012), improved positive affect (Gallegos et al.,
2013), and reduced depressive symptoms (Ernst et al., 2008; O’Connor et al., 2014).
Participation in as few as three sessions of mindfulness leads to improved life satisfaction and
reduced distress (Harnett et al., 2010), and the standard 7- or 8-week long MBSR training can
lead to improved emotion regulation (Kral et al., 2018). Improvements in coping and distress
may be maintained long-term, as found in a four-year follow-up study (Solhaug et al., 2019).

Thus, given previous research detailing the effects of mindfulness on well-being and speech in
noise, in the present study we utilized virtual mindfulness training as a similarly engaging social
activity from which to compare the effects of virtual choir training on speech-in-noise abilities
and well-being in older adults during the COVID-19 pandemic.

The COVID-19 Pandemic and Older Adults
The COVID-19 pandemic is a global public health threat, and older adults are especially
vulnerable both to the health consequences of the disease (Le Couteur et al., 2020; Verity et al.,

7
2020) and the psychological impacts of social distancing and isolation practices that were
implemented to curb viral spread (Krendl & Perry, 2021; Whitehead & Torossian, 2021). Early
research on the psychological impact of the COVID-19 pandemic suggests a range of detriments
to the well-being of older adults who experienced increased depression, loneliness (De Pue et al.,
2021; Krendl & Perry, 2021), stress (Whitehead & Torossian, 2021), and anxiety (Kobayashi et
al., 2021). Both music and mindfulness have been studied for their impact on wellness during the
COVID-19 pandemic. Studies reported individuals increasing their music listening, music-
making, and dancing to music (Cabedo-Mas et al., 2021) as well as utilizing music listening to
help cope with the stress of the pandemic and increase their well-being (Cabedo-Mas et al.,
2021; Hennessy et al., 2021; Vidas et al., 2021). Online mindfulness training during the
pandemic has been reported to decrease stress (Lim et al., 2021) as well as decrease anxiety in
concert with increased self-compassion (González-García et al., 2021).

Present Study
Previous work suggests there is potential for choir and mindfulness training to improve well-
being and auditory skills of older adults and extending this training to an online format could
prove beneficial to this vulnerable group during the COVID-19 pandemic. However, little
research has studied the impact of online choir or mindfulness training on auditory abilities or
well-being of older adults. As our global population ages and in times of increasing reliance on
virtual and online networks for communication and healthcare, more research is needed to
determine the efficacy of learning these skills in an online environment.

8
In this study, we expand upon previous work to determine the effects of short-term online choir
and mindfulness training on speech-in-noise perception and well-being in older adults during the
COVID-19 pandemic. We used a randomized-control trial design with an active comparison
group to determine if potential differences in speech-in-noise abilities and well-being are due to
specific qualities of either mindfulness or choir or simply to participating in a known
psychologically beneficial communal activity. Choir singing was chosen as the music
intervention as an extension of previous work: it is practical as a short-term intervention as it is
accessible, can be performed in a modified way online, and does not require excessive equipment
or financial resources. Mindfulness training was chosen as a comparison group as it is a group
activity with demonstrated benefits to psychological well-being and attention and demonstrates
similar accessibility and practicality as choir training, making it a reasonable activity to compare
against choral training. Most notably, one significant difference between mindfulness and choir
training is reliance of choir training on sound encoding and processing and auditory-motor
integration, an element that is not of significance in mindfulness training.

Methods
Participants
Participants between the ages of 50 to 65 were recruited from across the United States via online
platforms, including Research Match, our university’s Healthy Minds Research Volunteer
Registry, Facebook advertising, Craigslist community postings, and through our lab website.
Participants were screened for eligibility based on the following: to be included, participants
were required to be a native English speaker who did not meet the following exclusion criteria:
1) use of prescribed hearing aids or a diagnosed auditory processing disorder; 2) current

9
diagnosis of any major neurological or psychiatric disorders (individuals who reported disorders
such as anxiety or depression that were well managed and non-debilitating were included); 3)
formal music training of five or more years over their lifetime, excluding music instruction as
part of typical education curriculum; 4) mindfulness training of two or more years over their
lifetime. Exclusion criteria based on length of prior music training was different from length of
mindfulness training (5 versus 2 years) because access and engagement with informal music
training is a more ubiquitous than mindfulness, particularly for the target age group.

We used a series of studies with short-term music activities and control groups to estimate the
magnitude of expected effect sizes in adult population (Dubinsky et al., 2019; Hennessy et al.,
2021; Johnson et al., 2020; Zendel et al., 2019). Those studies evaluated adult populations,
longitudinal assessment, and the majority included an active yet non-musical comparison group.
No compatible virtual studies existed at the time of study conception, so studies used were all
conducted in person. Among those reports, the median effect size was d=0.58 for behavioral
outcomes in adults. To determine sample size needed to achieve a power of 0.80, an a priori
power analysis using the above median effect size was conducted using G*Power (Faul et al.,
2007), with alpha .05 and correlation between repeated measures of 0.5. A total sample size of
60 with two equal sized groups of n=30 would be sufficient to achieve 0.80 power.

81 participants (Female =64) completed the screening assessment, 78 (Female=61) individuals
were enrolled and randomized into one of two groups: Mindfulness (mean age= 57.5, SD = 4.4,
Female= 31) and Choir (mean age= 58.23, SD = 4.34, Female= 30). Throughout the study, 11
participants dropped out (8 Choir, 3 Mindfulness) due to personal circumstances, change in

10
schedule, or difficulty with the technology (issues with zoom, internet connectivity), leaving 67
participants who completed their classes as well as pre and post-tests (n=31 Choir, and n=36
Mindfulness). Six individuals were removed for sensitivity analyses due to insufficient
completion of the intervention which was determined as the absence or tardiness that exceeded
more than two classes or 2 hours of instruction, leaving 61 individuals (n=28 Choir, n=33
Mindfulness). Demographic characteristics of participants for each group are summarized in
Table 1.
Study design was a pre-post, randomized-controlled trial. Participants took part in two testing
sessions: the pre-test took place up to 3 weeks prior to the intervention, and the post-test took
place up to 3 weeks following the completion of the ten-week intervention period. After all
participants completed the pre-test, participants were randomized into two groups (Choir and
Mindfulness) using an automated Python script stratified by gender and age (mean=57.5). During
pre-test and post-test assessments, participants completed an online version of a suite of
behavioral assessments detailed below.

Interventions
The Choir Class
The weekly 1-hour choir class was led by a choral director, four section leaders, and an
accompanist from the university’s School of Music. The choir was structured similarly to an
amateur community choir. The weekly rehearsal included vocal and physical warm-ups, short
music theory lessons, and singing through a variety of choral repertoire in sectionals and as a
complete, four-part chorus. The repertoire included works from different periods, genres, and
countries, each providing opportunities for sharing the diverse background of the music and

11
composer. Section leaders for each voice part helped support the singers along with part-
dominant learning tracks to assist in rehearsing on their own. To aid in their singing and musical
development, participants were given homework in the form of pre-recorded videos of vocal
exercises three times a week. The videos progressed each week to include additional vocal
techniques focusing on building breath support, breath control, tone, and resonance. The
introductory music theory lessons during the weekly rehearsal were also reviewed and practiced
by participants in their weekly homework designed to take 1 hour per week. Topics included
measures, staves, note names, rhythms, rests, intervals, time signatures, key signatures, scales,
ear training, and sight-reading. The weekly exercises were formed to provide basic skills to help
understand the repertoire they were singing.

