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Running head: FEASIBILITY AND ACCEPTAB ILITY OF VISUAL ARTS 1 Feasibility and Acce ptability of Visual Arts Intervention s with Patients Undergoing Hematopoi etic Stem Cell Transplant : Phase II Michelle Reed University of Florida
FEASIBILITY AND ACCEPTABILITY OF VISUAL ARTS 2 Abstract The current study examined the feasibility and acceptability of delivering psychosocial assessments and art s interventions to patients undergoing hematopoietic stem cell transplantation (HSCT). Recruitment took place during pre HSCT evaluation s at the UF Psychology Clinic. After HSCT participants met an artist who pro vided an art kit and weekly interventions and a graduate student who delivered w eekly psychosocial assessments. Psychosocial measures assessed mood (depression, anxiety, stress, and benefit ). D escriptive statistics and inde pendent t tests evaluated partici pant characteristics, acceptability and feasibili ty. The sample included eight participants with an average age of 53 years ( SD =12). Utilizing Gabriel et al. (2001) as a reference for feasibility and acceptability, the study appeared acceptable as 73 % of eligible patients consented Three participants (3 8 %) completed at least one art s intervention, while all participants completed baseline assessments. After the baseline visit, completing interventions and a ssessments became less feasible due to patient f atigue/illness and preoccupation with medical procedures. Art s intervention delivery was successful 16 % of the time (5 completed/32 attempts), and assessment delivery was 53 % successful (19 completed/36 attempts). Though the study appeared to be acceptable, the feasibility waned with longer hospitalization due to medical complications and physical exhaustion.
FEASIBILITY AND ACCEPTABILITY OF VISUAL ARTS 3 Introduction Hematopoietic Stem Cell Transplantation (HSCT) Accor ding to the Center for International Blood and Marrow Transplant Research (2007), the number of HSCT has grown rapidly over the past 30 years, with an estimated 50 60,000 HSCT s performed annually worldwide. T he majority of these procedures treat hematol ogic and lymphoid cancers, but HSCT s also treat other malignant and nonmalignant disorders (Copelan, 2006). HSCT is a complex process as patients undergo a conditioning regimen involving chemotherapy and/or irradiation to eradicate the malignancy (Nationa l Cancer Institute, 2008) Subsequently, patients receive the transplantation of previously harvested stem cells, promoting immune reconstitution (Bevans, Mitchell, & Susan, 200 8). Patients remain hospitalized in isolation for two to four weeks post HSCT, but complete recovery of the immune system may take two years (National Cancer Institute, 2 008). Given the intensity of HSCT, many ph ysical complications may arise, chiefly fatigue, with one study reporting that 80 96% of patients experienced cancer relat ed fatigue after chemotherapy (Cella, Davis, Breitbart, & Curt, 2001). In addition to the physical concerns, there are myriad psychosocial implications of HSCT Several studies indicate that patient anxiety decreases over hospitalization while depression increases (Prieto et al., 2005 ; Syrjala et al., 2004; Wells, Booth Jones, & Jacobsen, 2009 ). Prieto et al. (2005) reported that transient pre HSCT anxiety might be due to patient anticipation of the HS CT In terms of depression, several studies link depressive symptoms post HSCT to an increased risk of death (Grulke, Larbig, KaÂ¨chele, & Bailer, 2008; Loberiza et al., 2002). To counteract psychological distress, several studies indicate that social support facilitates patient coping during hospit alization S pecifically, patients who have an opportunity to express
FEASIBILITY AND ACCEPTABILITY OF VISUAL ARTS 4 their feelings with others (Ho, De L. Horne, & Szer, 2002; Grulke et al. 2005 ) and those with someone to do activities with ( Wells et al., 2009) exhibit a better HSCT outcome. Methods a nd psychosocial effects of visual arts interventions Gabriel et al. (2001), a study exploring the feasibility and use of visual arts activities with HSCT recipients, compared with other studies evaluating arts with patients with cancer. In contrast to grou p arts interventions in the presence of other patients (Bar Sela, Atid, Danos, Gabay, & Epelbaum 2007; Heiney & Darr art therapists facilitated hour long art sessions with a single patient. Patients received an art ki t with materials and a supply list from which to create pictures during their hospitalization (Gabriel et al., 2001). The study speculated that arts interventions that addressed cancer would be too threatening to HSCT recipients given the long and isolated hospitalization, which differed from other interventions that specifically focused on cancer ( Heiney & Darr Hope, 1999; Visser & patient interpretation. Moreov er, similar to other studies, Gabriel et al. (2001) stressed the importance of informing patients that prior artistic skills were unnecessary in order to obviate possible discomfort with the creative process ( Heiney & Darr Hop e, 1999; Nainis et al., 2006). M oreover, quantitative findings established feasibility implications as well as short term benefits with patients with cancer Walsh & Weiss (2003) found that patients reported significant anxiety and stress reductions after one intervention. Similarly, Nainis et al. (2006) noted statistically significant reductions in pain, tiredness, depression, and anxiety. Ninety six percent of the patients who completed the interventions felt comfortable making art despite having no previous experience with art therapy, and 92% of the patients were interested in doing it again. After four sessions, Bar Sela et al. (2007) indicated a statistically significant reduction in patient
