RESUMEN: Objetivo: comprender la percepción de los adolescentes, participantes de un coro, sobre de la utilización de la música como instrumento para promover la salud. Método: estudio descriptivo, exploratorio, de perspectiva cualitativa, realizado con ocho adolescentes, integrantes de un coro, en Chapecó-SC. La recolección de los datos se desarrolló por medio de grupo focal, en cual ser basó en un guion de cuestiones orientadoras, en el primer semestre de 2017. El análisis e interpretación de los datos se realizó por análisis de contenido. Resultados: los adolescentes conceptuaron salud como tener alimentación sana, dormir, hacer ejercicios físicos y relataron beneficios de la participación en el coro, como relajación, integración social, mejora de la timidez y disminución de la ansiedad. Consideraciones finales: la práctica de la música, por medio del coro, es una forma de promover la salud, proporcionando beneficios físicos, emocionales y sociales, resultando a la enfermería el desafío de conocer el camino de la música en la promoción de la salud de los adolescentes.

Descriptores: Adolescente; Música; Promoción de la salud.

Introduction

The expanded concept of health includes physical, mental and social well-being, in which the State has the duty to carry out actions to guarantee the promotion, protection, and restoration of health of the population in order to contribute to the maintenance of a healthy life and with quality, reducing the risk of diseases and injuries.^1-2

Health promotion is necessary in adolescence because this is a period of vulnerability, a phase in which changes occur and there is the possibility of innumerable influences depending on the social, cultural and economic environment in which the adolescent is inserted and is growing.²Adolescence is a period marked by experiences, discoveries, dreams, uncertainties, construction of identity, projects, and changes, both in the body and in the mind.³It is in this environment that methods to promote health are pursued, thus preventing adolescents from going through situations of helplessness and avoidable problems, aiming at a healthy development.²

One strategy to promote health is the use of music. Music is gradually inserted in the process of nursing care and used to provide moments of comfort, reduce tension, pain and feelings of anxiety, contribute to the communication and relationships between people, as well as enable moments of leisure and relaxation.⁴

Music is a tool that can promote health, since it acts on the physical, intellectual and emotional development of the people involved.⁵ However, whereas music is generally related to rehabilitation and therapy in literature, there is a shortage of studies addressing the effect of music in the health promotion.⁶

Besides all these benefits that music produces, Nursing performance in this context is essential, because it is a profession that works strongly with interpersonal relationships, performing actions at the primary, secondary and tertiary level sof health care. Nursing is a unique profession in the health promotion of socially vulnerable groups, as in the case of adolescents, because it cooperates with other professionals in the area, in the constant search for improvement of quality of care, and in the struggle for the consolidation of the principles of the Unified Health System (SUS) from the point of view of comprehensiveness and humanization of care.⁷

In this sense, in view of the importance of music and its positive effects on health promotion, the outreach project "Promoting the health of children and adolescents through music" was developed in early 2014 by academics and a professor of the Nursing course of the Federal University of Fronteira Sul (UFFS) in the municipality of Chapecó - Santa Catarina (SC). Through this outreach project, the choral singing Coral Encanto was created. The members were students enrolled in a state school. The choir had the purpose of promoting a healthy life in childhood and adolescence, reducing the idle time of the members, and promoting moments of mutual learning through the choral singing. Coral Encanto has approximately forty participants and it is headed by a nurse, who is the coordinator and teacher responsible for the outreach project, and counts on the important support of nursing students for organization of the logistics of the rehearsals, the choice of repertoire, playful and educational activities, transportation and presentations.

Research projects have stemmed from the outreach project mentioned, and this article is the result of one of them, which brings as research question: What is the perception of the adolescents participating in choral singing about the practice of music as instrument for health promotion?

In this perspective, this study aimed to understand the perception of adolescents participating in choral singing about the use of music as a tool to promote health.

