Long-term impacts of health education on university music students: A retrospective qualitative case study

Abstract

The high prevalence of physical and mental health problems among music students is well documented. To address playing-related health risks, many tertiary institutions include health education programmes in their core curricula; however, the long-term impact of these programmes remains unexplored. This study investigated the retrospective reflections of 10 fourth-year music students regarding a health education course they completed during their first year. The study aimed to explore the course’s perceived impact in fostering learning and behaviour change. The findings reveal that the course greatly enhanced students’ awareness and knowledge of health promotion and injury prevention. Participants reported substantial positive changes in health-related and practice-related behaviours, indicating transformative learning. These findings corroborate existing literature on the benefits of health-promotion programmes for music students, underscoring the essential role such courses play in music students’ education, providing valuable evidence for the long-term efficacy of musicians’ occupational health education.

The acquisition of musical skills necessary for performance at a professional level is complex and places substantial physical and psychological demands on musicians (Kenny & Ackermann, 2015; Silva et al., 2015). Long hours of practice, repetitive movements often performed with asymmetrical postures, and continuous pressure to perform place professional musicians and music students at high risk for physical, vocal, and mental health problems (Achey et al., 2016; Araújo et al., 2017; Pestana et al., 2017; Ziegler et al., 2012). Moreover, given the extent of music-induced noise exposure, musicians are at higher risk for auditory disorders such as tinnitus, hearing loss, and hyperacusis than the general population (Crawford et al., 2023; Isaac et al., 2017; Schink et al., 2014).

Brandfonbrener (2009) reported that 79% of music students experienced playing-related disorders. Music students in higher education face particularly intense challenges, including significant psychological stress from competitive environments (Kegelaers et al., 2021; Pecen et al., 2018). The demands of rigorous practice, performance, and examinations contribute to elevated general anxiety and music performance anxiety, often leading to low self-esteem, negative perfectionism, and poor self-concept (Botha et al., 2022; Spahn et al., 2004, 2014; Zander et al., 2010). These students are prone to mental health issues such as stress, anxiety, and depression (Jääskeläinen et al., 2023; Vaag et al., 2016, 2021) and are also at risk of playing-related pain, which exacerbates mental health problems (Brandfonbrener, 2009; Guptill et al., 2000). Research shows that 68% of music students experience health-related problems during their studies (Spahn et al., 2001) and display poorer health behaviours compared to peers in other fields (Antonini Philippe et al., 2019; Araújo et al., 2017; Ginsborg et al., 2009). Music students across South Africa experience similar rates of playing-related pain, mental health, and health behaviour problems, showing that music students’ health-related problems generalise across socio-cultural contexts (Ajidahun et al., 2017; Ajidahun & Phillips, 2013; Botha et al., 2022; Cohen & Panebianco, 2022; Panebianco, 2017; Panebianco-Warrens et al., 2015).

Health education and injury prevention programmes have been officially implemented in Germany (Spahn, 2006), the United States (Chesky et al., 2006), and the UK (Clark et al., 2013; Williamon & Thompson, 2006). However, few studies have investigated the long-term impact of these courses, despite evidence suggesting that organised health education courses are positively received (Barton & Feinberg, 2008; Evans et al., 2024; Martín López & Farías Martínez, 2013; Spahn et al., 2001; Zander et al., 2010). Zander et al. (2010) reported that students experienced positive changes in physical and psychological wellbeing and improved attitudes towards health after attending a health promotion and wellbeing course. Clark and Williamon (2011) explored the impact of a mental skills training programme on music students, finding improvements in self-efficacy for performing and self-awareness. Árnason et al. (2018) highlighted that formal music education does not adequately prepare music students for the mental and physical demands of a professional music career and emphasised the potential for long-term benefits of early health education.

