Supportive Care in Cancer

https://doi.org/10.1007/s00520-020-05833-y

ORIGINAL ARTICLE

Pediatric brain tumor survivors’ lived experience of engaging

in a musical training program which promoted their psychological
well-being: a qualitative study
Ankie Tan Cheung 1 & William Ho Cheung Li 1 & Laurie Long Kwan Ho 1 & Wei Xia 1 & Godfrey Chi Fung Chan 2 &
Joyce Oi Kwan Chung 3

Received: 13 May 2020 / Accepted: 15 October 2020

# Springer-Verlag GmbH Germany, part of Springer Nature 2020

Abstract
Purpose Musical training has been found to promote psychological well-being and quality of life among pediatric brain tumor
survivors. Yet, the essential elements of musical training that influence its efficacy remain unknown. This study aimed to examine
the lived experience of engaging in the musical training program from the perspectives of pediatric brain tumor survivors, their
parents, and interveners.
Methods We employed a descriptive phenomenological approach. Twenty pediatric brain tumor survivors (aged 8–15 years)
who had undergone musical training in a previous trial were selected, along with their parents (13 mothers and 7 fathers) and 7
interveners, to participate in individual semi-structured interviews. Data analysis was conducted according to Colaizzi’s descrip-
tive phenomenology method.
Results Five main themes emerged from the interviews: overcoming difficulties encountered during the initial phase of the
musical training program, improved psychological and emotional well-being, facilitation of participation in musical training
program, appreciation of the benefits of joining the musical training program, and expectation of future musical training program.
The musical training program improved the psychological and emotional well-being of pediatric brain tumor survivors by
promoting positive mood, facilitating emotional management and expression, and enhancing self-confidence. In addition,
learning in a supportive environment is crucial in facilitating survivors to overcome adversity during their learning process.
Conclusion This study addressed a literature gap by exploring how a musical training program promoted psychological well-
being among pediatric brain tumor survivors. The study findings inform the importance of tailoring musical training program
based on survivors’ learning abilities and needs.

Keywords Cancer . Pediatric brain tumor survivors . Depressive symptoms . Qualitative study . Quality of life . Self-esteem

Introduction

Pediatric brain tumors are the most common type of solid

tumor in children and the second most common type of pedi-
atric cancer [1]. With advances in healthcare technology, the
overall survival rate for pediatric malignant brain tumors has
* William Ho Cheung Li
william3@hku.hk increased to over 75% [2]. However, survivors of pediatric
brain tumors often experience a wide array of side effects,
1 including physical [3–5], neurocognitive [6, 7], and psycho-
School of Nursing, The University of Hong Kong, 4/F, William M.
W. Mong Block, 21 Sassoon Road, Pokfulam, Hong Kong, Hong logical sequelae [8, 9], that adversely affect their psychologi-
Kong cal well-being and quality of life [10, 11]. According to the
2
Department of Adolescent Medicine, Queen Mary Hospital, Hong Children’s Cancer Foundation, an average of 40 children de-
Kong, Hong Kong velop brain tumors each year, which account for about 22% of
3
School of Nursing, The Hong Kong Polytechnic University, Hong all cases of pediatric cancer in Hong Kong [12]. A recent
Kong, Hong Kong study revealed that pediatric brain tumor survivors exhibited