Due to the COVID-19 Pandemic, all sessions took place on zoom: warm-ups, theory lessons, and
singing through repertoire occurred in the main Zoom room with participants singing while their
channel was muted. Sectionals occurred via breakout rooms led by the section leaders, allowing
participants to ask questions as they were guided in small groups through the repertoire and
voice part. Online is not an ideal format for choir training, as there are challenges with singing in
sync with others over the zoom platform. This was mitigated by having participants sing along
with the director or section leader (who was unmuted) while remaining muted themselves, and
the “hand raise” function was utilized to keep participants from talking over one another when
they had questions.

The Mindfulness Class

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The weekly 1-hour mindfulness class was led by a Mindfulness-Based Stress Reduction (MBSR)
certified mindfulness instructor from the university’s Center for Mindful Science and InsightLA.
The mindfulness class focused on developing deeper focus and concentration, learning to be
present, recognizing and letting go of old habit patterns of thinking and reacting, practicing wise
responding to stressful life events, and cultivating compassionate self-talk. Participants were
encouraged to pay close attention to their daily life, moment by moment, through a series of
meditations to help develop self-awareness and mindful engagement with life experiences. In
weekly homework designed to take 1 hour per week, participants were invited to practice
formally by meditating and listening to an audio recording specific to the theme being practiced
each week. They were also given opportunities to practice informally by being present in their
everyday tasks and paying attention to the moment, i.e., directing attention from mind
wandering, planning, or worrying to instead pay particular attention in a mindful accepting way
to the five senses during meals, washing hands, brushing teeth, etc. Each week's hour-long
mindfulness practice sessions took place over Zoom. The instructor started each class with a
review of the previous week's home practice before the participants were randomly placed in
breakout rooms of roughly 4 participants for a short discussion about the week's prompt. They
were brought back to the main room for a full class discussion, during which all participants
were muted except those who "raised hands" to contribute or ask questions. At the end of each
class, the instructor led the class through a guided meditation.

Assessments
The assessments were broadly designed to assess auditory abilities, musical abilities, socio-
emotional wellbeing, and mindfulness.

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Measure of Musical Ability
Musical experience was measured at pre-test only utilizing a subset of questions from the self-
report Goldsmith's Music Sophistication Index v. 1.0 (Müllensiefen et al., 2014). Specifically,
only questions pertaining to the subscales of Music Training and Music Listening Hours were
obtained.
Auditory Assessments
Loudness Levels. As in-person audiometric assessment was not an option, before
beginning the hearing tasks each participant was asked to set loudness levels on their device
while wearing headphones used for all subsequent tasks. Four loudness levels were required:
"soft," "medium soft," "medium," and "medium loud." Participants were asked to set the
loudness levels between 0 and 76 dB using "+" and "-" buttons to adjust the loudness scaling of
an 880 Hz pure tone that was 400 ms in duration with 20 ms raised-cosine attack and release
ramps until each level reflected what subjectively sounded "soft," "medium soft," "medium," and
"medium loud" to their ears. These levels were used as a perceptual calibration for the
subsequent tasks with the sound stimuli presented with the same RMS value as the "Medium"
level of a pure tone for the loudness scaling. If a participant failed to properly complete and save
their personalized loudness levels, the default level was -40 dB relative to the sound card max
level.
Pure Tone Detection Thresholds. This task was modeled off a standardized AMCLASS
audiogram to collect audiometric thresholds bilaterally at octave steps from 125 Hz to 8 kHz.
AMCLASS audiogram classification system is a standardized set of rules that allows for the
categorization of the configuration, severity, and interaural asymmetry of an audiogram to best
describe and interpret different types of hearing loss (Margolis & Saly, 2007). The task required

14
participants to discern which visual stimulus was paired with a tone, with trials decreasing in
volume until a lower threshold of their hearing ability measured for 400 ms sinusoids with 20 ms
raised-cosine attack and release ramps at each of 7-octave frequencies from 110-7040 Hz was
reached. A three-alternative, three-interval forced-choice method was used. To begin the task,
participants clicked the "okay" button. Three buttons labeled "1," "2," and "3" appeared on the
screen. At the start of each trial, button "1" would flash, followed by button "2" and button "3."
One of the three button flashes was paired with a tone of a starting gain set from the "medium"
loudness level, while the other two buttons were paired with silence. The button the tone was
matched with varied with each trial. After all three buttons flashed, the participant chose which
of the three buttons was paired with the tone. If correct, the gain was reduced by a step, and if
incorrect, the gain would be increased by three times the step for the next trial. The first step was
6 dB and was decreased by 2 dB after the first correct answer was given following an
error. Participants were allowed three errors in the task. When a third error was made, the run
concluded, and the final gain value was taken as the lower threshold of tone detection. This is
repeated for each of the seven frequencies until all thresholds have been obtained.
Pitch and Rhythm Discrimination Task. This task was modeled off of a previous study
design with a goal of detecting deviations in pitch and rhythm (Habibi et al., 2016) and required
active assessment of two short musical phrases as being the "same" or "different" from each
other by pressing a button. The first five notes of the C major scale (fundamental frequencies
261, 293, 329, 349, and 392 Hz) were used to create 24 pairs of melodies divided equally into
four different conditions. In the two tonal (or "pitch") conditions, the pairs of melodies contained
five notes, were set at a steady beat of 120 bpm, and had tonal durations of 500 ms each. The
pitches varied to create a melodic phrase lasting 2500 ms with a 2000 ms break between each

15
pair. If the second melody was identical to the first, the condition was "pitch same," whereas if
the second melody had one note different in pitch from the first, the condition was "pitch
different." In the two rhythmic conditions, phrases were confined to a single pitch (varied
between the first five notes of C major between trials), with five notes whose durations varied
between 125 ms and 1500 ms to create rhythmic patterns. As in the tonal conditions, the second
phrase was either identical to the first, giving a "rhythm same" condition, or the second phrase
differed rhythmically from the first, giving a "rhythm different" condition. The "rhythm
different" condition was obtained by changing the duration values of two adjacent notes,
resulting in different rhythmic groupings while keeping the same trial length and total number of
notes (5). As an example, two eighth notes (each 500 ms) could be changed to a dotted eighth
note (750 ms) and a sixteenth note (250 ms). Three runs of 24 trials were completed. At the start
of the task, the participant was informed of the three runs and clicked an "okay" button to start
the first run. The two musical phrases were then played, and after the phrases finished, the
participant could click either the "same" or "different" button on their screen. As soon as a
selection was made, they received feedback if their answer was "correct" or "incorrect," and then
the next phrase would begin. The same 24 pairs of melodies were used in each run, randomly
rearranged for each run.
Melodic Contour Identification (MCI). This task was designed to detect participants'
ability to assess the melodic contour of a musical phrase and match it with a visual representation
of the phrase's shape. Nine melodic phrases containing five notes each were created based on
stepwise movement of pitches up and down the scale to create a melodic contour with a root note
of A2 (220 Hz). These contours were comprised of pitches stepping up (“rising”), pitches
stepping down (“falling”), pitches remaining the same (“flat”) or a combination of two of the

16
three previous constraints (“rising-flat,” “rising-falling,” “flat-rising,” “flat-falling,” “falling-
rising” and “falling-flat”). Three runs comprising 18 trials each were completed at 220 Hz, with
the first run a 1-semitone spacing condition, the second run a two-semitone spacing condition,
and the third run with a four-semitone spacing condition. To begin the task, participants were
informed of the three runs and clicked a "start" button. A set of 9 buttons appeared on their
screen, each labeled with one of the nine phrase shapes and containing a visual representation of
the "shape" of the phrase comprised of 5 rectangles (representing the notes) arranged to reflect
the changing pitches (i.e., if the phrase is "rising," the five boxes are arranged on in a diagonal
line up and to the left to reflect the increase in pitches with each note; see Figure 1). Participants
listened to the musical phrase, and clicked which button matched the shape of the phrase they
heard. As soon as a selection was made, they received feedback if their answer was "correct" or
"incorrect," and then the next phrase would begin. This was repeated for a total of three runs,
with a different semitone condition at the start of each run.