Matei (2019) encouraged researchers to address questions relating to when a health promotion course can be considered successful, recommending that factors such as desired outcomes, measurement methods, course evaluation adjustments, and the extent of incorporating student feedback should be considered. In 2022, Matei and Ginsborg reported on a qualitative evaluation of a health education course for undergraduate music students in the UK as part of the Music Impact Project. The study found that students viewed the course positively, valued its engagement with health issues, and reported that it inspired behavioural changes. These findings align with a recent scoping review by Evans et al. (2024), which examines a range of evidence from musicians’ health education programmes. Debate exists on whether these courses should be introduced in the first year of music studies or later, when students are more mature. Introducing the course early may better prepare students for physical or mental health challenges and encourage healthy behaviours and adaptive strategies to manage increased practice and academic demands (Araújo et al., 2017; Matei et al., 2018). Research on the long-term effects of health education courses is limited, acknowledged by Evans et al. (2024, p. 1), who emphasise the need for future implementation studies to address key challenges, including effective behaviour change and factors that enable or hinder long-term adoption of strategies.

This retrospective case study aimed to explore final-year music students’ critical reflections on a compulsory first-year health education course. Grounded in Mezirow’s (2018) Transformational Learning Theory, the study investigated students’ perceptions of the course’s impact on their learning, behavioural change, and relevance to their music studies.

Materials and methods

Background and context

The first compulsory health education course for first-year music students at a South African university was presented in 2019. The course, which consisted of weekly 50-minute lectures from July to November, was based on existing health promotion programmes and incorporated the COM-B model (Michie et al., 2011) to explain behaviour change factors.

The course content broadly focused on health, wellbeing, and injury prevention, aiming to raise awareness of musicians’ mental and physical health. Key topics included: anatomy and physiology for musicians; deliberate practice; mental imagery and mental rehearsal; music performance anxiety; performance preparation; healthy lifestyle and health habits (physical activity, nutrition, sleep); noise-induced hearing loss in musicians; and yoga. Most of the course was taught by the author, a music psychologist. Participant specialists were invited as guest lecturers to enhance the learning experience. These included an orthopaedic surgeon, an international concert pianist, a piano lecturer, an audiology professor, and a yoga instructor. The formative and summative assessment approach was designed to be constructivist and encourage learner-centred critical reflection. Assessment tasks included maintaining a health behaviour and practice diary, informal class tests, and written assignments. In the summative exam assignment, students were encouraged to integrate their lived experiences with the assessment topics. Specifically, 25% of the written assignment required a critical reflection on their personal experiences and the role of their instrument in shaping their health practices.

Design

A qualitative approach with a retrospective cross-sectional case study design was used. Grounded in social constructionism, this perspective acknowledges that students’ experiences and meaning-making are subjective and shaped through dynamic interactions over time. Mezirow’s (2018) Transformative Learning Theory served as a useful theoretical framework, suggesting that learning can expand viewpoints, change perspectives, increase awareness of and reflectivity on one’s personal assumptions, and impact behaviour and understanding (Mezirow, 2018). The core concepts of Transformative Learning Theory (TLT) – critical reflection, experiential learning, dialogue, and shifts in frames of reference – provided a robust lens for interpreting learners’ reflexive perceptions of their learning experience and whether the course influenced awareness and change over four years.

Participants

Ten fourth-year music students, originally part of the cohort of 21 first-year students in 2019, volunteered to participate in this study. Recruitment was conducted via email. The participants consisted of three males and seven females, including five vocalists, three string players, one flute player, and one pianist. At the time of data collection, all students were aged 22–23 years. The participants are labelled 1-10 and referred to as ‘P’ in the findings. The study received approval from the Research Ethics Committee of the University of Pretoria, and signed informed consent was obtained from all participants prior to the interviews.

Procedure

Data were collected through semi-structured interviews conducted by two independent researchers who had not taught the students. The interview schedule, adapted from Matei and Ginsborg (2022) for this context (see Supplemental Material), focused on students’ recollections of the health promotion course taken four years earlier. Questions explored the usefulness of the course content, its influence on behavioural changes and attitudes towards health, desired additional topics, and the appropriateness of the course timing in their first year. Interviews allowed participants to reflect and respond flexibly, either face-to-face or via recorded phone calls, lasting 25 to 50 minutes. All interviews were audio-recorded and transcribed.