greater number of depressive symptoms, lower level of self-
esteem, and poorer quality of life than other pediatric cancer
survivors [13]. The study showed that over 70% of Hong
Kong Chinese pediatric brain tumor survivors reported a sig-
nificant number of depressive symptoms [13]. This value is
high compared with a rate of only 19% reported by studies
conducted in Western countries [9]. One possible explanation
for the higher rates of depressive symptoms reported in Hong
Kong may be the lack of psychosocial support for this vulner-
able group as medical interventions and physiological care are
the main focus of cancer treatment in Hong Kong.
Music-based interventions have shown promising effect on
improving depressive symptoms among various populations,
including adults with psychiatric problems [14, 15], patient
with Alzheimer’s disease [16], and children with behavioral
and emotional problems [17]. Music-based intervention ap-
pears to be a potential strategy to mitigate the negative psy-
chological sequelae experienced by the pediatric brain tumor
survivors. Hence, we developed a weekly 45-min lesson on
musical training for 52 weeks and conducted a randomized
controlled trial (RCT) to evaluate its effectiveness in reducing
depressive symptoms and enhancing self-esteem among
Chinese pediatric brain tumor survivors [18]. Musical training
is the training in rhythm, melody, harmony, and timbre with
the use of any types of musical instrument in that RCT.
Compelling evidence shows that musical training could trig-
ger the modulation of emotion, cognition, behavior, and per-
ception, which in turn produces positive effects on an individ-
ual’s psychological well-being [19, 20]. Some neuroimaging
studies have suggested that engaging in musical training can
activate the emotion and reward pathway in the brain [21, 22].
In particular, the release of dopamine, a neurotransmitter the
controls reward and pleasure centers in the brain, is stimulated
during engagement in a musical activity [23, 24]. The rhythm
and melody from the music may act as stimuli to activate
motor, auditory, tactile, and sensory pathways, and the com-
bined effects of the stimulation of these pathways may then
lead to the arousal of positive emotions [25].
The results of the trial showed that the musical training
program was effective in reducing depressive symptoms and
enhancing self-esteem and quality of life in Chinese pediatric
brain tumor survivors [18]. Nevertheless, the trial did not ex-
plore the essential elements of the musical training program
that make it effective in promoting psychological well-being
in pediatric brain tumor survivors. In addition, how the chil-
dren and their parents perceived the musical training program
is unclear. A previous study showed that Hong Kong Chinese
children with cancer used more emotion-focused coping strat-
egies, and that they preferred to spend their leisure time at
home watching television or playing electronic games rather
than engaging in extracurricular activities [26]. Fatigue, poor
concentration, and limited functional capacity are common
symptoms reported by pediatric cancer survivors that might
Support Care Cancer
hinder their continuous participation in extracurricular activi-
ties [18, 27, 28]. In addition, previous studies have indicated
that Hong Kong Chinese parents generally regard musical
training as a luxury and an optional extracurricular activity
that does not have therapeutic benefits with respect to their
children’s well-being [29, 30]. Furthermore, a group of par-
ents whose children had survived cancer preferred that their
children spent time resting as opposed to participating in ex-
tracurricular activities [31]. Therefore, whether parents of pe-
diatric brain tumor survivors would support their children to
engage in continuous musical training is uncertain.
Understanding the perceptions of parents is paramount in fa-
cilitating the continuity and sustainability of an effective mu-
sical training program that can promote the psychological
well-being and quality of life in pediatric brain tumor survi-
vors. This study aimed to explore the pediatric brain tumor
survivors’ lived experience of engaging in the musical training
program from the perspectives of the children, parents, and
interveners. Specifically, we obtained their views and experi-
ences in terms of the training process and effects of the musi-
cal training program.
Methods
Study design and participants
This qualitative study employed a descriptive phenomenolog-
ical approach, which focused on producing a comprehensive
description of a phenomenon in relation to lived experience
[32, 33]. The sample of this study was selected based on the
pediatric brain tumor survivors’ participation in a musical
training program from a previous RCT [14]. To capture a wide
range of experiences of engaging in the musical training pro-
gram, we selected pediatric brain tumor survivors with varied
demographic background (i.e., gender, age) and psychological
outcomes (i.e., depressive symptoms) in the previous RCT,
along with their parents and corresponding interveners, to at-
tend individual semi-structured interviews.
The musical training program
The details of the musical training program and the main re-
sults have been published elsewhere [18]. Pediatric brain tu-
mor survivors in the experimental group (n = 30) received a
weekly 45-min musical training session for 52 weeks. The
musical training was delivered by the Music Children
Foundation, which is a non-governmental organization
established by a group of local professional musicians, with
a mission to provide high-quality comprehensive musical
training at no cost to children from underprivileged families
