Formative evaluation of the development of a pilot participatory music program for housing insecure veterans | BMC Public Health

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Formative evaluation of the development of a pilot participatory music program for housing insecure veterans | BMC Public Health

Design: developmental formative assessment

This nonrandomized, single-site pilot project was conducted as a formative developmental evaluation to develop and iteratively refine the intervention program for a future, larger effectiveness and implementation study [9]. Formative developmental evaluations are conducted early in the research process and focus on enhancing the success of an intervention within a specific setting or context by examining potential barriers and facilitators to adoption of an innovation [9]. Formative development evaluations seek to identify and understand potential problems and possibly overcome them before embarking on larger-scale implementation or research projects [9].

We sought participants’ perspectives on barriers and facilitators to program engagement, their experiences with the intervention sessions, and suggestions for program improvement. We also sought the perspectives of nonparticipants to improve our approach to recruitment and intervention design (eg, suggestions for what could make the program more attractive so that they would consider participating). This pilot study was not designed to identify potential effects of the intervention on outcomes (eg, community reintegration).

Theoretical conceptualization

Participatory music education is designed to provide meaningful activity that has the potential to influence a person’s motivation, identity and well-being [10]. The intervention was designed to enable veterans living at home to engage in an activity that could replace previously unhelpful habits (eg, alcohol consumption when not otherwise engaged in a meaningful endeavor). As the intervention aimed to facilitate participation in meaningful activity, the program was aligned with the framework of rehabilitation medicine, specifically the Occupational Therapy Model of Human Occupation (MOHO; Table 1) [11,12,13]. MOHO is a widely applied occupation-focused conceptual framework that describes how participation in meaningful activities within a specific environment leads to personal agency and adaptation, and also describes how personal attributes contribute to an individual’s skills, performance, and participation [10].

Table 1 Intervention Mapping and Conceptual Framework


The Richard L. Roudebush VA Homeless Domiciliary was a 50-bed residence for veterans with housing insecurity. Veterans are adults who served in any of the branches of the US military (ie, Army, Navy, Marine Corps, Air Force, Non-Defense Forces, Reserve Forces). Veterans include individuals who served in wartime (e.g. World War II, Korean Conflict, Vietnam era, etc.) and peacetime (e.g., before World War II, between the Vietnam era and the the Persian Gulf War, etc.). As of September 2020, there were 19.4 million living American veterans [15].

Veterans living in the home received interdisciplinary care that included medical, psychiatric, vocational, educational, recreational, and social services to address mental illness and substance abuse, co-occurring medical problems, and psychosocial needs. An in-home interdisciplinary team does not include an occupational therapist, but includes recreational therapists who offer both creative arts opportunities (eg, shoe and mask making, expressive arts) and recreational activities (eg, bowling). Although America’s active military and veteran communities have a long history of using music for therapeutic and recreational purposes, [16] the Domiciliary had no programming to make music. The intervention was implemented from 2018 to 2019 as an optional option for recreational rehabilitation. This study was prospectively registered at (NCT03653130) on 08/31/2018.

Participant and non-participant right

Program participants and non-participants were recruited from Domicile residents who were eligible for elective activities. Veterans were eligible for elective activities if they had resided for at least two weeks and had not committed any violations. Veterans typically resided at the Domicile for six to nine months. Veterans with visual impairments, profound hearing impairments, cognitive impairments, or other conditions that might interfere with their ability to play an instrument were excluded.

Recruitment of participants and non-participants

Project staff attend community meetings at the Home to inform veterans about the program, invite them to attend intervention sessions, and reiterate that participation is entirely voluntary; the music educator plays short songs on various instruments during these sessions. Posters for the program were placed in high-traffic areas of the House. Participants were invited for interviews during the music-making intervention sessions. Veterans who chose not to participate were invited for interviews at community meetings. The latter were recruited from veterans living in the home who were willing to participate in the study but chose not to participate in the music group.