Data analysis

The transcribed interviews were thematically analysed using Braun and Clarke’s (2006) six-step method, including both inductive and deductive approaches. Initial themes were inductively derived through researcher interpretation and reflexive engagement, guided by Mezirow’s TLT to identify signs of critical reflection, learning, and change. These themes were then compared against Matei and Ginsborg’s (2022) deductive framework to explore alignment and divergence. Their five themes – engagement with health, behavioural changes, barriers, suggestions for improvement, and misinformation –provided a comparative reference. An independent researcher cross-checked themes to enhance rigour. This study builds on the foundational work of Matei and Ginsborg, who were involved in the initial design of the current course, and whose research provided a novel qualitative exploration of this topic (Matei & Ginsborg, 2022). While their deductive themes served as a valuable framework, this study differs in scope and analytic approach, offering a longitudinal perspective on learning and transformation.

Findings

Four primary themes were identified through iterative engagement with the data, each with several subthemes: 1) Relevance and impact of the course as a stimulus for health awareness and engagement, 2) Behavioural changes, 3) Barriers to implementing changes, and 4) Suggestions for course improvements.

Notably, the interview process revealed that students’ recollections of the course were often non-linear. They frequently circled back to previous topics as new memories and insights emerged, capturing a rich, interconnected narrative of their learning experiences over time.

Theme 1: relevance and impact of the course as a stimulus for health awareness and engagement

The most prominent theme to emerge in this study was students’ perceptions of the relevance of the course. Students responded to questions about their recollections of the course four years prior, the topics they found most relevant, and the overall impact of the course on the rest of their studies. Two subthemes reveal students’ descriptions of topics they most valued, and the role the course played in raising awareness of health-related topics.

The first subtheme, most valued topics, highlights the topics students considered most prominent and useful. The topic Deliberate Practice was regarded as most beneficial, mentioned by nine students. In one interview, the word “practice” was mentioned 23 times. Participant 1 commented: “That deliberate practice lecture definitely stood out for me. [. . .] I think one of the better ones, one of the most impactful, . . . and for years. [. . .]”.

In addition to recognising the importance and benefits of learning effective practice strategies, several students reflected on the lack of being taught effective practice techniques before university. This gap in previous training became evident as they learned structured approaches for the first time. Participant 5 describes this shift in perspective, emphasising the impact of learning about deliberate practice:

I learned a lot. But mainly deliberate practice was something I hadn’t thought of or hadn’t been introduced to yet. So that was the most beneficial part for me. [. . . ] How I understand it now, is that it’s the opposite of mindless practice. Using as much concentration and focus as you can, and really being highly self-aware about what you’re doing, and using as many techniques, practice techniques and stuff to improve it, and then analysing if it has improved. P5

Four students expressed that they valued the topics of mental practice and mental rehearsal. They highlighted how engaging cognitively with these concepts became an important part of their learning and performance development. They learned to mentally simulate performance conditions, which significantly contributed to their growth.

One of the most important things that I remember was mental practice. I realized that it’s actually an important thing to do because before you perform, it starts with what you think about and mental practice what it does is that it helps you to sort of like simulate on what you do on stage or prior. P4

I remember mental practice was important. I realized that it’s actually an important thing to do because before you perform, it starts with what you think about, what it does is that it helps you to sort of like, simulate what you do on stage. P7

Interestingly, yoga was enthusiastically mentioned by one participant: “Oh, yes, we had yoga! I loved it so much, I think that was probably the best yoga session I’ve ever had in my life” (P3). Several statements highlighted how the experience stood out as transformative. For example, participant 6 mentioned, “I remember we did a yoga class actually once. We did weird poses and everything, but it was actually relaxing, doing something totally different to your body”. Yoga helped students develop a greater embodied awareness of the physiological aspects of stress, tension, and breathing.