and children with chronic diseases. One-to-one musical train-
ing was implemented by professional music educators at the
Support Care Cancer
participants’ homes for the sake of facilitating favorable learn-
ing environments. The participants were assigned a musical
instrument to learn, based on their interests and their capabil-
ities (i.e., fine motor skills), as assessed by the training musi-
cian. Musical instruments used in the study included piano,
keyboard, violin, guitar, ukulele, and percussion instruments.
Semi-structured interviews
Each interview lasted from 20 to 30 min and was audio-re-
corded. Children, parents, and interveners were interviewed
separately in a private counseling room at the University. An
interview guide was developed by a research committee,
which comprised the head of a pediatric oncology unity, an
oncology nurse specialist, an associate professor, an assistant
professor, and a research student. All had extensive experi-
ence in conducting research to promote the psychological
well-being of pediatric cancer survivors. All participants were
interviewed based on the interview guide, which focused on
four areas: (1) the experience of participating in the musical
training program, (2) perceived changes in the children fol-
lowing the program, (3) overall feelings and concerns about
the program, and (4) suggestions for improvements to the
program. A probing technique was used throughout the inter-
view process to elicit detailed responses from the participants.
In this technique, the interviewer repeated questions when
appropriate and asked probing questions, such as “Why do
you feel like this?” or “Could you give me some examples?”
All interviews for the children, parents, and interveners were
performed by the same researchers: one who acted as the
interviewer and one who acted as an observer. The interviewer
was open to both positive and negative views and feedback
from the participants.
Data analysis
All interviews were audio-recorded and transcribed verbatim.
Colaizzi’s descriptive phenomenology method was employed
to explore and develop the essential structure of the phenom-
enon under investigation [33]. First, the transcript was read
repeatedly to gain a general sense of the data. Next, significant
statements related to the musical training program or psycho-
logical well-being were identified and extracted from the tran-
scripts. The researchers then formulated meanings from the
significant statements. The formulated meanings were clus-
tered into different themes based on similarities in meaning.
After integrating all of the findings, an exhaustive description
was formed. The exhaustive description was then condensed
to short and dense statements that capture all the aspects found
to be essential to the structure of the phenomenon. These
statements were returned to all the participants to ensure that
the findings accurately captured their lived experience. To
enhance the quality and rigor of the study in terms of
credibility, dependability, confirmability, and transferability,
we used several strategies. First, to ensure credibility, member
checking was adopted [34]. Transcribed interviews were pre-
sented to the participants for review, to verify the accuracy of
the interpretations [33]. Second, peer debriefing was applied,
in which two researchers performed the data analysis indepen-
dently [33]. Comparisons of the coding and thematic structure
syntheses were made after the data interpretation to identify
any disagreements and ambiguities, which were then resolved
in regular research meetings. Third, an external expert who
was a pediatric oncologist was invited to read all the data and
findings and confirm that the statement of findings was ac-
ceptable. We also included a comprehensive description of the
study procedures to strengthen the dependability of the results
and allow repetition of the study by other researchers [33].
With respect to confirmability, all researchers were
interviewed separately by an independent expert who had ex-
tensive experience conducting qualitative research to mini-
mize investigator bias. In these interviews, the researchers
reflected and reported any predispositions that might have
affected the data interpretation and presentation of the findings
[35]. This process and the transcriptions of the interviews
ensured that the researchers maintained an awareness of po-
tential biases during the data analysis phase. The strategy of
“thick description” was applied to strengthen the transferabil-
ity of the data [36]. Explicit descriptions were provided for the
research design and methods, along with examples of raw
data, to ensure that the conclusions made in the study are
transferable to other settings with similar participants and
context.
Results
All interviews took place between June 1 and August
10, 2018, after the children had completed the interven-
tion. A total of 20 pediatric brain tumor survivors (11
boys, 9 girls), their parents (13 mothers and 7 fathers),
and corresponding interveners (4 females, 3 males) were
successfully interviewed. Table 1 shows the demograph-
ic characteristics of the interviewed pediatric brain tu-
mor survivors, their parents, and corresponding inter-
veners. The mean age of the children was 12.2 years
(SD = 2.8). Sixty percent of them had received mixed
treatment modality. Nearly half (45%) had completed
cancer treatment for 6–12 months. Parents were on an
average 40.9 years old (SD = 6.7). Most parents (75%)
attained at least upper secondary education. The mean
age of interveners was 27.6 (SD = 1.4). Their average
total years of teaching experience was 5.3 (SD = 1.1).
Children in this study learnt the following musical in-
struments, which included piano (n = 3), keyboard (n =
 Support Care Cancer