17

Speech Perception in Noise (SPIN). The SPIN task was modeled off of work by
Kalikow et al., (1977) and Bilger, (1994; Bilger et al., 1984) and was designed as a clinical
measure of everyday speech perception by comparing verbal auditory closure (top-down
processing requiring the use of semantic and syntactic clues) to the utilization of phonetic
information (bottom-up processing of acoustic signal without the use of semantic/syntactic clues;
Elliott, 1995; Kalikow et al., 1977). As our goal was to test the processing of acoustic signaling,
a subset of 25 "low predictability" sentences consisting of five to eight words (or six to eight
syllables) ending in a monosyllabic noun or “key word” were chosen from the original SPIN and
SPIN-R lists (Bilger, 1994; Kalikow et al., 1977). Low predictability sentences contain no
semantic or syntactic clues as to the nature of the final keyword. The task requires active
detection of a male voice reading a target sentence and accurately choosing the final “keyword”
in the sentence from a setlist of 25 words. The task consists of five rounds with different Signal

18
to Noise Ratio (SNR) parameters in each. The first round consisted solely of a male voice
reading each target sentence without background noise (SNR=100dB). Rounds 2-5 consisted of
the male voice reading each target sentence in two-talker background babble as described by
Leibold & Buss (2013), read by two female voices at SNRs of 0dB, -5dB, -8dB, -10dB. To begin
the task, participants clicked the "start" button, and a list of 25 buttons, each containing a word,
appeared on their screen in alphabetical order. Participants listened to a sentence, which was also
written at the bottom of the screen with the last word left blank, and then clicked on the button
containing the word they thought matched the last word of the sentence they had just heard.
Participants received feedback if their answer was "correct" or "incorrect," then the next sentence
was read. This procedure is repeated for a total of 20 sentences (randomly chosen and arranged
from the full list of 25) per run for five runs, with the SNR increasing at the start of each run.
Measures of Socio-emotional Well-being
To measure socio-emotional well-being, participants self-reported using Ryff’s Psychological
Well-Being Scale (PWB; Ryff, 1989) which measures six aspects of socio-emotional well-being:
autonomy, environmental mastery, personal growth, positive relations with others, purpose in
life, and self-acceptance.

The measurement of state and trait anxiety was completed with the State-Trait Anxiety Inventory
for Adults (STAI; Spielberger et al., 1999) with 20 questions measuring state anxiety (assessing
anxiety experienced in the moment of filling out the questionnaire) and 20 questions measuring
trait anxiety (a general assessment of anxiety symptoms over the past week) on a 4-point Likert
scale.

19
To measure resilience, or an individual’s capacity for adaptation, balance, competence,
determination, optimism, and acceptance in response to their environment, the 25-question
Likert-style Resilience Scale was used (Wagnild, 2009).

Assessment of mindfulness was measured using the Five Facet Mindfulness Questionnaire (Baer
et al., 2006), a 39-question 5-point Likert-type scale of five facets of mindfulness. In addition to
a global mindfulness score, this scale yields scores on each of the following five facets: Acting
with Awareness (attending to present moment activities and experiences), Non-judging of inner
experience (taking a non-evaluative stance toward thoughts and feelings), Non-reactivity to inner
experience (tendency to allow thoughts and feelings to come and go, without getting caught up in
or carried away by them), Describing (the capacity to labeling one’s internal experiences with
words), and Observing (noticing or attending to internal and external experiences including
sensations, cognitions, emotions).

Self-transcendence, as assessed via the Adult Self Transcendence Inventory (ASTI; Levenson et
al., 2005), refers to a decreasing reliance on social definitions of self, increasing interiority, and
greater sense of connectedness with past and future generations (Tornstam, 1994). The ASTI is
an 18-item Likert scale which measures two factors: self-transcendence and alienation,
measuring withdrawal and social isolation.

Wisdom was assessed utilizing the 39-item Three-Dimensional Wisdom Scale (Ardelt, 2003).
This questionnaire measures the wisdom construct using the following three dimensions:
cognitive (ability to understand the significance or deeper meaning of life's events), reflective

20
(ability to look at events in life from different perspectives), and affective (having positive
emotions and behaviors towards other people and life events and lacking negative behaviors and
emotions towards others and life events).

Procedure
Recruitment and enrollment protocols were approved by the university’s Institutional Review
Board. Due to the COVID-19 Pandemic, all assessments and interventions took place remotely.
Phone calls and emails were utilized for recruitment and orientation, TeamHearing.org (a web-
based platform used to remotely conduct behavioral and auditory assessments for research
studies) and Qualtrics for completion of behavioral and auditory assessments during the pre-test
and post-test, and the Zoom Video Platform for the implementation of the weekly choir and
mindfulness intervention classes. TeamHearing.org was used under the direction of R.
Goldsworthy. Following a phone or email screening for eligibility, informed consent was
obtained utilizing a secure electronic form, and participants could end their participation at any
time. Participants received monetary compensation for assessments ($20 per hour) as well as for
class attendance ($5 per class). All participants were tested individually online, with assistance
provided via phone or Zoom as needed. If participants were unfamiliar with Zoom prior to their
participation in our study, they were given a tutorial to familiarize themselves with the platform.

Due to the unique nature of the pandemic and the need to conduct research in an online
environment, several troubleshooting techniques were utilized to improve the implementation of
the research study. Research assistants were available via phone, email, and Zoom to help

21
participants who struggled with internet connectivity, utilizing the Zoom platform during class
time or navigating the TeamHearing.org website for assessments.

Statistical Analysis
All statistical analyses were performed using R statistics (R Core Team, 2021). Only participants
that included both pre- and post-test data and attended at least 8/10 classes were included in
analyses. Outliers were identified as observations 1.58 times the interquartile range beyond the
upper and lower quartile (Chambers, 1986; Mcgill et al., 1978) and were removed individually
for each task. Separate 2 x 2 ANOVAs were conducted for each outcome variable, with Time as
the within-subjects factor (pre-test, post-test) and Group as the between-subjects factor (Choir,
Mindfulness). In tasks that included multiple subscales (Mindfulness FFMQ, Transcendence,
Wisdom, STAI, Ryff's, Pitch and Rhythm), each subscale was assessed using separate ANOVA
analyses in addition to the main scale analysis. In tasks that included multiple related conditions
(SIN, Melodic Contour Identification), Condition was included as a within-subjects factor in the
respective ANOVA analysis.