METHOD

This is an exploratory, descriptive research with qualitative approach. The study had the participation of eight adolescents who are members of the Coral Encanto, including four females and four males aged between 12 and 15 years; of the forty singers, only fifteen were adolescents, and the others were children below 12 years of age. Of the 15 adolescents, only eight met the inclusion criteria, which were: participation in the choir for more than six months, assiduity to the rehearsals that were carried out weekly in the school, and participation in presentations of the choir in events and holidays as invited by society.

It is noteworthy that the study participants resided in the municipality of Chapecó - SC, in a context of social and economic vulnerability, in a neighborhood away from the city center, with few recreational and cultural activities to reduce idle time.

Term of Assent was given to the participants of the research and the Informed Consent Form was given to their guardians, thus formalizing the confidentiality of the information and the acceptance of participation in the research. In order to protect the identity of the participants in the study, it was decided to name them through musical notes, as follows: Do, Re, Mi, Fa, Sol, La, and Do major.

Data collection was performed in the school in the first half of 2017, on a rehearsal day of the choir, which was reserved for the Focus Group (FG). The FG has the goal of gathering detailed information on a specific topic from a selected group of participants. Such information can provide insight into perceptions, beliefs, attitudes about a given theme, product, or service.⁸FG differs from interview in the sense that the collection of data needed for the research is based on the interaction between people.⁸

The FG was developed in a classroom with the support of the researchers who organized the adolescents sitting in a circle, creating opportunities to observe the interaction between the participants and make notes about their reactions and significant speeches.

In order to encourage the discussions, a video of the adolescents singing in the choir was played, and from then on, the FG was developed with the support of a script with guiding questions. The script brought themes about the meaning of health for the adolescents, choral singing as an instrument to promote a healthy life, and the benefits experienced after joining the choir. The FC lasted approximately two hours. With the use of a recorder, the speeches were recorded, transcribed and organized for later analysis. Only one FG meeting was performed, as the participants responded satisfactorily to the questions, thus leading to sampling termination due to saturation of data, in which the information started to present a certain redundancy/repetition, and it was therefore considered not necessary to persist or to perform an additional FG meeting for data collection.

Data were organized according to the content analysis method, which is a set of communication analysis technique that aim to reach, through systematic and objective procedures for describing the content of the messages, an inference of knowledge regarding the conditions of production/reception of these messages.⁹The first stage consisted of the pre-analysis, in which an overview of the data obtained during the FG was made, a table was created, choosing documents for the constitution of the data to be submitted to the analytical procedures. In the second stage, the material was explored and the coding was organized; there were three moments: selection of excerpts and choice of units; enumeration, with choice of the counting rules; and classification, with the choice of categories.⁹ From then on, two categories emerged: music as a health promoter and benefits of choral singing in adolescence. For the better chaining of ideas, the two categories will be presented together as The Importance of music for health promotion in adolescence.

The research began only after being approved by the Research Ethics Committee of the UFFS, under Opinion number 2,050,383/2017, and Certificate of Presentation for Ethical Appreciation: 65028417.8.0000.5564, of May 08, 2017, following the precepts of Resolution nº 466/12 of the National Health Council.

RESULTS AND DISCUSSION

The importance of music for health promotion in adolescence

Over the years, the concept of health has come to be understood in a different way. As a historical milestone in this definition, the Magna Carta contains the concept of health and encompasses the social and mental dimension, from a more complete and holistic perspective, combined with complete well-being, with the idea of balance and consonance in life. Thus, health began to be defined as a complete state of physical, mental and social well-being, and not merely as the absence of diseases.¹⁰

There are major limitations in the health care of the people evidenced in the treatments offered in hospital and drug care and focusing only on diseases, without questioning and analyzing the determinants that could cause the health-disease process, or considering cultural aspects and experiences of individuals, and without the ability to understand their health as part of a process.¹¹