I think it really helps with easing a lot of tension and stress and, and ja, just being aware of breathing, it was the most relaxed, I’ve ever felt after any session. P3

Several statements indicated that students gained a heightened awareness of their bodies through yoga. Participant 1 explicitly states of the yoga session, “the stretches help us get back into our body and help us remind ourselves that our bodies exist out of our heads”, suggesting a renewed mind–body reconnection. Participant 6 made a connection between yoga and broader wellbeing: “the yoga made me realise that you should probably work out . . . . Or do something”. The statement “Just like, getting like, new inspiration to do something else while you study, . . . be fit, or do something” (P6) suggests the student generalised the yoga learning experience to recognise the importance of physical fitness for performance and mental resilience. In essence, yoga was not just about relaxation but a trigger for lifestyle reflection.

Several student reflections highlighted practice and health-related behaviours and their impact on performance. The lecture on warming up and stretching before and after practice sessions was not just remembered but deemed impactful by three students, suggesting that it was received as meaningful and applicable. Participant 2 meaningfully linked the topics warming up, stretching, and strength exercises, and health-related behaviours such as sleep and diet, as important: “How to warm up correctly, do stretches, do strength-like exercises to strengthen muscles . . . probably the correct amount of sleep and diet and stretches, those were the ones that popped up for me.”

Topics related to health behaviours, such as sleep, were recalled as significant learning points. Participant 2’s statement reflects a shift in awareness from habitual sleep deprivation “I would sleep for four hours a night” to acknowledging the benefits of improved sleep “it is very beneficial. I feel like when I do get a good amount of sleep lately, I feel like everything just kind of comes into place, and that I can focus better, and I can perform better” (P2).

The interviews revealed students’ shifting attitudes and understanding of muscle care, injury prevention, and perceptions about pain and discomfort. Participant 10 highlights an increased awareness of the importance of stretching before and after practice and performance for injury prevention: “I remember the importance of stretching before and after practice sessions and performances and how we need to take care of our muscles to prevent injuries.” Moreover, participant 10 noted that musicians should be more vocal about injuries and not perpetuate the common mindset that pain and discomfort should be silently endured.

I think that is the part that I remember best and that stood out to me the most. I also vaguely remember that we need to be more vocal and open regarding injuries and should not keep pushing through ‘uncomfortability’ and think that is it normal. P10

The second subtheme, The course’s role in raising health awareness, highlights a consistent narrative of enhanced self-awareness and embodied consciousness among the students. The course content played a pivotal role in shaping an informed understanding of performance dynamics, physical health and wellbeing, as well as the associated risks of performance-related injuries. Participant reflections revealed a paradigm shift in how they perceive their physical and mental wellbeing in relation to musicianship, encapsulated in this statement from participant 8: “. . .we all are athletes, just like dancers, just like musicians.”

A key theme was an increased awareness of the risk of injury and the prevention of injury. Participant 1 expressed surprise at the prevalence of performance-related injury among music students, and mentioned the lack of open discussion of issues: “It was kind of shocking to find out how many people develop these performance-related injuries because it’s not spoken about very freely”. The students emphasised the value of learning about musculoskeletal health and tools for injury prevention, as expressed by participants 1 and 10: “I really enjoyed the musculoskeletal lecture, because that opened my eyes to all of these injuries and stuff.” (P1); “I am very aware of the presence and influence of my body and its impact. I definitely gained a bigger awareness of the body and what impact it has on us on musicians” (P10).

Participant 3 mentioned a heightened awareness of posture and tension management, acknowledging that stretching and self-reflection play a critical role in injury prevention.

I think my awareness of tension has improved a lot, I’m more aware of my posture, and I will really reflect on everything that’s happening. Physically,. . . it’s mainly the posture and tension in certain areas that my awareness has improved. I feel a lot more prepared now. [. . .], and just being aware that injuries can happen, but there are ways to prevent the injuries with like little stretches. P3

Participant 9 found that learning about stretching techniques and correct posture resonated deeply with them due to their personal experience with shoulder injury: “. . . the main reason it resonated with me so much is that I had shoulder injuries, so playing the viola makes it difficult sometimes” (P9).

Students made meaningful interconnections between physical and mental wellbeing. Participant 1 realised the association between anxiety and physical health by linking body awareness to relaxation and stress management.

I found out that I am a super anxious person, and the course helped with that a lot because we had to focus on our bodies. Um, so that kind of helped with my physical health. P1

Similarly, participant 10 developed a deeper understanding of how the body influences performance and that musicianship involves more than developing technique, but also holistic self-care.