Results
Means and standard deviations for each task by Group and Time are reported in Appendix A.
Measures of Musical Abilities and Habits
At pre-test, no significant differences were observed between groups on music training scores or
daily music listening hours (p’s > 0.05).
Auditory Assessments

22
Performance in the Pitch and Rhythm Discrimination task was assessed with d’, calculated by
subtracting the normalized False Alarm rate ([1- accuracy] during Same condition) from the
normalized Hit rate (accuracy during the Different condition). 5 participants were removed for
incompleteness, leaving 56 participants. A main effect of Group was observed in the Pitch
Condition, where the Choir group had higher overall d’ scores across time points than the
Mindfulness group (F(1, 54) = 5.24, p = 0.026, η
2
= 0.09). While the main effect of Time was
not significant (p=0.55), a Group by Time interaction effect was observed in the Pitch condition
(F(1, 54) = 5.12, p = 0.03, η
2
= 0.09). The subsequent post-hoc contrasts indicated that the
difference of d’ between the Choir and Mindfulness groups was significant at pre-test (p=0.02;
see Figure 2) but not post-test (p=0.73).

In the Rhythm condition (Figure 2) a Group by Time interaction effect approached significance
(F(1, 54) = 3.07, p = 0.09, η
2
= 0.05). Subsequent post-hoc contrasts indicated that similar to the
pitch condition the Choir group trended towards higher d’ scores than the Mindfulness group at
pre-test (p=0.11) but not at post-test (p=0.9). No main effects of Time (p = 0.84) or Group (p =
0.10) were observed in the Rhythm condition (see Figure 2).

23

For the Melodic Contour Identification task, 5 participants were removed for incompleteness,
leaving 56 participants. A significant Time by Interval interaction was observed (F(2, 108) = 5.6,
p = 0.005, η
2
= 0.09). Post-hoc contrasts between pre- and post-test scores were only significant
in the 4-semitone interval condition (p = 0.009; see Figure 3). Explaining the Time x Interval

24
interaction, a significant Group x Time x Interval interaction effect was also observed (F(2, 108)
= 3.13, p = 0.048, η
2
= 0.05). Post-hoc analysis indicated that this significant interaction was
driven by the Choir group performing better at post-test than pre-test in the 4-semitone interval
condition (p=0.0006) with no such improvements seen in the Mindfulness group (p=0.99).

25
For the Speech-in-Noise task, 4 participants were removed for incompleteness, and 11
participants were removed for outliers, leaving 46 participants (23 in each group). A main effect
of Time was observed, related to improved scores from pre- to post-test (F(1, 44) = 19.01, p =
0.00008, η
2
= 0.3). A main effect of SNR was also observed, (F(4, 176) = 190.2, p < 0.00001, η
2

= 0.8). where both groups showed stepwise greater accuracy in easier conditions than harder
conditions (specifically, 100dB > 0dB, -5dB, -8dB, -10dB; 0dB > -5dB, -8dB, -10dB; -5dB > -
8dB, -10dB; -8dB > -10dB). A Time by SNR condition interaction was observed (F(4, 176) =
8.28, p < 0.00001, η
2
= 0.16), wherein post-hoc analyses indicated that across groups
participants increased their accuracy from pre- to post-test in the two most difficult conditions of
the task (SNR = -10, p = 0.00001; SNR = -8, p = 0.00006), but not the other three conditions. No
other significant main or interaction effects were observed. Given that the focus of this
investigation was centered around speech-in-noise perception changes related to training, we
further assessed the effect of Time in each group separately for each SNR condition (see Figure
4). In the Choir group, there was no significant effect of Time in the 100 dB SNR (F(1, 44) =
1.49, p = 0.23, η2 = 0.03), or 0 dB SNR (F (1, 44) = 1.84, p = 0.18, η2 = 0.04) conditions.
However, a significant effect of Time was observed in the -5 dB SNR (F(1, 44) = 6.55, p = 0.01,
η2 = 0.13), -8 dB SNR (F(1, 44) = 9.39, p = 0.004, η2 = 0.18), and -10 dB SNR (F(1, 44) = 9.09,
p = 0.004, η2 = 0.17) conditions, indicating that participants in the Choir group improved their
performance from pre- to post-test in these three conditions. In the Mindfulness group,
significant improvements over time were observed only for the -10 dB SNR (F(1, 44) = 6.38, p =
0.02, η2 = 0.13) condition. There was no significant effect of Time in the other SIN conditions
for the Mindfulness group: 100 dB SNR (F(1, 44) = 1.05, p = 0.31, η2 = 0.02), 0 dB SNR (F(1,

26
44) = 0.00, p = 1.00, η2 = 0.00), -5 dB SNR (F (1, 44) = 0.24, p = 0.63, η2 = 0.005), -8 dB SNR
(F (1, 44) = 1.40, p = 0.24, η2 = 0.03) conditions.

Measures of Socio-emotional Well-being

27
Analysis of the overall Ryff Scales of Psychological Well Being scores indicated a main effect of
Time (F(1,56) = 5.57, p=0.02), indicating improvements in overall well-being across groups.
Analysis of the 6 subscales Autonomy, Self-Acceptance, Environmental Mastery, Personal
Growth, Positive Relations, and Life Purpose was as follows. Six total outliers were removed (1
in Self-Acceptance, 1 in Environmental Mastery, 1 in Positive Relations, 1 in Personal Growth,
and 2 in Life Purpose). In the Autonomy subscale, a significant main effect of Group was
observed (F(1,59) = 4.52, p = 0.04, η2 = 0.07), in favor of the Mindfulness group compared to
the Choir group, however there was no change from pre- to post-test (p=0.2) or Time x Group
interaction (p=0.6), thus this did not seem related to the intervention. For the Self-Acceptance
subscale, a main effect of Time trended towards significance (F(1, 58) = 3.80, p = 0.056, η2 =
0.06), indicating that across groups, scores trended towards increasing from pre- to post-test. No
other significant main or interaction effects were observed for the remaining Ryff’s subscales of
Environmental Mastery, Personal Growth, Positive Relations, or Life Purpose (p’s > 0.10).

For the STAI, one participant was removed as an outlier. On the Trait Anxiety component, a
main effect of Time was observed (F(1, 58) = 5.19, p = 0.03, η
2
= 0.08), as across groups there
was a significant decrease in trait anxiety from pre- to post-test, and there was no main effect of
Group or Group x Time interaction. On the State Anxiety component, a main effect of Time was
again significant (F(1, 58) = 4.18, p = 0.045, η
2
= 0.07), as was a Group x Time interaction F(1,
58) = 4.18, p = 0.045, η
2
= 0.07). Post-hoc analysis revealed that the reduction in State Anxiety
was primarily driven by the Choir who were less anxious at post-test than at pre-test (p = 0.04;
see Figure 5), with no such changes observed in the Mindfulness group (p=1.0).

28

No significant main effects were observed on the Resilience scale (ps > 0.10). One participant
was removed as an outlier. A Group x Time interaction effect approached significance (F(1, 58)
= 3.15, p = 0.08, η
2
= 0.05), where the Mindfulness group scored marginally higher than the
Choir group at pre-test only.

29

Analysis of the overall mindfulness score on the FFMQ revealed a main effect of Time (F(1, 54)
= 9.03, p = 0.004, η
2
= 0.14) but no main effect of Group or Group x Time interactions. Analysis
of the facets of mindfulness revealed specific main effects of Time in three of the five FFMQ
mindfulness facets: Acting with awareness (F(1, 59) = 8.21, p=0.006, η
2
= 0.12), Observing (F(1,
59) = 6.14, p = 0.016, η
2
= 0.09), and Describing (F(1, 59) = 8.50, p = 0.005, η
2
= 0.13). In all
three cases, these main effects of Time reflected that score were higher at post-test compared to
pre-test across groups, and no Group or Group x Time interaction effects were identified in any
of these facets. The other two FFMQ facet subscales, Non-judging and Non-reacting (5 outliers
removed) demonstrated no significant main or interaction effects (p’s > 0.10).

