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. 2025 Nov 10;14:217. doi: 10.1186/s13643-025-02971-4

The effect of group singing interventions on health biomarkers in people with stigmatising conditions: a scoping review protocol

Ayoub Bouguettaya 2, Kylie Reeves 1, Phoebe Tat 1, Judy Y Tan 1,✉
PMCID: PMC12604213  PMID: 41214833

Abstract

Background

Group singing has been shown to have positive effects on health and well-being. These interventions have been shown to generally be helpful in enhancing health outcomes in people with stigmatising conditions. However, the effect of these interventions on biological markers of health is less understood. This scoping review will map the existing evidence on the effect of group singing interventions on biomarkers in people with stigmatising health conditions, such as HIV. This scoping review aims to explore the relationship between group singing interventions and biomarkers in people with stigmatising health conditions.

Methods

This review will follow the Joanna Briggs Institute methodology for scoping reviews. We will search the following databases: PubMed, CINAHL, PsycINFO, EMBASE, and Cochrane Library. We will also search grey literature sources, such as conference proceedings and dissertations. Two reviewers will independently screen titles and abstracts, and full-text articles for inclusion. Data will be extracted using a standardised form (PRISMA-SCR), and a narrative synthesis will be conducted. This review will consider studies that include adults with stigmatising health conditions who have participated in group singing interventions. Studies must also include biomarkers as outcome measures.

Discussion

Our research will provide a significant contribution by taking a more specific approach to understanding how group singing interventions affect health biomarkers in populations that have been historically excluded due to stigma. Our focus on objective outcomes of this social intervention may inform future research on the best ways to use group singing interventions, including who is most affected, what specific health benefits can be derived from group singing, and the strength of evidence of group singing in general.

Systematic review registration

This review was pre-registered on OSF at https://osf.io/qbg7x/.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13643-025-02971-4.

Keywords: Group singing, Choir, Mental health, Benefits, Physiological, Social support, Stigmatised illness, Cancer, HIV, Biomarkers

Background

Belonging to a social group, or group membership, is associated with improved health outcomes. Considering how and why people identify with their group might explain why group membership improves health, but this remains under-explored. Research using the social identity approach has found that interventions that seek to foster or reinforce group membership have dramatic positive effects on wellbeing [1]; this effect is demonstrative of a ‘social cure’. The social identity approach posits that understanding people’s actions, beliefs, and thoughts requires knowing how they categorise themselves in relation to others [2, 3]. People can think of themselves in personal identity terms (e.g. what makes them unique) or how they see themselves in social identity terms (e.g. a sense of identity they derive from their group membership), shared with other group members [2]. Health interventions are increasingly employing the social identity approach due to the clear health benefits of increasing access to and encouraging group membership.

Group singing as a ‘social cure’ intervention encourages the health benefits of group identity and membership. Group singing has a low barrier to entry (low cost, low skill requirement), easy adaptation to cultural contexts, safety, and a strong collaborative atmosphere [4–8]. Engaging in group singing can foster a sense of purpose, belonging, and personal control, thereby reducing social isolation and enabling faster social bonding compared to other creative group activities [9–17]. Group singing has physical [18] and psychological benefits [11–13, 19–21]. A wide variety of research has shown that people who participated in a group singing intervention reported greater wellbeing and reduced anxiety compared to those who did not participate [4]. For example, participating in a choir reduced feelings of loneliness and improved quality of life in older adults [5]. Group singing can improve the health and wellbeing of people, regardless of whether or not they have chronic health conditions [22]. A more recent systematic review with patients with cancer found that anxiety reduction was the most common outcome from group singing [23].

While group singing interventions likely have positive effects on psychosocial health and well-being, two important knowledge gaps remain. First, much of the research on group singing interventions exclusively focuses on people without health conditions that could constitute stigmatised social identities [4]. Having a health condition that is socially devalued (i.e. a ‘social curse’) can thwart the positive impacts of group membership, and the mechanisms by which this occurs remain underexplored [24]. For example, in the context of stigma’s impacts on well-being, it is unclear the association and strength of associations between personal control, which group singing is purported to increase, loneliness, and social isolation [24]. Second, many of these interventions measure self-reported changes—in depression or anxiety [25], reductions in specific negative behaviors (e.g. drug use [8]), or reductions in specific symptomology (e.g. hallucinations [26])—rather than physiological markers. Biomarkers of health, such as those associated with stress (oxytocin and cortisol), significantly improved as a response to group singing in a healthy population [27], suggesting that the benefits of group singing interventions are likely related to stress reduction. While these are valuable, a broader consideration of how group singing interventions affect people from a wider variety of stigmatised groups is required for understanding the manifestation and progression of disease. For example, exploring biological markers of stress reduction may provide a stronger evidence base for group singing interventions; in general, subjective reductions of stress are not always linked to physiological stress reduction [28, 29]. We aim to examine the research on group singing interventions in stigmatised groups that measure physiological markers of health, in order to understand how effective this type of group intervention can be for a stigmatised population.