Table 1 Demographic characteristics of the pediatric brain tumor & Theme 1: Overcoming the difficulties encountered during
survivors (n = 20), parents (n = 20), and interveners (n = 7) in the semi-
the initial phase of the musical training program
structured interviews

n (%)
Some children expressed that they had experienced
Child characteristics (n = 20)
difficulties in acquiring musical knowledge and skills
Age of children, mean (SD), years 12.2 (2.8)
at the initial stage of the program, such as reading mu-
Sex of children
sical notation, memorizing musical information, coordi-
Male 11 (55.0)
nating their hands or finger placement, and recognizing
Female 9 (45.0)
rhythm. Children described how the interveners offered
Treatment received
support by applying useful strategies and techniques to
Surgery 7 (35.0) facilitate their gradual acquisition of music knowledge
Radiotherapy 1 (5.0) and skills. A few children also reported that while they
Chemotherapy 0 (0.0) had trouble with concentration and focus at the begin-
Mixed method 12 (60.0) ning of the program, they noted that their abilities to
Time since treatment was completed concentrate and focus for longer periods improved grad-
6–12 months 9 (45.0) ually. The interveners reported that some children ap-
13–24 months 3 (15.0) peared to need extra time and practice to acquire the
25–36 months 2 (10.0) musical skills due to poor memory and concentration.
37–48 months 1 (5.0)
49–60 months 0 (0.0) & Theme 2: Improved psychological and emotional well-
> 60 months 5 (25.0) being
Parents’ characteristics (n = 20)
Age of parents, mean (SD), years 40.9 (6.7)
Sex of parents Promotion of positive mood
Male 7 (35.0)
Female 13 (65.0) Most children reported that the musical training program had a
Parents’ educational attainment positive effect on their mood. Many found it very pleasant and
Primary school or below 1 (5.0) relaxing to engage in playing the musical instruments. Some
Lower secondary school 4 (20.0) stated that playing instruments distracted their attention away
Upper secondary school 9 (45.0) from worrying about cancer recurrence. Likewise, many par-
Tertiary education 6 (30.0) ents described the program as beneficial to their child’s psy-
Interveners’ characteristics (n = 7) chological well-being, especially in terms of promoting posi-
Age of interveners, mean (SD), years 27.6 (1.4) tive mood.
Sex of interveners
Male 3 (42.9) Facilitation of emotional management and
Female 4 (57.1) expression
Years of teaching experience, mean (SD) 5.3 (1.1)
Many children reported that the program improved their abil-
ity to manage their emotions and provided a means for them to
express their emotions. Many parents shared similar thoughts;
6), violin (n = 3), guitar (n = 4), ukulele (n = 4), and per- they stated that their child was better able to manage their
cussion instruments (n = 2). negative emotions, and that they showed less anger, anxiety,
A full table of the themes, subthemes, and examples of and distress after participating in the program.
quotes from the interviews is presented in Table 2. Five
themes emerged from the interview results: theme (1) over- Enhancing self-confidence
coming difficulties encountered during the initial phase of the
musical training program; theme (2), improved psychological Although the children experienced different degrees of
and emotional well-being; theme (3), facilitation of participa- failures during the initial stage of the program, many of
tion in musical training program; theme (4), appreciation of them perceived the acquisition and development of mu-
the benefits of joining the musical training program; and sical skills as a personal accomplishment, which ulti-
theme (5), expectation of future musical training program. mately enhanced their confidence. Similarly, most par-
Details pertaining to these themes are described below. ents and interveners stated that the children gained a
Support Care Cancer

Table 2 A full table of themes, subthemes, and examples of quotes from the interviews