For the ASTI Self Transcendence scale, there was a main effect of Time observed on Self-
Transcendence scores (1 outlier removed), (F(1,58) = 9.38, p = 0.003, η
2
= 0.14), with higher
scores at post-test than at pre-test across groups, with no Group or Group x Time interaction
effects. For Alienation, a main effect of Time trended towards significance (F(1, 59) = 3.89, p =
0.058, η
2
= 0.06), where scores decreased from pre- to post-test across groups, with no Group or
Group x Time interaction effects observed.

On the 3-Dimensional Wisdom Scale, the overall Wisdom score revealed no main effects of
Time or Group and no Group x Time interactions. Two outliers were removed for the Reflective
condition and 1 was removed for the Affective condition. No significant main or interaction
effects were observed for the Cognitive or Affective subscales (p’s > 0.40), however the

30
reflective subscale did show a trend towards increased scores at post-test relative to pre-test (F(1,
57) = 2.67, p = 0.11, η
2
= 0.04), with no Group or Group x Time interaction effects (p’s>0.2).

Discussion
This study investigated the effects of participation in a short-term virtual and online-based choir
or mindfulness program on perceiving speech in noise, auditory perception and attention, and
socio-emotional well-being in a 10-week randomized control trial with adults aged 50-65.

We report the following observations: 1) Both interventions were effective in a) improving
speech-in-noise perception in the most difficult conditions (-10dB); b) decreasing trait anxiety
and reducing feelings of alienation; and c) increasing feelings of self-acceptance, mindfulness,
and self-transcendence. 2) Choir training was advantageous to mindfulness training in reducing
state anxiety and in improving performance on the 4-semitone condition of a melodic-contour
discrimination task. 3) Participation in choir training significantly improved speech-in-noise
perception in two challenging conditions of -8dB and -5dB from pre to post assessment, however
this improvement was limited to when the choir group was compared to themselves, and
differences did not reach significance when compared to the mindfulness group. Below, we will
discuss each finding in detail and in the context of existing literature.

Speech-in-noise Perception
In the speech-in-noise perception task, we observed two main findings: First, participants in both
groups improved their accuracy from pre- to post-test, particularly in the hardest condition of the
task (-10 dB SNR). Improvement in this condition was greater than that of the easier conditions

31
of the task (-5 dB, 0dB, 100 dB SNR). Secondly, participants in the Choir group, but not the
Mindfulness group, showed additional pre- to post-training improvements during the -8dB and -
5dB SNR conditions, relative to their own performance.

Findings observed in the Choir group are in line with previous work that has demonstrated that
both short-term piano as compared to video games and no training (Zendel et al., 2019) and choir
as compared to no training (Dubinsky et al., 2019) improves speech-in-noise perception in older
adults. In particular, Zendel et al., (2019) observed group differences only in the most difficult
SNR condition (0dB) of the speech-in-noise task, highlighting that training effects may be visible
only at higher levels of difficulty. Previous work observed neurophysiological, but not
behavioral, improvements in speech-in-noise perception in a cohort of older adults with
subjective hearing loss after 12-weeks of in-person choir training (Hennessy, et al., 2021), with a
lack of behavioral change attributed to limitations of task sensitivity and difficulty. Here, we
utilized a speech-in-noise task that, due to the wider range of SNR conditions, was more
sensitive and able to detect potential improvements. With increased sensitivity, we observed a
pattern of improvement inversely related to the level of difficulty; the most robust improvement
in the Choir group was observed in the -10dB SNR condition (16.73% accuracy change),
followed by the -8 (15.21% accuracy change) and -5dB (9.13% accuracy change) conditions.
The present improvements in the Choir group in the most difficult conditions are in line with
previous findings demonstrating SIN enhancements after short-term choir training in high-noise
contexts and additionally suggests that improvements may be observed in larger magnitudes with
each increased level of difficulty. This pattern may help to explain why significant improvements
are not seen at all SNR levels (0dB or 100dB SNRs). Notably, while this difference may be

32
explained by the observed ceiling effect in the 100dB SNR condition (where accuracy did not
reach below 98% in either group or time point), the 0dB SNR condition did not show a ceiling
effect. This finding illustrates that, even in a virtual setting in which opportunities for listening
among a full ensemble of voices were limited, choir training produced some degree of
enhancement in SIN abilities. In addition, given the unique setting and auditory constraints of the
virtual choir, it is notable that we see similar results as were found in a study on piano training by
Zendel et al., (2019): the presence of multiple competing voices during training may not be
necessary to result in improved speech-in-noise abilities in singers.

Training-related improvements may be due to enhancements of bottom-up processes, in which
choir training improves participants’ ability to encode auditory features such as frequency and
temporal fine structure. In vocal and choir training, participants are constantly engaged in fine
frequency adjustments of their own voice in an effort to match to the voice of others or to a
piano, which may ultimately lead to better perception and encoding of acoustic features. This is
supported by behavioral research showing that pitch discrimination improvements mediate SIN
changes over time (Dubinsky et al., 2019), and neurophysiological evidence demonstrating
improved early auditory encoding (Hennessy et al., 2021; Musacchia et al., 2008). Alternatively
or additionally top-down processes may contribute to training-related improvements specifically
in older adults, where choir training has been shown to modulate attentional networks (George &
Coch, 2011) and improves participants’ ability to compensate for declining central hearing
abilities via higher-level cognitive mechanisms (i.e.: “filling”). This mechanism is supported by
reports of auditory working memory mediations of SIN perception in musicians (Zhang et al.,
2020), and with enhancements in later attention-related auditory evoked potentials such as the

33
P300 (George & Coch, 2011). We hypothesize that bottom-up mechanisms likely contributed
more to the observed trend-level improvements in SIN perception. Given that participants in this
virtual study did not practice attending to or away from other voices in the context of a full
ensemble, attentional control mechanisms likely did not play a large role in improved SIN
perception. Instead, choir participants’ improvements may reflect improvements in auditory
encoding as a result of repetitively comparing and adjusting one’s voice to a leading voice or
piano. Future work investigating online choir participation with improved technology allowing
for multiple voices to be heard at once may provide insight into these underlying mechanisms in
this setting and the efficacy of larger-scale remote programs for speech-in-noise perception
improvement.