Health promotion from group interventions: theory and research

There is strong theoretical evidence behind how and why group-based interventions have positive effects on people’s health [30]. When people think of themselves in terms of their social identity (saliency), they focus on similarity with others in their group and how they differ from other groups [31–34]. This shared group membership has a significant impact on the wellbeing of the individuals in the group because the health and wellbeing of a member is tied to the situation of the groups to which they belong [30, 35, 36]. Group memberships can make people healthier, theoretically, because these groups provide self-efficacy, belonging, a sense of control, and purpose [36]—if those groups are positive, people identify with that group strongly, and the circumstances of the group are also positive [37]. In addition, groups tend to be more willing to share material resources with members, directly leading to economic, psychological, and physiological benefits [36, 38].

Social identity building interventions have, on average, medium to strong effects on physical health outcomes. A Canadian study on group-based health management programs on people with past lung disease, stroke, heart disease, and stroke found that social identification with the new health management group was significantly linked with physical health outcomes [39]. A small study on older adults found that instituting new groups designed around sharing activities improved memory performance and wellbeing [40]. Furthermore, one review found joining groups for exercise is much more effective for health outcomes than exercising individually [41].

While group interventions likely improve the circumstances of individuals who join these groups, the social identity approach posits that the circumstances of the group are also important [42]. When the group is a low-status group, it is generally more difficult to get the benefits of group membership. Low-status groups cannot provide benefits that reinforce positive social identity; efficacy benefits can only come when the group has considerable power to enact its needs and goals [43]. This is why students coming from poorer, minoritised backgrounds tend to suffer both psychologically and academically in universities dominated by white students or middle/upper-class students [43, 44]; their social identity as a minority (with lower status) is constantly salient, and this identity does not provide psychological or material benefit. Therefore, it is not enough to be part of a group to get positive effects; the group must also be a good group in context [30]. Joining a group that is exclusive to a minority background, but provides a positive social identity, can therefore have significant positive effects for the members of this new group.

Group singing interventions as social cure for the effects of stigma

Group singing may confer a positive social identity, and therefore be a strong intervention target for group-based interventions for stigmatised or minoritised backgrounds. Stigmatised groups gain a positive social identity they can use, as well as a group that provides resources [45]. There is considerable review-based research (mostly pre-pandemic) showing that, in general, when people join such a group, they tend to have significant positive mental health outcomes as a result [4, 7, 46, 47], with most of the included studies focusing on stigmatised groups.

In addition, the outcome measures for these group singing interventions appear to be varied. The most common measurements tend to be psychological measures of wellbeing, including stress, anxiety, self-efficacy, and depression. For example, in a large systematic review published in 2018 on group singing outcomes, the authors suggest the most commonly measured outcomes are increased self-efficacy/confidence and stress reduction [4]. This suggests that stress reduction and self-efficacy—two key components of social identity interventions—are a likely key part of how and why these group singing interventions work. Of course, there are many conditions for these group interventions to work (e.g., people need to identify with the group, they need to join the group, and they need to participate), and minoritised groups tend to have more barriers to join new groups. To this end, two of the included studies in the review [11, 12] focused on stigmatised minorities (people with schizophrenia and experiencing homelessness), finding the effects on their self-esteem and self-efficacy were particularly strong.

Research gap, rationale, and present study

It is very likely that group interventions in general have positive effects on people’s health and psychological wellbeing. However, much of the research focuses on groups that are not explicitly stigmatised, and the outcome measures are inconsistent. It is already established that, theoretically, stigmatised groups are in greater need of social identity interventions [30] but the research outcomes appear to be highly heterogeneous [37] and mostly on subjective measures [4, 7, 22, 23, 46, 47]. While pre-pandemic research has systematically examined group singing on mental health and wellbeing [4], to our knowledge, no research has reviewed the available literature on group interventions after the pandemic (which was marked by a greater digital focus on group interventions), and none have specifically focused on physiological outcomes.