Themes Subthemes Examples of quotes

1. Overcoming the difficulties encountered
during the initial phase of the musical
training program
2. Improved psychological and emotional
well-being
“I was not good at guitar fingering at the beginning (of the program). The
intervener was so patient, and we practiced the basic fingering
exercises together. My fingering skills improved a lot.” Child 19,
male, 10 years, played a guitar.
“I could not remember the chords very well in the first few lessons.
However, the intervener taught me to use a slogan to remember the
chords. It helps a lot!” Child 10, male, 15 years, played a guitar.
“I could not concentrate well when attending musical training at first.
After a few months, I found that my concentration was improving, so I
could focus and concentrate for a longer time.” Child 2, female,
15 years, played a keyboard.
“They really invested enormous effort in learning the musical
instruments. Sometimes participants took more time when acquiring a
new skill, they were determined and tried their best to remember the
tips I gave them during the session… Using mnemonic devices can
help them remember things better, like Good Boy Does Fine (to read
the line notes) and FACE (for the space notes)” Intervener 2 (female)
of child 11, female, 9 years, played a violin; and child 15, female,
14 years, played a violin.
“They learned quite slowly, so it’s better to teach them based on their
pace and learning abilities… At the beginning (of the program), I
encouraged them to explore and learn the instrument at their own
pace... Keep repeating things a lot is also a good way to help them
acquire the (musical) skills” Intervener 7 (female) of child 6, male,
13 years, played a ukulele; and child 12, female, 13 years, played a
ukulele.
2.1 Promotion of positive “It made me more optimistic, I feel happier after participating in the
mood program. I sometimes feel worried about the recurrence of a brain
tumor, playing musical instruments can keep my mind off of this
worry.” Child 9, male, 15 years, played a guitar.
“Really good, it gives her joy, she always shares her happiness about
learning percussion instruments with me and her dad.” Mother of
child 8, female, 8 years, played a percussion instrument.
“I could see my child laughing during the musical training session, he
seems happier than before.” Father of child 13, male, 11 years, played
a keyboard.
2.2 Facilitation of “It calms me, I think I am dealing better with my emotions, as it provides
emotional management me a way to express my emotions, both negative and positive one via
and expression playing different melodies based on my feelings at that moment. After
playing the piano, I think I feel better.” Child 16, female, 15 years,
played a piano.
“It is very helpful for coping with his distressing emotions, before joining
this program, he used to isolate himself inside his bedroom when he
was feeling sad or angry, now he will express his emotions by playing
some simple notes and he is more willing to share his ups and downs
with us.” Mother of child 6, male, 13 years, played a ukulele.
2.3 Enhancing “It’s unbelievable that I am capable of learning to play a piano after
self-confidence having cancer, I am so happy and more confident now as I can play
well with both hands.” Child 20, female, 12 years, played a piano.
“I felt extremely proud of myself when I realized that I was capable of
acquiring some higher level musical skills, such as playing well with
both hands. Even though I encountered failure countless times at the
beginning, I never gave up and I think those failures are prerequisites
to my success. Throughout the program, my confidence was being
built up.” Child 2, female, 15 years, played a keyboard.
“I could see he became more confident gradually. At the very beginning,
he was quite hesitated to continue playing the violin when he made
some minor mistakes. I know maybe he was afraid of repeating the
mistakes. However, after 4 to 5 sessions, when he had acquired some
basic skills, he showed confidence to play even if it was not a perfect
piece.” Intervener 4 (male) of child 9, male, 15 years, played a guitar.
 Support Care Cancer

Table 2 (continued)