While the Choir group showed significant improvements from pre- to post-test in all three
negative SNR conditions (-10 dB, -8 dB, -5 dB), the Mindfulness group also showed significant
improvement in only the most difficult condition of the task (-10 dB SNR). In their investigation
of meditators’ speech-in-noise perception, Kumar et al., (2013) presented participants with only
one SNR condition (-5 dB), and thus comparing the present pattern of results is difficult.
Participants in the Mindfulness group showed a pattern of improvement that was observed in the
Choir training group, where participants showed the most improvement in the -10dB SNR
condition (~14% accuracy change), followed by the -8 (~6% accuracy change) and -5 (~2%
accuracy change) dB SNR conditions. While both training programs resulted in similar patterns
of improvement, mindfulness training did not result in the same magnitude or significance of
improvement across all negative SNRs, suggesting that short-term training in either intervention
may support speech-in-noise perception following the gradation of noise difficulty, but that choir

34
training is more effective at garnering improvement. This may reflect the fact that mindfulness
training did not involve activities geared towards improved auditory encoding. Instead, during
mindfulness training participants were encouraged to attune themselves to the auditory scene
around them at a level that is heightened in comparison to daily life. Improvements in attentional
capacities that have been observed after mindfulness training (Isbel et al., 2019; Klee et al.,
2020) may help explain the mindfulness intervention effects on speech-in-noise perception. This
may indicate that the interplay of bottom--up and top-down processes, as are involved in choir
training, may be more effective or efficient at improving speech-in-noise perception than top-
down processes alone, as are involved in mindfulness training. While improvements in
attentional processes as gained through mindfulness training may lead to some level of improved
SIN perception, they are more robust and observable at lower SNR levels when coupled with
training that additionally targets auditory encoding. Given the scarcity of work on mindfulness
training’s effect on speech-in-noise perception, more research is needed to fully explore this
effect. Future research may elucidate if additional training may produce more robust
improvements in both groups in lower-noise contexts and if rates of change differ between
training methods. This highlights the importance of using an active control group when assessing
the effects of an intervention to accurately determine the effectiveness of the program of study.

Melodic Contour Identification
Across groups, we observed increased accuracy in the least difficult condition (4-semitone) of
the melodic contour identification (MCI) task, driven primarily by the Choir group, which
showed greater improvements than the Mindfulness group. That is, Choir more than Mindfulness
participants increased their ability to identify relationships between musical pitches that were

35
four semitones apart. We interpret this as a near-transfer effect; Choir participants regularly
practiced identifying contours and vocally producing intervals as a nature of their training. This
is in line with previous research indicating that musicians, as compared to non-musicians, show
greater contour (Crew et al., 2015) and interval (Banai et al., 2012; Zarate et al., 2012)
perception, and increased neural response to deviations in predictable contours and intervals
(Fujioka et al., 2004) and that short-term melodic contour and interval training increases contour
identification (Davies & Yelland, 1977) and interval identification (Pavlik Jr et al., 2013)
respectively. This finding demonstrates that short-term virtual choral training was successful in
improving one aspect of auditory perception that is emphasized heavily in vocal training.
Improvements between or across groups were not observed in the 1- or 2-semitone conditions.
These conditions are markedly more difficult and require more fine-tuned discrimination of
relationships between pitches. It may be that, with more training or with training that included
more personalized feedback (i.e., an in-person program), performance may have improved in the
more difficult conditions, as well. Specifically, greater improvements may have been seen if
participants were able to sing with others in person or with virtual audio-sets, where they could
receive feedback on their heard and vocalized interval estimations from an instructor and other
singers.

Pitch and Rhythm Discrimination
In the pitch and rhythm discrimination task, Choir participants had overall higher scores in pitch
perception across time points. This was driven primarily by the fact that the Choir group, in both
pitch and rhythm conditions, had greater discrimination than the Mindfulness group at pre-test
and therefore had less room to improve. It may be that participants that had lower overall pitch

36
and rhythm discrimination dropped out of the study once being placed in the Choir group due to
their perceived lower inherent musical abilities. Participants were notified of their score on each
task directly after completion, and Choir participants who dropped out scored an average of 17%
below Choir participants who remained in the study in each of the pitch and rhythm task
conditions, whereas Mindfulness participants who dropped out scored an average of 1% below
Mindfulness participants who remained. Thus, this group difference likely is driven by post-
randomization attrition and thus does not reflect any true training-related difference.

Socio-Emotional Well-being
Participants across groups showed improvements in scores from pre to post-test on a number of
psychological measures: The global FFMQ mindfulness score as well as the Observe, Describe,
and Act with Awareness subscales of the FFMQ, the global well-being measure on Ryff Scales
of Psychological Well-Being as well as the self-acceptance subscale, the Self-Transcendence
subscale of the ASTI, and the Alienation subscale of the ASTI. Among the subscales of the Ryff
Psychological Scales of Well-Being, we observed that across the Mindfulness and the Choir
groups there was a strong trend-level increase in feelings of self-acceptance (p=0.056). Self-
acceptance is an important facet of both choir and mindfulness training. Singing out loud can be
vulnerable, especially for individuals that have little to no choir experience, as in this study.
Practicing a new and challenging vulnerable task, and eventually overcoming the associated
discomfort, may result in improved feelings towards oneself. Similarly, mindfulness training
specifically emphasizes self-acceptance, and mindfulness as a trait is correlated with self-
acceptance and self-esteem (Thompson & Waltz, 2008). Self-acceptance has been shown to
mediate the link between trait-level mindfulness and socioemotional wellbeing and peace of

37
mind (Xu et al., 2015, 2016) lowered depressive symptoms (Jimenez et al., 2010) and decreased
stress (Rodriguez et al., 2015). Our results here show that mindfulness training, rather than a
trait-level mindfulness measure, may also confer similar benefits to self-acceptance, which may
in-turn have positive effects on other downstream facets of well-being.

In regards to measures of anxiety on the State Trait Anxiety Inventory, we found that both
groups demonstrated decreases in trait anxiety and the choir group in particular demonstrated
decreases in state anxiety. While trait anxiety is thought to remain relatively stable (Carmel &
Bernstein, 1989; Newmark, 1972), results from previous research on short-term internet
cognitive behavioral therapy (ICBT) showed a significant reduction in trait anxiety (Hedman et
al., 2014). This finding is in line with previous work demonstrating reduction in anxiety for older
adults following Mindfulness training (Young & Baime, 2010) and Choir training (Sanal &
Gorsev, 2014). While reductions in trait anxiety were rather equal between groups, reductions in
state anxiety observed across groups was largely driven by the Choir group, where post-hoc
analysis indicated that the Choir group, but not the mindfulness group, reported a reduction in
state anxiety from pre- to post-test. One previous study found a reduction of state anxiety in
older adults after 1 hour of choir singing (Sanal & Gorsev, 2014), and our findings suggest that
regular participation in a Choir group may have lasting effects on improving state anxiety in this
population. State anxiety as a construct refers to anxiety in-the-moment, and we asked
participants to rate their state anxiety while taking the battery of behavioral assessments at the
pre- and post- intervention time points. The fact that there was a greater specifically decreased
state anxiety in the choir group concurrently with an equally decreased trait anxiety across
groups implies something unique about the anxiety response to the testing situation. Specifically,

38
the testing session was accompanied by less anxiety in the choir group whereas general anxiety
across life circumstances was generally equally improved across groups, possibly related to an
effect of choir training on dealing with the psychosocial stressor of “performance” – in this case
the performance of the battery of tests. This preferential impact of choir training on performance
anxiety is in line with previous findings (Clements-Cortés, 2014; Coulton et al., 2015). This
supports the work of two previous studies that showed anxiety reductions in older adults
participating in a choral group of sixteen (Clements-Cortés, 2014) or fourteen weeks (Coulton et
al., 2015) though neither utilized an anxiety measure that allowed for the specific measurement
of state vs. trait anxiety, respectively. Previous research on music listening has shown that music
valence and arousal influences stress and is mediated by music preference (Jiang et al., 2016). It
is possible to extend this beyond music listening to our study and music-making: perhaps the
Choir participants found the music they learned and the experience of singing pleasurable, thus
reducing their anxiety. Music has been demonstrated to induce relaxation and pleasure responses,
causing lowered activity in neuroendocrine and sympathetic nervous systems, leading to reduced
levels of anxiety, heart rate, and respiration rates (Lai et al., 2008). Additionally, learning a new
skill such as singing in public later in life is a vulnerable and anxiety-inducing experience, but
overcoming this challenge could lead to an increased sense of one’s own abilities and confidence
and reduced discomfort. Singing in smaller vocal groups such as voice-part sectionals also gives
agency and builds community. Combining music’s ability to induce relaxation and pleasure
responses with overcoming the challenges of learning a new performative skill in a socially
engaging and participatory activity, may explain the reduced levels of state anxiety specifically
seen in the Choir participants.