The fact is that each individual has his own definition of health established through his experiences, knowledge and values. In this study, some adolescents defined health as having a healthy eating, practicing physical exercises, and having adequate sleep:

having good food, taking care of what you eat. And do not eat just junk food [...]. Doing physical exercises [...].(Do)

health is to have a regular diet. And when you do not have a good diet, besides the mind, the body also weakens.

it is important to rest because we cannot just study, or work, and we need to have leisure time [...].(Sol)

to be healthy you also need to have fun moments [...].(Do major)

The conception of health of the individuals is relevant to value the elements that provide well-being, leading to the promotion or maintenance of this state of disposition.¹²The National Policy for Health Promotion was created in 2006, with the objective of promoting quality of life and reducing vulnerability and risks related to the determinants of health, which include the environment, education, leisure, culture, and access to essential goods and services.¹³

It is also important to emphasize that when health care is concomitantly focused on individuals and the community, this encourages their participation in their own care, as well as the development and improvement of healthy habits and conditions that favor individual and collective health.¹²

Thus, one of the ways to promote health is music, which is present at various moments in people's lives and is also known as a form of language to express feelings and emotions:

Music is a means of expressing oneself, of channeling anger, sadness, any emotion, and this helps to expand our mind. (Sol)

Through music you can express yourself, you don’t keep feelings just for you. (La)

Music awakens in adolescents the capacity to develop an interesting and active way of self-expression, which can help the learning in a pleasurable way, be it to the physical or psychic body, in addition to effectively contributing to the formation of identity as a citizen.¹⁴Music has the ability to directly influence the emotional state of the human being, as it is able to trigger physiological reactions whose extent will depend on the retrograde emotional content of the individual.¹⁵ In this way, musical perception invades many variables, reaching encephalic areas, influencing the whole body, explaining the emotional and physiological reactions that take place.¹⁶

Other important factors are the benefits that the music promotes, depending on the tone and rhythm, providing relaxation, agitation or concentration:

[...] when we sing the song, we feel relaxed, because we think about the music. (Mi)

if you listen to a relaxed song you feel relaxed too, if you listen to a heavy rock you instantly get agitated. (Fa)

Music can basically be differentiated into two styles: the sedative and the stimulant. The sedative style consists of slower movements, simple harmonies and slight musical variations, reproducing relaxation, reducing the heart rate, blood pressure and consequently ventilation, while the stimulating style produces an exciting effect, thus increasing the rhythm of the respiration, blood pressure and heart rate, causing a sense of alertness.^17-18

In this perspective, it is evident that music can increase attention, besides being an important means to express feelings and emotions. With music, the individuals develop possibilities to promote the improvement of their quality of life. Thus, the inclusion of music in health promotion actions is extremely pertinent, since it favors the integral development of human being.

Through music, each individual acquires an apprenticeship that the music awakens in his being, having different meanings and world views.⁶These views can be seen in the report of some study participants:

I feel good, it's good to do the choir, learn new things. (Mi)

just as the music Celebrate that is a song that means, for you, to celebrate life because, one day it will end, then, you have to lead life the way you think and enjoy. (Fa)

I like to think about the lyrics because they bring knowledge to us who sing. (Si)

The songs and their lyrics can bring deep reflections not only among adolescents, but for all people, highlighting the importance of having wisdom when choosing the musical repertoire of a choir, because music awakens feelings and memories, causing an experience in each individual.