Themes Subthemes Examples of quotes

3. Facilitation of participation in musical
training program
4. Appreciation of the benefits of joining the
musical training program
5. Expectations of future musical training
program
3.1 Teaching survivors in “I think the content (of the program) was suitable for me as the teacher
accordance with their would make adjustments to the content according to my progress.”
aptitude Child 18, female, 15 years, played a keyboard.
“The teacher was so helpful and patient, sometimes after a week long, I
might forget some skills that I learnt, she would clarify the key points
and instruct me again and again until I grasp the skills. These made me
feel more relaxed during the learning process.” Child 15, female,
14 years, played a violin.
3.2 Positive learning “The teaching mode is so interactive and relaxing, it makes me more
environment engaged in it.” Child 6, male, 13 years, played a ukulele.
“My teacher is so friendly, patient, and encouraging, she gave me a lot of
support and motivation to help me progress throughout the process. I
was learning in a happy and relaxed atmosphere.” Child 15, female,
14 years, played a violin.
“I think home is the best place for implementing the training, as we do
not have to travel to another place… Besides, I think learning in a
familiar environment is beneficial for her.” Mother of child 11,
female, 9 years, played a keyboard.
3.3 Highly flexible “Sometimes when my schedule was too busy on weekdays, such as
scheduling having tests or examinations, we arranged the session on weekends.
While sometimes if I had to hang out with my friends or family, we
arranged it on weekdays, it is very feasible.” Child 3, 15 years, played
a guitar.
“It was very easy to arrange one session each week because of the
flexible scheduling. We usually did not have a fixed schedule, but
adjusted it (the timing of the session) based on our availability.”
Mother of child 14, male, 9 years, played a keyboard.
“I like that, I really enjoy having the musical training session with my
trainer.” Child 5, male, 8 years, played a keyboard.
“We hope the program could be run continuously. This is really a
worthwhile program. It made us become aware of the power of
learning musical instruments, my son is now enrolled in a musical
course outside to continue learning the piano. But we are wondering
whether the course suits him, as you know he learns a bit slowly.”
Father of child 5, male, 8 years, played a keyboard.
“We are grateful that my daughter was able to join such a program. She
has been keen on learning violin for a long time, and now, she was
finally given the opportunity to do it. She is extremely happy and
enjoys it so much. We are planning to let her continue the learning by
hiring a violin teacher.” Mother of child 11, female, 9 years, played a
violin.
5.1 Increase in the duration “Would it be possible to increase the duration (of each session) to one
and frequency of the hour or maybe even one and a half hours? As I would like to grasp
sessions more skills and I think lengthening the duration could facilitate the
consolidation of new knowledge.” Child 10, male, 15 years, played a
guitar.
“Maybe it would be even better if the frequency of session could be
increased to two times per week during the first 2 to 3 months. I
believe doing so could facilitate the acquisition of musical skills, as it
usually requires more time and effort to establish the fundamental
skills.” Intervener 1 (female) of child 2, female, 15 years, played a
keyboard; and child 18, female, 15 years, played a keyboard.
5.2 Group performance at “It would be a good idea to conduct a mini concert at the end of the
the end of the program program, to gather all of the participants together and give them a
chance to invite the public, such as relatives, teachers, and friends.”
Father of child 15, female, 14 years, played a violin.
Support Care Cancer
sense of achievement as they made considerable prog-
ress throughout the program, and that this greatly
boosted the participants’ confidence.
& Theme 3: Facilitation of participation in the musical train-
ing program
Teaching survivors in accordance with their aptitude
Many children expressed that the content of the musical train-
ing program was appropriate and was delivered based on their