FEASIBILITY AND ACCEPTABILITY OF VISUAL ARTS 5 depression and fatigue. Contrastingly found no significant improve ment in mood or quality of life after eight sessions, but 92% of the patients stated that they would recommend the arts activity, and over 50% of the patients preferred longer, more frequent sessions despite 85% reporting fatigue after the activities. In most of the studies, patient illness and fatigue had an adverse impact on the feasibility of the arts interventions (Bar Sela et focus on HSCT recipients, Gabriel et al. (2001) set precedence for the current study measures of feasibility (the ratio of successful completion to total attempts of assessments and arts interventions as well as the percentage who completed at least one a ssessment battery and arts intervention) and acceptability (the percentage of consenting patients). Independent of Gabriel et al. (2001), this study determined assessment and arts intervention acceptability based upon whether patients withdrew from the stu dy due to lack of interest. Study Aims Using Gabriel et al. (2001) as precedence, the aims of this study were ( 1) to attain study acceptability based upon a 48% consent rate, and (2) to attain assessment and arts intervention feasibility based upon 50% com pletion rates and 75% participation rates. Considering previous research linking arts interventions to significant psychosocial changes in patients with cancer, the hypothesis was that the arts intervention would improve patient psychosocial scores if ther e were no major feasibility and acceptability issues. Methods Protocol Subsequent to a pilot phase, upon IRB revision approval researchers approached patients who were fluent in English and at least 18 years of age during their pre H SCT
FEASIBILITY AND ACCEPTABILITY OF VISUAL ARTS 6 evaluation at the U niversity of F lorida Psychology Clinic. Consenting patients received a baseline orie ntation within 48 hours after hospital admission for HSCT, where they met an Arts in Medicine (AIM) artist who provided an AIM kit and a graduate student who administered standardized psychoso cial assessments. T he artists and graduate students met separately with the patients each subsequent week Researchers abstracted demographic and biological data from patient medical records to control for variables and to provide des criptive statistics. Arts Intervention (Phase II) In attemp t to improve feasibility and acceptability with the weekly, hour long arts intervention from our preliminary phase research ers incorporated new approaches. An additional AIM trained artist (two t otal) facilitated intervention delivery, primarily making hospital room visitations to improve patient receptivity to the arts intervention s and rapport with the artist To alleviate creative hesitation, a prominent issue in the first phase patients recei ved their own AIM art kit at the baseline meeting and the artist discussed potential benefits of art and enjoyable projects that required little time. Furthermore, the artist described the contents of the art kit (e.g. watercolors, acrylics, markers, etc.) Patients also received reassurances that prior artistic skill was unnecessary, researchers would not rate their creations, and there was no right way to do art as each creation was inherently special They were encouraged to explore materials on their ow n time. The artists served as guides during the arts interventions, tailoring the sessions to the creative interests of the patients who produced their own works of art. Assessments (Phase II) In orde r to expand knowledge of patients during the HSCT p rocess, we broadened our assessment collection from the first phase. The weekly psychosocial measures included the Mini Profile of Mood States (McNair, Lorr, & Droppleman, 1992), Spielberger Stat e Trait Anxiety
FEASIBILITY AND ACCEPTABILITY OF VISUAL ARTS 7 Inventory (Spielberger, Gorsuch, Lushene, Vag g, & Jacobs, 1983) Beck Depression Inventory II (Beck, Steer, & Brown, 19 96), Benefit Finding Scale (Antoni et al., 200 1), Perceived Stress Scale ( Cohen, Kamarck, & Mermelstein, 1983) and the Functional Assessment of Cancer Therapy Bone Marrow Transplant ( McQuellon et al., 1997) The collection measured patient mood, anxiety, depression, stress, and perceived benefit from their cancer experience. Results The current sample included eight patients with an average age of 53 years ( SD =12). Five men and three women composed the sample of various ethnicities (four Caucasian, one African American, and one Asian participant). Diagnoses primarily included multiple myeloma ( n =3) or non Hodgk n =3). On average, patients remained in the hospital for three to four weeks ( M =26 days, SD =10). The small sample size would yield limited results in evaluating relationships between assessments and intervention, and