Furthermore, reviews that have previously examined the effect of group singing interventions tend to be limited to physiological measures of stress only [4]. However, stress has a bidirectional relationship with health; stress biomarkers can negatively affect other health biomarkers, but health can also negatively affect stress biomarkers. For example, biomarkers associated with diabetes (insulin) seem to affect stress biomarkers like cortisol, but this is a bidirectional relationship [48, 49]. It is possible that insulin levels will be more responsive to group singing than cortisol levels in diabetics, and previous research that focused purely on stress did not analyse this possibility. By taking an expansive approach to how biomarkers may change in response to group singing interventions, we may be able to better capture the range of research in this field.

Our main research objective was to examine the effectiveness of group singing interventions on biological markers of health, in stigmatised groups. While previous research [4] examined the effect of group singing broadly, our research is both narrower (in that we focus specifically on stigmatised groups) and broader in that we examined all physiological markers. Therefore, we elected to use a scoping review because we anticipate considerable heterogeneity in the research that examines physiological markers of health that cannot be compared effectively, with a relatively small number of studies.

Methods

Protocol and registration

The purpose for conducting scoping reviews is to identify and understand the available evidence, and understand or define key concepts in a given topic [50, 51]. A scoping review also gives an understanding of the research methods used in pursuit of a specific aim, and examines the type of papers used to explore these issues. Scoping reviews are also useful to identify where research gaps exist, and provide rapid evidence for emerging evidence [52]. Given that social identity research—especially social cure type research—has increased in popularity in the past 5 years, including in stigmatised minorities [45, 53–55], it is prudent to conduct a scoping review to understand and explore the research in relation to group singing in stigmatised groups with a physiological component.

This scoping review will be conducted in accordance with standard scoping review methods and reported following the PRISMA-SCR framework for scoping reviews [50]; the checklist is in Appendix 1, along with PRISMA-P for this scoping review protocol [56] (Appendix 2). The protocol is registered with the Open Science Framework (OSF) https://osf.io/qbg7x/.

Our study uses the following stages:

  1. Clarifying research question, objectives, theoretical framework

  2. Identifying relevant studies

  3. Selecting studies

  4. Extracting evidence

  5. Collating evidence, summarising the research, and identifying the effect of these findings on social identity interventions.

These steps will be overseen by two social psychologists with more than a decade of experience in publishing multiple reviews, as well as experience in social psychology, health psychology, health governance, and policy development.

Research question

The main objective for this scoping review is to identify, understand, categorise, collate, and interpret extant literature in understanding how group singing interventions in stigmatised groups affect physiological measures. To this end, we have the following research questions:

  1. What is the available evidence on group singing interventions in stigmatised groups and physiological measures?

  2. What methods do these studies use (experimental (between, within, or factorial), longitudinal, quasi experimental, etc.?)

  3. What research gaps exist in this research?

Eligibility criteria

To find all the relevant criteria, the research team will identify and explore several relevant databases (listed below). Research will be included if it was published after 1996 (as previous research on choir singing found the vast majority of work was published after 1997 [4]). Our criteria are as follows, following the PCC framework [57].

Inclusion criteria:

  • Population: any population that has been previously agreed that is stigmatised in a society through previous research or government designation [58]. Inclusion is based on the study's identification of the population as a stigmatised group; we will not require that the included studies measure participants’ individual perceived stigma. This includes ethnic minority groups, mental illnesses with considerable stigma attached, gender/sexual minorities, people with disabilities, or health conditions with considerable stigma (e.g. having obesity or overweight, HIV). Stigma is at least partially contextual, so we have elected to have a broad definition. Given the anticipated small and heterogeneous nature of the literature, we will analyse all stigmatised groups together. The primary focus is on the intervention's effect on physiological markers, rather than comparing effects across different types of stigma. However, if a sufficient number of studies exist for a specific population (e.g. k ≥ 3, we will consider a subgroup narrative analysis for that category.

  • Concept: the core concept is the effect of group singing on objectively measured physiological outcomes. The intervention is any group choir where other participants are visible or audible. The outcomes are any physiological health measures tested via objective means or by an expert, including heart rate, heart rate variability, blood pressure, brain wave activity, breath rate, skin galvanisation, and cortisol levels.

  • Context: a group singing setting or similar is the core context.

  • Study designs:this review will consider studies that include a comparison component. This can include a comparison between an intervention and control group, or a within-subject comparison, such as a pre- and post-intervention measurement of a physiological outcome. Randomised controlled trials, non-randomised controlled trials, pre-post studies, and quasi-experimental studies will be considered.