I also realised that there are many factors present that does not include simply learning the music and practicing the notes. [. . .] I am very aware of the presence and influence of my body and its impact. I definitely gained a bigger awareness of the body and what impact it has on us on musicians. P10

These reflections illustrate a transformative shift in students’ understanding, awareness and knowledge of musicianship as an embodied physical and mental practice.

Theme 2: behavioural changes

Theme 2 highlights students’ reflections on behaviour changes prompted by the course. Encouragingly, all participants recognised significant changes due to the course. Two distinct subthemes emerged, focusing on health-related and practice-related behavioural changes.

The first subtheme, Health-related behavioural changes, encompasses a range of adjustments mentioned by the students, including stretching, sleep hygiene, and time management. Five students reported that they have integrated stretching and yoga into their routines, indicating a deeper awareness of the mind-body connection. Their experiences highlight an emerging understanding of health that encompasses both physical and mental wellbeing. The students emphasised an increased awareness of bodily sensations, such as tension and relaxation, and the therapeutic benefits of these practices in reducing anxiety and managing stress. Participant 2 remarked:

I take warm ups and stretches a lot more seriously than I did back then. The stretches gives me a bit more calmness because it gives me time to just take breaths and relax, feel the muscles and release tension, which helps with my anxiety. P2

Moreover, participant 2 noted that “learning about the importance of sleep [. . .] was helpful in coping with some of my stress”.

Routine and consistency emerged as important aspects of students’ new health behaviour practices, reflecting better lifestyle choices. Many students mentioned actively engaging in stretching and yoga, and including these activities in their routines. Participant 1 stated, “I really enjoyed the yoga class. I use some of the stretching exercises a lot to warm up in the mornings, especially when I have an early morning singing session”. Others emphasised routinely adopting healthier habits, for example, Participant 7 mentioned they generally “try and exercise more . . . be more fit, . . . trying to be better, I do try to stretch, and I try to exercise”. The course inspired a greater awareness of better lifestyle choices for participant 10 who acknowledged an improved approach to nutrition and managing bad habits: “I’m making a conscious decision of eating healthy, I’m aware of what I put into my body [. . .] did a lot of exercise [. . .] I paid a lot more attention to my lifestyle”.

Participant 5 described the positive impact of physical exercise in reducing overall stress, acknowledging that regular physical activity can mitigate against performance anxiety before a performance.

I found that the more exercise I do, the less stressed I am in general, which helps obviously with performance anxiety, if you’re stressed beforehand, it honestly just contributes and makes it worse. And then also a day of a performance I found that like going for a walk along with the light exercise beforehand, really helps me keep, keep calm. P5

Moreover, deep breathing was identified as an effective tool for managing anxiety, especially in high-pressure situations such as performance exams: “The one thing from that course was the importance of deep breathing, and that’s something that I now still do, especially before performance” (P5).

Three students expressed an increased awareness of their posture and tension levels, noting that this awareness is vital for both physical and performance quality. Participant 3 commented, “My awareness of tension has improved a lot, I’m more aware of my posture, and there I will reflect on just everything that’s happening”. Two students associated improved posture with better breathing, which, in turn, enhances playing technique and tone. Participant 9 reported that focusing on posture alleviated shoulder pain, and improved breathing.

I can say that I don’t struggle with shoulder pain as much as anymore, [. . .] and I also make sure that my posture is much better [. . .] and breathing properly influences sound! When I play I kind of stop breathing, and when you stop breathing you kind of start closing yourself in, which causes bad posture, so that’s kind of what I saw, so the breathing helped me. P9

The second subtheme, Practice-related behavioural change, illustrates how the course influenced students’ practice habits, emphasising the importance of physical preparation such as stretching and warming up, as well as cognitive strategies like mental practice and deliberate practice. These reflections suggest a transformative shift in how students think about practice. Several students internalised the value of warming up and stretching as essential to their practice routine. Participant 10 shared, “I immediately started to incorporate stretching before my practice sessions. I can feel the difference. . .”, which describes an acute awareness of tension and discomfort. Following this, they commented on the direct impact of stretching on physical comfort and reduced tension: “When I forgot to stretch, I can very clearly feel how tense my nerves and muscles have become”. Participant 1 not only describes a transformative shift in learning to practice more effectively, but they also rather quaintly describe their renewed mind/body awareness: “I knew how to practice after the course, and it helped remind me that I have a body, and that I’m not just a brain floating around”.