With the participation in choral singing, the adolescents can gain a greater knowledge about the diverse musical styles, what increases the culture, mainly in Brazil, a intensely rich country in terms of musical culture:

And there are also various types of music, such as rock, it is heavier, there are some songs like jazz, and stuff like that, [...] and there are those that they use to levitate. (Fa)

Music is involved in several musical styles, pointing to the diversity of experiences and the problems of society as a way of expressing culture, being present in many ways, in different peoples and at different times.⁷

Another benefit mentioned by the adolescents regarding the participation in the choir was the improvement in their academic performance, as for example in presenting works, overcoming shyness, and communicating:

Before that, I used to be more shy, after the choir, I improved, I interact more. (Re)

like that poetry thing that they have here in the school that no one could and after the choir, they started to do it better, of being able to speak in public. (Fa)

before this, I didn’t want to presentworks at all, so I started to take classes at a music school and also at the choir, and now I feel more confident. (La)

Before this, I used to be super shy and could not present, now, after I started the choir, I can do it. (Do)

The contact with music improves learning due to the brain activities involved, making the individuals who participate in this process to become more sensitive, creative, communicative, imaginative, with active memory, concentration, self-discipline, respect for others, more sociable and more affective.²⁰ Still, in the choir, the possibility of developing friendships and meeting new people and places arises:

in the choir you know several people and places [...]. (Fa)

In a presentation, people end up singing together a song and they see friends, a bond between us starts, and new friends appear. (La)

Choral singing provides a way of interacting with various people through rehearsals and presentations in different places, establishing a bond between choristers, which awakens concern for the others in the teamwork, and is an interesting space for adolescents to build new friendships and thus broaden their social environment. The positive effect, lessening anxiety was also reported in this study:

I'm a very anxious person, but when I start singing in the choir, that's when the anxiety goes away. (Mi)

The reduction of anxiety is another benefit that participation in choral singing provides, contributing to the establishment of social skills, which are the developments of the individuals’ actions in their beings towards society.²¹ Anxiety, especially during work presentations, can be understood as the insecurity of adolescents regarding writing the response that their images arouse in others. Music can contribute to increase their self-confidence and decrease their fears and anxieties.²²

The practice of choral singing in adolescence can also develop creativity and good mood¹⁹, as highlighted by the adolescents:

when we begin to participate in the choir we realize that we start to have more creativity and have a good mood. On Mother's Day I could not do anything and when I started to be part of the choir, I always invent poetry or a song. (Fa)

Music can change the mood of individuals, according to their description in the lyrics, and creativity becomes a result.²³ Music provides benefits such as reduction of uncomfortable sensations and stimulation of positive feelings, which contributes to the awakening of good mood in the communication and integration of individuals.⁷When the song is sung, music becomes perceptible, transmitting a cognitive meaning to the signals of the neurons, aiding in the production of ideas, in the activities of learning, and in the awakening of creativity in human beings.⁶

In the moments of presentations of the choral, the adolescents also pointed out the benefit of the music not only for them but also for the listeners:

there are several songs in the choir and the people who watch us may reflect that they need to be friends with each other, that they need to have more respect, affection, emotions, expressing themselves. (Re)

I think it makes people better, especially in the case of those who see us, we make them think about the music. (Mi)

Choral singing is an instrument for social integration. It triggers the view of achoir member towards society, observing their differences as culture, the role of each person within the society in which they live.²¹Such reality was observed in the report of the adolescents:

in the choir you interact with various types of people, with the poor, the rich, the fat, the white, the black ... people there are not different, we are all together and is practically a family. (Fa)

Music offers countless benefits to those who listen, sing, play, or dance. Music provides relaxation, distraction, well-being, pleasant memories and comfort, and promotes moments of interaction and leisure, enabling the experience of collectivity through choral singing and calls attention to the importance of the other that, even with individual growth, appreciates the collectivity.²²

Some reasons to participate in choral singing may be the fact of enjoying music, having the opportunity to learn different songs, being free, and the use of uniform:

enjoying music, because I already had contact with music because of the other project of the school [...]. (La)

[...] I started to like it because I learn different styles of music and it's also a choral that is free. You get sweatshirt, a uniform. (Fa)

The main motive that leads adolescents to practice choral singing is the taste for music and its different styles, so that they can express their ideas, their feelings, their own knowledge, and self-confidence.²²There is also the issue of uniforms that the group receives and, in the case of a place lacking social and economic resources, the fact that the choir is free calls attention and arouses the interest of the adolescents, who, for the most part, do not have the financial conditions to pay for participating in a choral.