  • Language: English.

Studies will be excluded if they are the following:

  • Not published in English.

  • Published before 1997.

  • Outcomes are exclusively subjective or based on self-report, with no objective physiological measures included.

  • The study does not contain a comparison component (e.g. a pre-post measure or a control group).

  • Lacking a comparison co The study’s only form of comparison is to average levels in the general population.mponent (e.g. a pre-post measure or control group).

  • Reliant exclusively on subjective or self-reported outcomes.

  • The study does not include participants from a stigmatised group, or it does not report results for the relevant stigmatised subgroup separately.

Information sources

Potentially relevant English Language research, published between the 31 st of December, 1996 and the 29th of December 2024, will be searched for in both bibliographic databases and grey literature. The cutoff of 1996 was chosen to align with a previous major systematic review on this topic, which found that the vast majority of relevant research was published after 1997 [4]. The primary search strategy will use major electronic databases and will include: Web of Science, CINAHL, PubMed, PsycINFO, EMBASE, and the Cochrane Library. Our secondary search will include grey literature through searching Google Scholar, conference proceedings, and dissertations. Records identified from grey literature sources will be managed, screened, and organised using the same procedures outlined for bibliographic databases. For Google Scholar, our specific Boolean search query is expected to yield a manageable number of results due to the narrow overlap of these concepts. Therefore, we will screen all identified results rather than limiting the search to a pre-determined number of pages. Where data is missing or unclear in the included studies, we will attempt to contact the corresponding authors up to two times for clarification, one week apart.

Search strategy

The search strategy has been developed in consultation with a librarian and will be tailored to each database. The search will include a combination of keywords and controlled vocabulary terms. A draft of the search strategy is included in Appendix 3.

Study selection

We will use the Covidence online systematic review management platform to manage the review process. This software will support the uploading of search results, screening of titles and abstracts, full-text screening, resolution of conflicts between reviewers, and data extraction. Two reviewers will independently screen titles and abstracts for inclusion. Titles and abstracts will be examined first for inclusion separately by each reviewer. Then, full-text articles of potentially relevant studies will be retrieved, and the full-text screening will be conducted by two independent review authors. Any disagreements will be resolved through discussion, and if disagreement exists, with a third, senior reviewer.

Data extraction

Data will be extracted independently by two reviewers using a standardised form using Covidence. The following information will be extracted: study characteristics, participant characteristics (population), intervention features, outcome measures (including direction of effect), location, description of stigma in the target group (including types of stigma measured, if any, e.g. enacted, anticipated, internalised stigma), and key findings. This will be piloted by independently allowing each reviewer to look at three papers judged by the lead author to be relevant, with discussion between them to ensure consistency (arbitrated by a third reviewer with experience in multiple types of systematic reviews).

Data analysis and synthesis

A flow diagram will be used to explain the research review and inclusion/exclusion method (from PRISMA-ScR [50]). A narrative synthesis will be conducted to summarise the findings of the included studies. We will group findings based on population, intervention characteristics, and outcome type. We will present results in table format, including a narrative description that identifies patterns, themes, and gaps in the literature. The data for each study will be included on COVIDENCE and exported to an excel sheet. While there are objective characteristics (e.g. population, intervention type, and location), other characteristics (e.g. description of type(s) of stigma measured, if any) may require a flexible strategy to examine and synthesise. In addition, the inherent variability of measures used and variability of the measure used (e.g. heart rate variability can be measured multiple ways) mean a narrative explanation may be needed. To summarise the information found in the study, we will provide categories of who measured the outcome (self-report or assessed separately, like heart rate), method of measurement (e.g. lab-based), system affected (e.g. cardiovascular), comparison (e.g. pre–post), and reported size of difference. For interpreting the direction and strength of evidence within each study, we will report the conclusions and statistical significance as presented by the original authors. As appropriate, we will standardise reported effect sizes to Cohen’s D for comparability. However, we will not apply a uniform threshold for significance, instead summarising the findings as reported in the source material. While a formal comparative analysis between pre- and post-pandemic studies is not planned, we will comment on any discernible shifts in intervention delivery (e.g. online vs. in-person) or methodology in the narrative synthesis if sufficient data are available. No meta-bias analysis is planned due to the scoping nature of this study, although it will be commented on.