Participant 9 described the impact of warming up and stretching on sound quality, underscoring the role of physical relaxation in sound production and technical control. The participant’s positive feedback suggested that warming up not only improves movement but also produces an audible difference in tone quality. This emphasises the value of being aware of tension and its impact on tension and musical expression.

I changed my style of practice because I do warm-ups [. . .] My lecturers were telling me that my sound was a bit warmer and that my arm and fingers were a bit looser, so my overall technique was much better, by implementing these stretches and warm-ups. P9.

The transformative influence of learning about deliberate practice during the course was poignantly described by participant 5, who experienced a fundamental shift in their approach to practising:

I think it was actually the most useful course that I did in the degree even though it was only half a year. After that, I changed a lot of my practicing methods because I hadn’t heard of deliberate practice before. P5

Implementing deliberate practice principles such as structured, goal-oriented practice, reflection, and focused repetition shows the student meaningfully linking somatic awareness with deliberate planning and improved performance outcomes.

And it really, really, really impacted on how I practiced after that, um, I only started seeing improvements in my playing in second year, and that was partly because of implementing deliberate practice. [. . .] And having a practice plan, I have practice journals now, I plan what I need to practice. And then I mean, always kind of did that but something I implemented from deliberate practice was reflecting on how I practice something and if it had worked. I found that that really helps. I started was recording myself, that made a huge difference, and practicing things slower, in smaller chunks, and trying to use all my concentration. P5

Participant 5 mentioned the value of the formative assessment tasks in bridging the gap between theoretical knowledge and practical application. The assessment task reinforced key concepts and enabled a deeper connection with the material:

Also, I think one of the assignments, I chose to write on ways to reduce performance anxiety and exercise, was one of the things that I really researched into reducing anxiety, and that also made a massive difference in like, reducing my performance anxiety. [. . .] Yeah, so just it was becoming a lot more self-aware. P5

Participant 3 highlighted the role of mental practice and mental imagery in refining performance accuracy: “I definitely still do mental practice and reading through scores. I also then imagine my performance or my exam”. The student described a more structured cognitive approach, including problem identification by identifying potential problems before physical practice: “. . . and there’s, like, checklists of my practice sessions. So actually I would kind of see where the problem areas lie when I mentally practice”. This was approached by reflection and refining strategies: “. . . and then after I practice, like having an actual practice session, and then I do kind of make sure that I attend to those problematic areas” (P3).

Theme 3: barriers to effecting change

The analysis revealed three distinct barriers to implementing change: time constraints and academic pressure, the impact of COVID-19 on health behaviours, and institutional culture and perfectionism.

Participant 7 described difficulty finding time for exercise – “it’s just difficult with time in this degree” – suggesting that the academic and performance demands were prioritised above self-care, resulting in a struggle to create a balance with academic demands and physical wellbeing. Similarly, participant 5 cited a lack of time as a significant barrier to implementing health practices: “More time to implement this stuff. First year was pretty fast-paced, and so was the second year, so there wasn’t time to implement these things” (P5).

Not surprisingly, the COVID-19 pandemic effected health challenges for all the students, impacting both physical and mental health, and resilience. Participant 8 succinctly described the challenges of the pandemic: “Oh my word, COVID was just a mess, oh my soul. That was when things got really difficult”. Whereas some students managed to keep to healthy habits, others struggled with the emotional impact of isolation. Participant 6 described their mental health challenges during the pandemic: “The mental thing fluctuated because of COVID. Depression and performance anxiety for some reason came back, I don’t know why” (P6).