39
Change in Mindfulness Measures
Participants across groups showed improvements in scores from pre to post-test on the global
FFMQ mindfulness score as well as the Observe, Describe, and Act with Awareness subscales of
the FFMQ. There are mixed findings regarding the effects of mindfulness training on
mindfulness-specific measures in older adults, with some studies showing no changes after
mindfulness training (Morone et al., 2008; Mularski et al., 2009) others showing clear
improvements (Lenze et al., 2014; Shih et al., 2021) or even mixed results (increases in some
skills but decreases in others; Malinowski et al., 2017). Using an online platform for mindfulness
training for older adults has not been widely studied. The few studies on online mindfulness
training in a general population have shown mixed results, some showing increases in
mindfulness (Aikens et al., 2014), while other results are mixed, depending on the type of
training used (Mak et al., 2015), or did not measure changes in mindfulness at all (Tkatch et al.,
2017). Our results suggest that ten weeks of training for online mindfulness is long enough to
produce effects on self-reported mindfulness for older adults. Additionally, online choir training
seems to be an equally effective method for improving mindfulness skills in the older adult
population. The fact that choir training seemed to lead to improvements in self-reported
mindfulness was not expected, but given the voluminous evidence that self-reported mindfulness
is related to improvements in well-being and attentional flexibility in older adults (Kral et al.,
2018; Mallya & Fiocco, 2016; Prakash, 2021) we feel it is an understandable finding.
Specifically, we hypothesize that the impact of choir training in enhancing attentional
engagement with the sensory surround and related affective processing may help explain why
people’s self-reported observing, describing, and acting with awareness tendencies were
increased in the choir training group.

40

Absence of Additional Changes in Well-being
Aside from the overall score and the Self-Acceptance subscale, no differences between groups or
across time were observed for the other 5 subscales of the Ryff Scales of Psychological Well-
Being. Both groups showed slight increases from pre to post-test in the Autonomy subscale. The
Choir group showed a slight increase in Environmental Mastery and Positive Relations, while the
Mindfulness group showed virtually no change. The Mindfulness group showed slight increase
in Life Purpose and Personal Growth, while the Choir group showed virtually no change. We
additionally observed that the Mindfulness group showed higher scores than the Choir group in
the Autonomy subscale at both pre- and post-test, likely due to imperfect randomization. Higher
engagement in participatory activities has been shown to have a positive relationship with the
well-being of older adults (for review, see Vozikaki et al., 2017), possibly due to social
engagement’s enhancement of neuroendocrine and immune system functioning (Cohen, 2004),
or perhaps the ability for social interaction to increase adaptive coping abilities allowing for the
moderation of adversity (Musick & Wilson, 2003). The lack of difference in change between our
Choir and Mindfulness groups in these measures of well-being emphasizes the importance of
selecting active control groups in a study design to determine the specific efficacy of the
intervention in question. Previous research suggests membership in a group social activity may
be more important to improving well-being than the activity itself (Stewart & Lonsdale, 2016).
Research that compares an intervention to a passive control group runs the risk of inaccurately
attributing findings to the training specifically rather than what may be the result of participating
in any pleasant and motivating group activity. Additionally, the impact of the global COVID-19
pandemic on our well-being indices must be taken into consideration. Early research on the

41
impact of the COVID-19 pandemic shows a negative impact on the well-being of older adults,
with increased depression and loneliness (Krendl & Perry, 2021). As the case rates of COVID-19
in the United States were worsening throughout this study, this could have countered any
improvements in well-being resulting from choir or mindfulness classes.

In a recent study, participation in 6 months of choir singing led to reduced loneliness and
increased interest in life for diverse older adults (Johnson et al., 2020). However, another study
showed 12 weeks of choir intervention was not long enough to produce lasting quantitative
change in well-being long-term (Hennessy et al., 2021). Similarly, the effects of mindfulness
training on wellness in older adults are inconsistent: some studies have shown the standard eight
weeks of mindfulness training in older adults is enough to produce a wide range of well-being
improvements (Creswell et al., 2012; Young & Baime, 2010), while others suggest it is
insufficient (Malinowski et al., 2017; Mallya & Fiocco, 2016). It is possible that the length of our
choir and mindfulness interventions in addition to the virtual format may not have been sufficient
to improve other well-being measures in either group long term outside the immediate
environment of the class activity at a significant level.

It is possible that online interactions in the present study were not as meaningful as in-person
interactions: unlike during in-person group activities, online platforms make one-on-one personal
interactions much more challenging if not impossible, and communication between group
members is limited and unnatural, making personal connections less likely to occur. A recent
study on social connectedness during the COVID-19 pandemic indicated that forms of low social
presence media (email, social media, and games) have a negative relationship with perceived

42
social connectedness while higher social presence media (video and phone calls) have no such
relationship (Nguyen et al., 2021). A comparison of high social presence media to face-to-face
interaction has not been performed, making it difficult to determine how perceptions of social
connectedness differ between video and face-to-face interactions.

In addition, as this is one of the first studies exploring the efficacy of mindfulness and choir
participation over an online platform with older adults, much is still unknown about the efficacy
of learning these skills in an online environment. A qualitative paper based on interviews with
choral conductors struggling to teach choirs during the global pandemic underscores how online
technology is unable to replace in-person experiences of human connection, interaction,
collective breathing, and aesthetic experience, but instead leaves individuals isolated in discrete
units learning and singing (Martinec, 2020). Participants taking part in virtual choirs during the
pandemic indicate the lack of in-person rehearsals meant the usual boost to their well-being
associated with choir was lacking, while some even experienced a negative impact (Daffern et
al., 2021). Results from several studies on hour-long interactive online mindfulness training
show improvements in well-being after completion of training (Aikens et al., 2014; Mak et al.,
2015; Tkatch et al., 2017), yet only one focused on a population of older adults (Tkatch et al.,
2017). More research is needed on the efficacy of utilizing online platforms to implement choir
and mindfulness practice for older adults.

Limitations
Limitations of this study come from the novelty of performing auditory tasks in an at-home
environment for the participants. Given that all testing was done in participants' homes, we were

43
unable to control any background noise in participant's listening environments during the
completion of the tasks or during participation in the online classes. While we could control the
loudness levels output from the testing website, we were also not able to control the volume level
set on the participant's devices to ensure it would be consistent across tasks and at both testing
sessions. Additionally, though participants were assigned homework to complete on their own
time each week, we had no measure of at-home engagement in those assignments. Future studies
should include a means of tracking this portion of participation. Finally, we were unable to know
if all participants engaged fully in the online classes each week, as we could not directly monitor
or observe their participation levels in the ways that can be done in person. We attempted to
overcome this potential issue by asking participants to keep their video cameras on during all
class sessions. Still, it is possible that participants were not as focused or attentive during classes
as they may have been in an in-person setting. This may have been particularly relevant to the
Choir group, as participants kept their microphones muted, making it impossible to determine if
participants were singing as instructed.