progress, and so they did not feel pressured during the process
of acquiring musical knowledge and skills.
Positive learning environment
Most children expressed that they had received the musical
training in a favorable learning environment and that they had
been actively engaged throughout the program. Both children
and parents commented that the interveners were supportive
and helpful and that the teaching mode was comfortable and
encouraging. Most parents reported that their child showed
eagerness to attend the musical training sessions and men-
tioned that the family home was the best place for delivery
of the intervention.
Highly flexible scheduling
Most children and parents reported that the arrangement of the
weekly schedule was highly flexible as training sessions could
be arranged on either weekdays or weekends. This allowed
them to accommodate the weekly musical training sessions
throughout the 1-year study period.
& Theme 4: Appreciation of the benefits of joining the mu-
sical training program
In general, all of the children, their parents, and the inter-
veners were highly satisfied with the musical training pro-
gram. The majority of children commented that the program
was an enjoyable activity with a positive learning environ-
ment. Most parents were pleased that their child was given a
valuable opportunity to participate in the program and
expressed that the program enhanced their awareness regard-
ing the positive effects of musical training on their child’s
psychological well-being, and stated that they would allow
their child to continue studying music after the completion
of the program. Many parents commented that the learning
process was very positive and meaningful. Some also stated
that they noticed the outward expression of enjoyment from
their child.
& Theme 5: Expectations of future musical training program
Several suggestions were received from the children, par-
ents, and interveners. In the following section, we list aspects
that could be modified in future implementations of the
program.
Increase in the duration and frequency of sessions
Some children reported that they had encountered difficulties
in acquiring musical skills at the beginning of the program.
They suggested that the sessions be prolonged to 1 h or longer
to give the children more time to acquire and consolidate
music knowledge and skills in each session. Moreover, some
interveners suggested that the training sessions in the initial
phase of the program could be scheduled at an increased fre-
quency. This would facilitate the participants’ development
and acquisition of musical skills and knowledge, as relatively
greater effort is required in the initial phase of learning a new
musical instrument.
Group performance at the end of the program
Some parents recommended organizing a mini concert to offer
a platform for their children to demonstrate what they had
learnt. The parents proposed that this could elicit a sense of
achievement in their children.
Discussion
This qualitative study provides an in-depth understanding of
the pediatric brain tumor survivors’ lived experience of engag-
ing in the musical training program through exploring the
perceptions of the children, their parents, and interveners.
Overall, the participants reported being highly satisfied with
the musical training program. The children valued the experi-
ence of the musical training program and described how the
program exerted various beneficial effects on their psycholog-
ical well-being, including the promotion of positive mood,
facilitation of emotional management, and experience of per-
sonal accomplishment. These benefits were also observed by
the parents and interveners. It has been well-documented that
the cultivation of positive emotions can be achieved by en-
gaging in a musical activity repeatedly and regularly, as this
can activate emotion and reward pathways in the brain, lead-
ing to the arousal of positive emotions [22, 24]. Some children
also suggested that engaging in the musical training program
helped to draw their attention away from their worries about
cancer recurrence, and provided an alternative means for them
to process and express their negative emotions, which in turn
promoted a positive mood. These findings reinforced the idea