Beyond time and pandemic-related barriers, three students identified the institutional culture itself as a stressor, emphasising the perceived expectations of performance excellence and definition of success, which foster negative perfectionism. Participant 1 described their experience of pressure from the environment in their first year, “I feel like a lot of lecturers were expecting a lot of us, . . . kind of just ‘overwhelmed’, and not with the work, just expectations. First year was rough”.

Participant 7 felt that the pressure to excel as a performer led to maladaptive perfectionistic tendencies and created a rigid definition of success.

It seems to me that most of the department wants you to become a performer and if you’re not that then a lot of issues happen, and it stresses me out [. . .] musicians are constantly bombarded with the idea of having to be perfect and not making any mistakes, and just generally being quite pressured into a mould. P7

These barriers identified by students highlight the complex interplay between perceived personal limitations, the environment, and institutional culture in engaging with and sustaining practices conducive to wellbeing.

Theme 4 – suggestions for improvements

The participants mentioned key areas they thought would improve the course, particularly focused on mental health support, physical wellbeing, and suggestions for restructuring the curriculum. Notably, the most dominant topic was a need for mental health support. All ten participants used words associated with stress, anxiety and mental health. Students mentioned that they needed more support in managing feedback, performance anxiety, and stress. They felt that they were expected to manage these challenges alone without adequate tools or guidance.

Participant 8 described this concern:

I would call it mental conditioning . . . we don’t get taught how to handle the stress, how to handle anxiety, how to handle the negative criticism. We are just told, ‘get on with it, do better next time, don’t worry about it’. But getting feedback and knowing how to handle the feedback are two completely different things. . . So if that mental conditioning could have taken place earlier in my studies I don’t think I would have gone through the depression. P8

Participant 2 reaffirmed this opinion, suggesting that more formal support at the institutional level is needed:

I do feel like there could be better support systems. Like a counsellor of some kind, and maybe like, mental health days [. . .] maybe a course on why mental health days are important. That would be beneficial. P2.

Aside from mental health concerns, students called for physical wellbeing interventions, particularly focusing on injury prevention, stretching techniques, and implementing these principles into their training. Some students expressed frustration at the lack of guidance on preventing injury.

One participant recommended collaboration with physiotherapy:

A course that shows you how to stretch, so kind of the more active form of it, but I feel like there could be more focus [. . .]. So I think that if physiotherapy and music could kind of connect somehow, that would help a lot of instrumentalists as a whole. P9

Participant 3 recognised the value of yoga as essential to music student training “I think that yoga should be like, implemented quite a lot, it should be a weekly thing, [. . .] that would be so cool, that would be amazing.”

Encouragingly, several participants proposed expanding the course from a single semester to a full-year module, allowing deeper engagement with the topics. Some also advocated for presenting the course as a mandatory participant across all years of their study. Participant 1 ardently supported this notion: “More of the module, more for singers, start at the beginning of the first year, present a module every year. P1

Discussion

This study explored final-year music students’ perceptions of a health education course they attended in their first year, with a focus on its efficacy in fostering learning and behavioural change. Analysed through the lens of Mezirow’s Transformative Learning Theory (TLT), the findings revealed that the course substantially increased students’ awareness and knowledge of musician-specific health issues. This, in turn, encouraged proactive changes in health behaviours and practice. Meaningful learning appeared to have occurred as students critically reflected on their learning over time, revealing changes in self-understanding, reconsideration of prior assumptions, and the adoption of new perspectives, ultimately leading to behavioural transformation. The four major themes include: the relevance and impact of the course as a stimulus for awareness, and engagement topics related to health; behavioural changes; barriers to effecting change; and suggestions for improvement.

Similar to Matei and Ginsborg (2022) and Evans et al. (2024), the health education course was seen as relevant, enjoyable, and effective in raising awareness among music students about musician-specific health issues. All the participants reported significant gains in their understanding of health promotion and injury prevention. The course provided valuable insights into effective practice, challenging preconceived notions, and reinforcing the importance of effective practice strategies. Notably, some students highlighted that they learned to practice more efficiently in less time.