Quality of assessment and risk of bias

In line with established methodological guidance for scoping reviews, which aim to map the extent of evidence rather than assess its quality, a formal quality assessment or risk of bias analysis of the included studies will not be performed [59]. This approach is standard practice, as the goal is to identify the scope of available literature, regardless of study quality.

Discussion

Through systematically mapping the extant research on group singing on biomarkers in stigmatised groups, and identifying gaps and future directions in this space, this scoping review will provide insights to future research in designing, deploying, and assessing the impact of group singing interventions. Group singing interventions are cheap, rapidly deployable interventions that likely have clear subjective, positive impacts on people negatively affected by stigma [11, 12], but by focusing on studies that use biomarkers, this review will provide a deeper insight into how well these interventions work in a population often neglected in research and society; the American public in general underestimates the impact of social factors on health [60]. Our examination of the research methods, results, stigma, and range of research may inform policymakers, healthcare organisations, general audiences, and more, in order to build a more inclusive society. By taking a physiological measure as well, we aim to improve the link between social science and medicine.

This review has some limitations that are likely to arise. Although this review examines physiological measures, there is natural variation that exists within this measure, meaning highly robust research will likely require a large effect size. However, most studies of this nature tend to be small. There is also considerable heterogeneity amongst what it means to be stigmatised, and some stigma sources have direct effects on some of the physiological measures of health; for example, amongst people who are stigmatised for having obesity or overweight, heart rate variability is often lower [61] and therefore, the effect sizes may be smaller than in stigmatising conditions or society-driven stigma that do not affect heart rate directly (e.g. living with HIV, disabilities). Furthermore, studies tend to be low in quality, with significant potential confounds, and sometimes are conducted by teams who are in either medicine or social science, not both, with moderate to high risk of bias [4]. The analysis we intend to use will take these factors into account. The team does recognise that cross-discipline research like this tends to also get published in venues outside of academic areas, like in government documents. However, with the need for a narrow focus, and concerns for quality, came a need for restrictive criteria for this scoping review, meaning our research scope will optimise quality and range.

Supplementary Information

13643_2025_2971_MOESM1_ESM.docx (25.8KB, docx)

Supplementary Material 1: Appendix 1. PRISMA SCR checklist to be filled in, Checklist for the eventual scoping review.

13643_2025_2971_MOESM2_ESM.docx (20.7KB, docx)

Supplementary Material 2: Appendix 2. PRISMA-P 2015 Checklist, checklist identifying where facets of scoping review are addressed.

13643_2025_2971_MOESM3_ESM.docx (13.5KB, docx)

Supplementary Material 3: Appendix 3. Search strategy provides PCC search strategy.

Acknowledgements

We would like to thank Cedars-Sinai’s library services for assistance in developing the search strategy.

Authors’ contributions

AB and JT led the review’s conceptualisation and design. AB and JT made significant contributions to drafting and revision, including the OSF pre-registration. AB, JT, KR, and PT collaborated to develop the search strategy. The guarantor of the review is JT.

Funding

This work was not supported by any funder or otherwise supported by any other external organisation.

Data availability

This published article includes all data generated or analysed during this study. Future data will be made available on OSF (DOI 10.17605/OSF.IO/QBG7X), alongside the pre-registration at https://osf.io/qbg7x/, as an Excel file (.xlsx).

Declarations

Ethics approval and consent to participate

Ethical approval is not needed as this scoping review will only analyse secondary sources that are published, using public materials. No individual participants will be identified. All amendments to this protocol will be published on OSF, with explanations for the reasons, and in the final paper, any deviations from this protocol will be outlined. The results of this paper will be published in peer-reviewed journals, healthcare organisational news pages, and presented at relevant conferences for medicine and social psychology.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Footnotes

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

13643_2025_2971_MOESM1_ESM.docx (25.8KB, docx)

Supplementary Material 1: Appendix 1. PRISMA SCR checklist to be filled in, Checklist for the eventual scoping review.

13643_2025_2971_MOESM2_ESM.docx (20.7KB, docx)

Supplementary Material 2: Appendix 2. PRISMA-P 2015 Checklist, checklist identifying where facets of scoping review are addressed.

13643_2025_2971_MOESM3_ESM.docx (13.5KB, docx)

Supplementary Material 3: Appendix 3. Search strategy provides PCC search strategy.

Data Availability Statement

This published article includes all data generated or analysed during this study. Future data will be made available on OSF (DOI 10.17605/OSF.IO/QBG7X), alongside the pre-registration at https://osf.io/qbg7x/, as an Excel file (.xlsx).

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