Conclusion
During the COVID-19 pandemic, our reliance on virtual platforms for communicating and
socializing has grown exponentially. In this randomized-control trial, we showed that 10-weeks
of an online choir or mindfulness program produces improved speech-in-noise perception in
high-noise conditions, decreases in trait anxiety, increased feelings of self-acceptance,
mindfulness, self-transcendence, and reduced feelings of alienation. We also show that singing in
a virtual choir produces additional reductions in state anxiety, improvements in melodic contour
identification, and greater improvements in speech-in-noise perception in noisier conditions. Our

44
findings provide evidence for the feasibility of an online choir and mindfulness training program,
and preliminary evidence for associated improvements in well-being and auditory measures in
older adults across the United States during the COVID-19 pandemic. More research is needed
to explore whether these findings can be replicated in a more robust manner in a larger or longer-
term trial.

45
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Appendix A. Means and standard deviations for each task by group and time.

Pre-test
mean
(SD)
Post-test
mean
(SD)
Choir Mind Choir Mind
Mindfulness
FFMQ

Global Score 27.20
(3.48)
27.18
(2.90)
28.40
(3.52)
28.02
(3.18)
Observe 26.79
(5.53)
27.39
(4.53)
28.46
(6.43)
29.15
(5.39)
Describe 28.68
(5.30)
28.39
(6.29)
30.11
(6.03)
30.12
(6.41)
Aware 27.89
(5.93)
27.09
(4.32)
29.71
(5.92)
28.15
(5.34)
Nonjudge 30.61
(7.04)
30.70
(5.45)
31.64
(6.72)
30.15
(6.33)
Nonreact 21.56
(2.97)
22.03
(3.74)
22.12
(3.18)
22.77
(2.83)

69
Transcendence Transcendence 26.63
(4.11)
27.76
(3.67)
28.04
(3.48)
28.79
(3.36)
Alienation 12.04
(3.56)
12.39
(2.97)
11.43
(2.99)
11.52
(3.55)
Wisdom Global Score 3.75
(0.31)
3.73
(0.32)
3.76
(0.31)
3.75
(0.31)
Cognitive 3.71
(0.39)
3.68
(0.45)
3.65
(0.37)
3.68
(0.41)
Reflective 3.86
(0.45)
3.91
(0.44)
3.98
(0.41)
3.93
(0.43)
Affective 3.64
(0.37)
3.54
(0.50)
3.60
(0.44)
3.60
(0.48)
Resilience 142.04
(14.18)
147.39
(15.42)
145.26
(15.05)
146.15
(16.88)
STAI State 35.59
(10.37)
32.85
(7.03)
30.93
(7.47)
32.85
(8.74)
Trait 34.11
(10.28)
35.52
(9.62)
30.96
(9.07)
34.55
(9.60)

70

Ryff’s Global Score 32.27
(4.23)
33.22
(3.78)
32.92
(4.38)
33.22
(3.78)
Autonomy 31.39
(5.60)
34.27
(4.38)
32.21
(5.83)
34.61
(4.98)
Environmental
Mastery
30.81
(4.22)
30.61
(4.95)
31.22
(4.12)
30.42
(5.61)
Self Acceptance 31.30
(7.28)
31.88
(5.85)
32.85
(6.10)
32.36
(7.22)
Personal
Growth
35.39
(3.83)
35.81
(4.93)
35.71
(4.03)
36.78
(4.50)
Positive
Relations
31.93
(5.95)
33.81
(5.11)
32.86
(6.60)
33.91
(5.63)
Life Purpose 33.37
(4.86)
33.59
(3.98)
33.52
(5.24)
34.28
(4.71)
MCI Small (1) 80.13
(26.86)
68.89
(33.73)
78.42
(30.08)
68.33
(36.59)

71
Medium (2) 77.78
(27.71)
71.11
(35.45)

79.27
(31.45)
69.81
(36.38)
Large (4) 72.01
(30.45)
69.44
(33.04)

82.90
(25.09)
70.37
(31.77)
Pitch and
Rhythm d’
Pitch 2.82
(0.83)
2.02
(1.04)
2.48
(1.01)
2.21
(1.01)
Rhythm 2.22
(0.75)
1.64
(1.01)
1.99
(0.97)
1.80
(1.00)
SPIN -10 SNR 46.96
(20.77)
50.43
(21.42)
63.70
(16.67)
64.57
(16.16)
-8 SNR 60.00
(19.54)
65.22
(18.31)

75.22
(13.61)
71.30
(16.53)
-5 SNR 76.52
(14.65)
78.26
(14.97)

85.65
(8.83)
80.43
(15.37)
0 SNR 90.43
(13.64)
90.43
(9.28)
94.57
(5.20)
90.43
(7.37)
Silent 98.26
(4.91)
99.57
(2.09)
99.57
(1.44)
98.48
(4.63)

Abstract (if available)

Abstract Previous work suggests that both choir and mindfulness training may improve well-being and auditory skills in older adults. As our global population ages and in times of increasing reliance on virtual and online networks for communication and healthcare, for example, during the COVID-19 pandemic, more research is needed to determine the efficacy of such interventions in an online environment. This randomized control trial investigated the effects of a 10-week virtual choir or mindfulness program on speech-in-noise (SIN) perception, auditory perception and attention, and socio-emotional well-being in adults (N = 61) aged 50-65. We observed that both interventions improved SIN perception in high-noise conditions, decreased anxiety and feelings of alienation, and increased global well-being, self-acceptance, mindfulness, and self- transcendence. Choir participants, compared to their own performance, showed improvements in additional noise conditions of the SIN task relative to mindfulness participants. Choir training produced greater advantages than mindfulness training in reducing state anxiety and improving melodic interval discrimination. These findings provide evidence for the feasibility of online singing and mindfulness interventions, and preliminary evidence for associated improvements in well-being and auditory measures in older adults in the U.S during the COVID-19 pandemic.

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University of Southern California Dissertations and Theses

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Asset Metadata

Creator Herschel, Ellen (author)

Core Title Effects of online choir and mindfulness interventions on auditory perception and well-being in older adults during the COVID-19 pandemic

School College of Letters, Arts and Sciences

Degree Master of Arts

Degree Program Psychology

Degree Conferral Date 2022-08

Publication Date 05/06/2022

Defense Date 04/06/2022

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag auditory perception,choir,COVID-19,mindfulness,music training,OAI-PMH Harvest,speech-in-noise,well-being

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Habibi, Assal (committee chair), Damasio, Hanna (committee member), Kaplan, Jonas (committee member)

Creator Email ellen.herschel92@gmail.com,herschel@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC111271660

Unique identifier UC111271660

Document Type Thesis

Format application/pdf (imt)

Rights Herschel, Ellen

Type texts

Source 20220506-usctheses-batch-939 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the author, as the original true and official version of the work, but does not grant the reader permission to use the work if the desired use is covered by copyright. It is the author, as rights holder, who must provide use permission if such use is covered by copyright. The original signature page accompanying the original submission of the work to the USC Libraries is retained by the USC Libraries and a copy of it may be obtained by authorized requesters contacting the repository e-mail address given.

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA

Repository Email cisadmin@lib.usc.edu