The intervention was a participatory music program in which participants participated in making music as members of a string orchestra. Participants were given an instrument of their choice (violin, viola, or cello). One-hour lessons with a music educator experienced in music education for adults took place three times a week. Sessions include thirty minutes of group music instruction followed by thirty minutes of ensemble participation [17, 18].

The repertoire was chosen by the music teacher after consultation with the participants. Participants were given sheet music to use during their own practices and group sessions. The music educator has created instructional videos demonstrating how to play the instruments and providing suggestions for practice. Participants were encouraged to exercise during their free time.

The participatory music program focuses on the use of stringed instruments for several reasons. String instruments are suitable both in solo and in a group. Many home programs used a group format that was familiar and comfortable to potential participants. Playing a stringed instrument within an orchestra can foster a sense of responsibility, provide opportunities for social participation, and encourage the development of a new role (“I’m the cellist of the orchestra”). Stringed instruments are melodic (unlike the drum or triangle, which typically produce a single note), allowing participants to play music that is familiar, facilitating both enjoyment and skill acquisition. Also, string instruments (as opposed to keyboards) make it easier to learn and play because the music is written in one line in one key. Finally, although cellos are larger, stringed instruments can be conveniently transported, even if public transportation is used.

Implementation of a pilot project

The music educator developed and facilitated the lessons because, based on MOHO’s conceptualization, a key goal of the program was to provide participants with new skills. An occupational therapist and a music therapist were consultants to the program implementation team.


The assessment is mainly guided by the MOHO framework, [11,12,13] supplemented with selected constructs from the Consolidated Framework for Implementation Research (CFIR) [19]. Specifically, we examined CFIR constructs related to intervention and organizational context.


We assessed participants’ experiences of the program by collecting qualitative data from semi-structured interviews conducted one month after enrolment. Veterans participating in the program were asked about prior music education, barriers and facilitators to program participation, experiences with intervention sessions, perceptions of their orchestra membership, and suggestions for program improvement (see Appendix A for interview guide).


Veterans who had not participated in the program were invited for a one-time semi-structured interview that asked about barriers to participation, suggestions about whether and how the program could be modified to overcome these barriers, and experiences with music (see Appendix B for an interview guide).

Qualitative analysis

Qualitative researchers were from diverse fields including occupational therapy (SW, female interested in occupational therapy approaches to promote social justice), anthropology (NAR, male interested in veteran community reintegration), social work (JM, a woman interested in implementing innovative interventions for veterans with unmet social needs), music education (SC, a woman interested in implementing music-based interventions to improve well-being), and medicine (DMB, a woman interested in developing and evaluating interventions to improve patient outcomes). Interviews were conducted by NAR, JM, AJC and DMB; none of whom had previous relationships with the interviewees, but all of whom had experience with qualitative methods. Only the veteran and the interviewer were present during the interviews. Participant interviews took approximately 30 minutes, non-participant interviews took approximately 15–20 minutes.

Interviews were audio-recorded, transcribed and reviewed by members of the research team (all of whom had previous experience with qualitative methods) to ensure accuracy. Transcripts were imported into NVivo11 for analysis using the constant comparison technique [20]. This method includes: inductive coding, category refinement, exploration of relationships between categories, and data integration. They independently analyzed several transcripts and then met to compare coded data and develop a codebook. The team used coded samples and analytic notes to form consensus on relevant themes while recursively engaging in epistemological dialogue to accommodate multiple perspectives on emerging concepts. With a codebook established, the team then independently coded the remainder of the transcripts, after which they met for cross-checking—examining whether different researchers had coded the same data in the same way and discussing any discrepancies. Trustworthiness was supported by researcher triangulation, where different and diverse perspectives are applied to qualitative data [21]. The application of researcher triangulation is relevant to this study where an occupational therapy framework was used to develop a music making intervention. Our multidisciplinary team’s engagement in researcher triangulation allowed us to explore emerging themes from multiple perspectives to develop a robust and comprehensive understanding of each construct. The study received institutional review board (IRB) approval.

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