thus, was not included in this report. Utilizing Gabr iel et al. (2001) as a reference the current study appeared to be acceptab l e as 73 % (11/15) of eligible patients consented. Of the eight patients, three (38%) completed one arts intervention or more, and one withdrew due to lack of interest. Completion of the arts intervention was only 16% successful (5 interventions delivered / 32 attempts), predominantly due to patient reports of illness, fatigue, and treatment preoccupation, rather than lack of interest. This suggests that the arts intervention was acceptable but exhibited low feasibility. In terms of assessment delivery, all p atients completed baseline assessments with no withdrawals. Collection of assessments had a success rate of 53% (19 assessments completed / 36 attempts). Although the chief reasons for refusal were the same as the arts intervention, more patients stated la ck of interest when refusing the assessments. Thus, the assessments were initially feasible and
FEASIBILITY AND ACCEPTABILITY OF VISUAL ARTS 8 acceptable. After the baseline visit, intervention and assessment completion became less feasible, primarily due to patient fatigue and illness as well as preoc cupation with medic al procedures. Independent samples t tests revealed that, on average, the three participants who completed an arts intervention ( M =27 days, SD =12.2) had significantly longer yet more variable length of hospitalizations than the five ( M = 23.3 days, SD =1.5) who did not complete an arts intervention ( p <.01). A variety of complications may be responsible for increased hospital stay for art intervention nonparticipants ( Bishop, Welsh, Coons, & Wingard, 2001) and the same factors may lead to p atients feeling too ill to participate, a commonly expressed reason for participation refusal. However, this theory lacks explanation for the nonparticipating patients with relatively short hospital stays. A larger sample size may help to clarify this phen omenon. Discussion The HSCT procedure is an intense, isolating process in which patients are in great need of psychosocial attention but remain difficult to reach. According to established measures (Gabriel et al., 2001), this study demonstrated sizeable acceptability at recruitment, but participant treatment and ensuing illness during hospitalization appeared to constrain feasibility. Baseline assessments and initial visits from the artists were more successful than attempts in subsequent weeks as medical treatment and the recovery process intensified. Though one patient withdrew from the arts intervention due to lack of interest, most patients expressed fatigue or illness as a reason for refusing participation in assessments and the arts intervention, in dicating that, regardless of initial acceptability, study adherence became increasingly infeasible. Despite feasibility issues, the arts intervention provided an inexpensive, versatile resource with the capacity to empower capable patients and visitors du ring their hospital stay. Two of the eight patients took advantage of the kit while alone to create projects. Akin to Gabriel et al.
FEASIBILITY AND ACCEPTABILITY OF VISUAL ARTS 9 (2001) and Walsh & Weiss (2003 ), some patients used their artwork to embellish their rooms and to create gifts, and one not ed that the arts intervention served as a distraction from the treatment. Additionally, two patients (including the patient who withdrew from the arts intervention) had children who utilized the art kit during their visit. Moreover, the information packet helped to spark patient interest, as several patients requested supplies during their stay. Contrastingly, the odor of the arts kit was an unforeseen consequence; a patient cited its overwhelming smell. persensitivity to smell ( Epstein et al., 2002 ). Though treatment and fatigue are inherent HSCT circumstances that hindered arts intervention participation, further alteration to the development of the arts intervention may improve participation. As aforem entioned, Nainis et al. (2006) affirmed the energizing nature of the arts. Enlightening fatigued patients that the arts can counteract their tiredness may improve their motivation to participate. Furthermore, given that patients were often in the presence of friends and family, developing collaborative arts activities that welcome family and friend participation might boost participation. The visitors could encourage patient participation, and patients may be more willing to participate if they have familia r persons with whom to create. One limitation of the study was the small sample size hindering the evaluation of a potential relationship between the battery of assessments and the arts intervention. This information will be beneficial to expand understand ing of the psychosocial implications of HSCT recipients and their interaction with the arts intervention. Moreover, given that research surrounding arts in health programs has historically involved qualitative designs and surveys to determine the effects o f arts interventions, with study expansion, this posttest/pretest study employing standardized assessments will help to solidify the previously indicated benefits of arts programs ( Hacking, Secker, Spandler, Kent & Shenton, 2008)
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