[[alternative]]Investigation of the Benefits of Drawing and Coloring Art Activities for Female Breast Cancer Patients on Anxiety and Physiological Responses

[[abstract]] 背景及目的：乳癌是全世界婦女最重要的癌症，因其發生率至今仍然居高不下。早期診斷與治療乳癌的醫療已大幅進步，所以乳癌病人的存活率與復發率相較其他癌症有較佳的成效。但是，乳癌病人治療期間或存活期階段，經常因反覆受焦慮情緒困擾而影響其繼續接受治療的意願與降低生活品質，進而延遲疾病的恢復時間，嚴重者甚至出現自殺的念頭而影響病情治療進展。為減輕抗癌過程中的不良反應，輔助療法已被廣泛運用於女性乳癌病人，尤其是用來改善病人的情緒困擾方面。藝術治療已被證實能有效改善焦慮，更有研究指出曼陀羅繪畫可做為乳癌病患治療期間非侵入性評估治療成效的工具。因此，本研究希望探討彩繪藝術活動對緩解女性乳癌病人焦慮和生理反應的可能效益。 研究對象與方法：本研究採前後測實驗設計法。招募南部某區域教學醫院住院接受化學治療之女性乳癌病人，排除腦部轉移、患有失智症或嚴重精神疾病者，以亂數表隨機分成彩繪曼陀羅組、格子畫組及自由畫組共三組實驗組及對照組。除以問卷收集基本資料、藝術休閒活動參與情形、治療狀況、不適症狀與輔助療法等，同時於實驗前、中、後分別填寫情境特質焦慮量表與量測血壓（包括舒張壓、收縮壓）及心跳等生理反應。彩繪藝術活動是以紅、橘、黃、綠、藍和紫六色的彩色鉛筆進行二十分鐘著色。研究結果以SPSS 22.0統計軟體進行描述性統計、獨立樣本t檢定、單因子和二因子變異數分析，分析實驗組間與對照組之差異及相關因子等。 結果：本研究於2018年2月至2019年4月進行招募及試驗。結果共47名受試者完成前後測資料收集，其平均年齡為54.3歲。試驗前平均情境特質焦慮量表得分為41.3（± 11.4），進行焦慮誘導後得分增高為46.2（± 11.6）。分組實驗結果顯示彩繪曼陀羅組焦慮得分具有顯著改善（P值為0.034 v.s 對照組3.8 ± 2.4）。在生理反應方面，試驗前後血壓與心跳並未呈現顯著性差異。 結論：本研究發現彩繪曼陀羅是最能有效降低受試者焦慮的彩繪藝術活動，藝術活動確實可作為改善正在接受化學治療期間的女性乳癌病人焦慮情緒的輔助療法。期望本研究結果能提供相關醫療及健保單位，作為減緩癌症病人焦慮及舒緩情緒之參考，建議將藝術活動運用於臨床照護實務中，主動建議病患可選擇以彩繪藝術活動緩解其焦慮情緒。[[abstract]] Background and objective: Breast cancer is well known as the most common cancer in women worldwide and the prevalence is still fairly high until now. The 5-year relative survival rate and recurrence rate after treatment are much better than others due to the prognosis and treatment modalities for early breast cancer improved greatly. However, a frequent and disabling symptom in breast cancer patients and survivors is anxiety which might worsen quality of life, elevate risk for severe depression, induce medical treatment failure, and influence clinical outcomes. To reduce the adverse effects caused by anticancer treatments, the complementary and alternative medicine (CAM) therapies were widely used to overcome the anxiety in female patients with breast cancer. Art therapies have been shown to decrease anxiety and especially the mandala drawings was proposed as qualified assessment tools for women with breast cancer. Therefore, the aim of this study was to investigate the potential effects of coloring art activities on reducing anxiety and affecting physiological responses in female breast cancer patients. Participants and methods: The pre-test post-test comparison group design was conducted in this project. Female breast cancer patients receiving chemotherapy at a metropolitan hospital in southern Taiwan were invited to participate. Subjects were excluded if they had brain metastases, dementia, severe mental disorder, or refuse to continue with the trial. After completing consent procedures, the applicants were randomly divided into three experimental groups: (1) coloring mandala group, (2) plaid group, and (3) free-form group; and a normal activity control group. In addition to the socio-demographic, degree of engagement in different artistic and cultural activities, perceived health status, previous therapeutic modalities and medication of the participants; the following physiological responses were also measured before, during, and after the study intervention: State-Trait Anxiety Inventory (STAI), blood pressure (diastolic blood pressure and systolic blood pressure), and heart rate. The anxiety induction in participants was by asking them to think about the time that they felt most fearful, and then writing for 4 minutes about that experience on a piece of unlined A4-sized paper. Regardless of whether they were assigned to any experimental group, all participants were instructed to color the paper in front of them for 20 minutes using the six colored pencils (red, orange, yellow, green, blue, and purple) provided by executor. SPSS 22.0 statistical software was used to analyze the data. Independent-Sample t test, One-way and two-way analysis of variance (ANOVA) were conducted to compare the scores of STAI and the physiological responses between the groups. Results: The study period from recruitment to completion was from February 2018 to April 2019. The mean age of the participants was 54.3 years. The mean total STAI score of the sample before anxiety was 41.3 ± 11.4 (meanSD), and it was higher after anxiety induction (46.2 ± 11.6). Result indicated that anxiety scores were significantly declined in the coloring mandala group (-11.3 ± 7.3, P=0.034 versus +3.8 ± 2.4 of the control group). There were no statistically significant differences between the groups with respect to the physiological responses. Conclusion: The present study found that coloring mandala activity could effectively reduce the anxiety level in participants. This finding enable us to understand the possibility of coloring art activities for reducing anxiety in breast cancer patients during receiving chemotherapies. Our study recommends that health care units could provide more innovative and effective information during policy decision-making process against anxiety in breast cancer patients. This finding also could be provided to female breast cancer patients as a safe nondrug remedy for anxiety and encourage them to engage mandalas drawing activities for relieving their adverse side effects