The health topics covered in the course were perceived as most useful. Students revealed the focus on healthy lifestyle habits – such as physical activity, nutrition, and sleep – was highly relevant, leading many to internalise and apply the knowledge in ways that resulted in sustained behavioural changes, such as stretching, better sleep hygiene, and improved fitness. This contrasts with Zander et al. (2010), who argued that preventive programmes may impact psychological but not physical health.

Students reported a substantial increase in their awareness of health and injury risks associated with musicianship, which they attributed directly to the course content. Several participants indicated that the course prompted them to adopt healthier approaches to practising, such as warming up, having a good posture, and stretching for injury prevention, as well as encouraged them to be more mindful of their physical and mental wellbeing. The proactive behaviour change in lifestyle and practice suggests the efficacy of the course in motivating students towards meaningful and sustained change.

Despite positive outcomes, participants identified several barriers to change, including time constraints, institutional culture, a lack of ongoing support, and the effects of the COVID-19 pandemic. These challenges suggest that while the course was effective, sustaining health-promoting behaviours long-term may require additional institutional support and continuous education. Given that such behaviours take time to develop (Barton & Feinberg, 2008; Zander et al., 2010), addressing these barriers is essential to maximise the course’s impact. Two students specifically mentioned the negative impact of institutional culture and perceived expectations of constant perfection, echoing research on hierarchical structures in music education (Nettl, 1995; Perkins, 2013). More research is needed to understand the competitive environment in South African music departments (Juuti & Littleton, 2010), the role of lecturers in perpetuating negative cultures, and the connections between institutional culture and student wellbeing. As advised by Papageorgi et al. (2010) and Jääskeläinen et al. (2023), tertiary music institutions should create environments that foster health and wellbeing by addressing these institutional and environmental barriers.

Participants provided several suggestions for improving the health education course. Similar to the findings of Matei and Ginsborg (2022), they emphasised the need for more sessions addressing instrument-specific needs, the need to include topics related to mental health, and integration of health education throughout the entire music curriculum. These suggestions highlight the importance of continuous engagement and reinforcement of health principles to foster long-term behavioural change. Incorporating these improvements could enhance the course’s efficacy and ensure that students are better equipped to manage their health throughout their careers.

A key strength of this study is its examination of the sustained outcomes of a health promotion course for first-year music students, assessing its perceived value throughout their BMus studies. However, the study’s reliance on retrospective self-reports may introduce recall bias, and the sample size was small – though it represented nearly half of the initial cohort. Another limitation is that the themes represent the perspectives of students who attended the course in its inaugural year. From 2020, the course was expanded to facilitate deeper engagement, particularly with mental health topics. Insights from the initial data guided subsequent improvements.

Whereas these findings are promising, they should be viewed in the context of this specific case study, which focused on the first compulsory health education course for music students in South Africa. Future research should explore the long-term benefits of similar courses across different institutions and cultural contexts. A mixed-methods approach could offer a more comprehensive understanding of the sustained impacts of health education on music students.

Conclusion

This study adds to the literature by providing evidence of the sustained impact of health education on music students in the South African tertiary context, a group often neglected in health education research. There is significant potential for South African institutions to recognise that music students’ health should be a shared responsibility among students, teachers, and the institution (Rose et al., 2021) and to advocate for policies mandating health education to address the unique occupational health risks they face. The findings suggest a need for a cultural shift towards healthy performance practices in music departments (Baadjou et al., 2019; Williamon & Thompson, 2006). The study underscores the importance of health education in music programmes and its potential for lasting positive changes in students’ health and practice behaviours. It fills a critical gap in the literature and sets the stage for further research into effective health education for developing musicians. The integration of health education should begin earlier than the tertiary level, prompting a broader discussion on foundational health education. Nonetheless, including health education in tertiary curricula is crucial, benefiting individual students and promoting a culture of health consciousness and injury prevention within the music community.

Supplemental Material

sj-pdf-1-pom-10.1177_03057356261429836 – Supplemental material for Long-term impacts of health education on university music students: A retrospective qualitative case study

Supplemental material, sj-pdf-1-pom-10.1177_03057356261429836 for Long-term impacts of health education on university music students: A retrospective qualitative case study by Clorinda Panebianco in Psychology of Music