that the program could attenuate the overwhelming impact of
depressive symptoms through emotion and mood regulation.
Pediatric brain tumor survivors have been found to exhibit
some types of neurocognitive dysfunction that may affect their
learning abilities [6]. Despite encountering difficulties in acquir-
ing musical knowledge and skills during the initial phase of the
program, some children positively perceived these difficulties as
stepping stones to their success. Significantly, some children
were surprised and pleased that they were still capable of learn-
ing a musical instrument after surviving cancer, and reported
that they gained a sense of achievement and competency as they
made progress throughout the program. These findings suggest
that the reported enhancement in self-esteem could be attributed
to the significant personal accomplishment and intense sense of
achievement experienced throughout the process of learning a
musical instrument [37, 38].
A key finding from our study was the importance of having
motivated and supportive interveners, who were cognizant of
the special learning needs and abilities of the pediatric brain
tumor survivors, to deliver the intervention according to their
aptitude. Children appreciated that with the continuous en-
couragement and guidance from the interveners, they were
able to overcome the difficulties encountered during the initial
phase of the program and were empowered to progressively
improve their musical skills. The findings reveal that creating
a positive learning environment is beneficial for facilitating
pediatric brain tumor survivors to deal with adversity and
overcome difficulties during their learning process. These ex-
periences are deemed to be important to develop resilience
and self-confidence in students [39].
Our findings indicate that although enrolling children in
musical training is a common practice in Hong Kong, many
parents in the present study were unaware of the beneficial
effects of musical training on their child’s psychological well-
being. After their children joined the program, the parents
experienced a change in terms of their perception regarding
the musical training program. Specifically, they more readily
acknowledged the significant beneficial effects of musical
training on their child’s psychological well-being. Many par-
ents stated that, following the completion of the program, they
would enroll their child in an additional musical training
course. Yet, they expressed concerns about the appropriate-
ness of general courses for their children, who were relatively
slow learners compared with their peers. They were worried
that such courses may not address their child’s special learning
needs, and hence may represent a source of stress for their
child. Additionally, both children and parents displayed an
ardent desire to engage in the program continuously. These
findings imply that more resources should be allocated to
promote the continuity and sustainability of such programs
to promote the psychological well-being of this vulnerable
group. Most importantly, it is pivotal to tailor the musical
training program for children with cancer-related
Support Care Cancer
neurocognitive effects based on their learning abilities and
needs, thereby enhancing their learning experience [40].
When generating intervention protocols for a larger-scale
study or developing new care models, the following sugges-
tions should be taken into account. First, the duration of each
musical training session could be prolonged from 45 to 60 or
90 min, with a break to avoid fatigue. Moreover, the frequen-
cy of training sessions could be increased from once to twice
per week for the first 2 to 3 months of the program. During the
initial phase of learning a musical instrument, extra effort is
required for pediatric brain tumor survivors to acquire skills
and reach goals. Thus, this modification would facilitate the
acquisition and consolidation of musical skills within each
lesson. Second, appropriate teaching strategies should be in-
corporated into the musical training program to foster chil-
dren’s learning process according to their abilities. Strategies
employed by the interveners in this study included the use of
mnemonic devices to improve the memory of information,
repetition of instruction, and allowing children to learn at their
own pace. In a theoretical paper reinforcing the positive effect
of music-based interventions to improve the cognition and
quality of life among children with cancer, the authors
highlighted the importance of tailoring strategies based on
children’s abilities and recommended various music and com-
munication strategies to facilitate music learning [40]. Such
strategies included encouraging self-directed musical play and
exploration, making music and playing musical games togeth-
er, and use of electronic music technology as an interactive
and intriguing medium to facilitate active engagement. Future
studies may consider employing these strategies to optimize
learning in children with cancer-related neurocognitive ef-
fects. Third, holding a mini concert after the completion of
the program could offer the children an opportunity to show
their musical achievements to the public, which may further
enhance their confidence and facilitate social interaction
among pediatric brain tumor survivors [41].
This qualitative study provides insight regarding how a
musical training program promoted psychological well-
being in pediatric brain tumor survivors. We identified poten-
tial improvements for future studies and discerned the crucial
factors that promoted adherence and engagement in the pro-
gram. The findings of the present study enhance the transfer-
ability of the findings of the previous RCT to other settings by
rendering useful information about the impact of the context
in which the program was implemented within the trial.
Additionally, the findings indicated that the musical training
program was considered a feasible and acceptable interven-
tion for the pediatric brain tumor survivors. Our findings may
enlighten healthcare professionals to develop innovations or
care models with improved designs and quality, which will
enable them to better advocate for the psychological needs and
promote an optimal quality of life for pediatric brain tumor
survivors, which are a particularly vulnerable and
Support Care Cancer
understudied group. The government could also collaborate
with non-governmental organizations and educational sectors
to facilitate the continuity and sustainability of such musical
training programs to provide psychosocial support to the pe-
diatric brain tumor survivors. Further research is warranted to
explore how to tailor musical training programs to cater for the
special learning needs of children with cancer-related
neurocognitive effects, with the aim to optimize their overall
well-being.
The transferability of our findings is limited as the 20 pe-
diatric brain tumor survivors selected for interviews were from
a previous RCT with only 30 pediatric brain tumor survivors
who had received musical training.
In conclusion, this study bridged a gap in the literature by
exploring the essential features of a musical training program
in promoting psychological well-being among pediatric brain
tumor survivors, which is crucial for enhancing the quality of
the intervention. Our findings suggest the importance of
adopting a child-centered teaching approach and creating sup-
portive learning environment for the pediatric brain tumor
survivors to maximize their learning experience and facilitate
their learning process.
Acknowledgments We would like to thank the children, parents, and
musicians for participating in the interviews.
Funding This study was funded by the Seed Fund for Basic Research,
The University of Hong Kong (grant number 201511159063).
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
Ethics approval This study was approved by the Institutional Review
Board of the Hospital Authority Hong Kong West Cluster/the University
of Hong Kong (reference number, UW 16-023). The Declaration of
Helsinki (http://www.accreditgcp.com/download/Helsinki.pdf) was
strictly followed to ensure the rights of the participants are protected.
Statement of informed consent The nature and purposes of the study
were explicitly explained to the participants prior to the interview. Written
and verbal consent were obtained from all participants, who were assured
that they would have complete anonymity and confidentiality with re-
spect to the opinions and responses given during the interview. Consent
from children was gained by inviting them to put their names on a spe-
cially designed assent form to indicate their voluntary participation in the
study.
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