Another reason that led the adolescents to participate in the choir was the lack of activities in their daily life:

I joined because I had nothing to do, thus, as my mother did not like me to stay at home, just watching TV and on the cell phone, she told me to start making choirs. (Do)

The lack of activities leads to idle time among adolescents, facilitating their involvement with other activities and situations that imply their healthy development. Because they live in a neighborhood that is poor in many aspects, i.e. economic, social and cultural, the opportunity to participate in other leisure activities is not at the reach of the adolescents, and there is a shortage of adequate, safe places that offer sports and cultural activities free of charge, which are extremely important in adolescence.²⁴

In addition to all that has already been reported, it is worth stressing the importance of the work of health professionals, who must work in a dynamic and interactive way to hold pleasant and joyful meetings for the adolescents. This important factor was also cited by the adolescents:

And also because I like the people of the team, of the teachers [...].(La)

I keep coming to the choir, because it's really cool, there are the teachers that are really cool. (Mi)

There must be a good relationship among the acting team, because this facilitates and contributes to the exchange of knowledge, learning, future social relations, and influences the behavior of the adolescents at that shared moment.²⁵ Therefore, choral singing brings physical, emotional and social benefits. Thus, it is incumbent on nursing professionals and other health professionals to dare and open the way of music in the promotion of health among adolescents.

CONCLUSION

In this study, it was possible to know the adolescents' view of the concept of health; some understand it as having good nutrition, adequate rest and social conditions, encompassing a more comprehensive conception that opposes the simplistic idea of absence of disease. It was also possible to understand that it is necessary to promote health as a means of producing healthy living and quality of life in adolescents.

It was observed that music, specifically choral singing, used as a tool for health promotion is capable of bringing innumerable benefits, involving biological, psychological and social aspects. In the biological understanding, the adolescents pointed out that music provides relaxation or stimulation of brain activities, interfering in heart rate and communication. In the psychological expression, it was noticed that choral singing promotes the identity of the adolescents in society, the loss of shyness aiding in school performance, and control of anxiety. In the social aspect, in addition to the possibility of developing greater integration, the participation in the choral allows the adolescents to see different realities, highlighting the cultural diversity existing among people, the need for respect, the fellowship with different people, the inclusion, and the creation of bonds friendship.

Through this research it was possible to show that Nursing can go through unpracticed paths, such as using music for health promotion, through choral singing, and this implies the challenge of studying, daring to do different things, and actually getting involved with the community, in order to offer quality and creative health care to adolescents. Thus, this study brings the incentive for further research involving music and health promotion, since there are few studies that address this theme.

However, there are limitations in the use of music in the field of health, since not all professionals in the area have musical knowledge. In this perspective, as there are difficulties in using music in the practice of care, whether in primary care or in secondary and tertiary care, research in the area by health professionals is slow because they are not close to music, leading to little scientific production. As a matter of fact, a limiting factor for the present research was the scarce production of the proposed theme, focused on the use of music as a health promoter, pointing to the need for new studies.

It is suggested the encouragement of the use of music in health promotion not only for adolescents, but for the general public. Further studies on the benefits of music in the care for individuals, as well as the publication of successful experiences in the area, are encouraged. It is also suggested that health teams act in an intersectoral way, seeking the support of musicians and music therapists so that, through a joint multi professional work, they can develop actions to improve the health of the community.

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Correspondent author

Jeane Barros de Souza

E-mail: jeanebarros18@gmail.com

Address: Rua Guaporé, n.299 E, apto 805, Bairro Centro, Chapecó-SC.

CEP: 89802300

Authors contributions

1 – Jeane Barros de Souza

Conception and planning of the research Project, obtain, analize and interpret informations. Composition and critical revision.

2 – Simone dos Santos Pereira Barbosa