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IJCRR - 14(4), February, 2022

Pages: 15-23

Date of Publication: 15-Feb-2022


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Effect of Art Therapy versus Bubble Breaths on Anxiety among Children Undergoing Surgery in Selected Hospitals

Author: Manisha Padekar, Shweta Joshi, Rupali Salvi, Nisha Naik

Category: Healthcare

Abstract:Introduction: Anxiety among children undergoing surgery has an impact on postoperative outcomes, and is an extremely unpleasant experience for children and their family. To reduce preoperative anxiety art therapy and bubble breaths were tested in this study. Aim: To compare and evaluate the effect of art therapy and bubble breaths on anxiety among children undergoing surgery in selected hospitals. Methods and Material: Quasi-experimental pre-test post-test control group design was adapted. The study was conducted among children undergoing surgery. 90 samples were selected using non-probability purposive sampling and data collection was done using demographic variables and Modified Short State-Trait Anxiety Inventory. Art Therapy & Bubble Breaths were administered to Experimental Group1 & Experimental Group 2 respectively. Both groups received interventions 2 times. Results: Bubble breaths were significantly more effective in reducing anxiety among children undergoing surgery as compared to art therapy. Conclusion: This study concludes that bubble breaths are more effective in reducing pre-operative anxiety and are enjoyable for children of all ages. This is cost-effective and can be included as a preoperative routine for reducing anxiety among children in preoperative period.

Keywords: Art Therapy, Anxiety, Bubble Breaths, Children, Effect, Surgery

Full Text:

Introduction:

Anxiety among children undergoing surgery is usually characterized by subjective feelings of tension, nervousness, apprehension and worry that may be expressed in various forms such as crying. Postoperative maladaptive behaviours include, feeding difficulties, apathy and withdrawal, new onset enuresis and sleep disturbances, these may also result from anxiety before surgery.1

Children are human being in the stage of birth and puberty. They are innovative, active, bubbling and happy when their parents are in their house. A hospital stay can be a painful experience for a child as children miss home and normal everyday life. They may experience unfamiliarity with events, fear and confusion.2

Apart from the impact on postoperative outcomes, preoperative anxiety is an extremely unpleasant experience for children and their family. Some children prefer to vocalize their fears while others manifest it in behaviours such as agitation, crying and cessation of conversation or play and also attempting to escape from care providers. This is also accompanied by significant physiological changes such as secretion of stress hormones and increase in heart rate.3

Anxiety is defined as “apprehension without apparent cause”. It is a normal emotional state that we all experience at different times in our life. It is usually associated with anticipated fear of something that might happen in future. Anxiety is a psychological and physiological state characterized by cognitive, somatic, emotional and behavioral components.4

Total number of children in India is 164.5 millions. Childhood is often associated with illness and hospitalization. The National Center for Health Statistics has estimated that around 3.5 million children below 15 years of age are getting hospitalized every year.5

Reports of preoperative anxiety in children are varied, but are estimated to be 60.0% among children who are admitted for surgeries.6

A scheduled surgical procedure in children is a stressful procedure for child &family. Operative procedures in paediatrics is an unpleasant & potentially threatening experience which leads to preoperative anxiety due to child’s illness, hospitalization, fear of surgical intervention etc. Moreover it is well known that preoperative anxiety in children lead to negative postoperative responses, including long term behavioural problems, longer period of hospitalization and more pain.7

Preoperative anxiety can be seen commonly during the surgical experience in all age groups, higher levels of anxiety alter a patient's surgical course and cause increased postoperative pain.8

Preoperative anxiety among pediatric patients is very common,it has been associated with the display of maladaptive behaviors post-surgery, including high postoperative pain, parent-child conflict and increased anxiety and sleeping disturbances.9

Children who exhibit more anxiety preoperatively are 3 times more likely to exhibit post-operative negative behaviors. As many as sixty-seven percentages of children may develop postoperative negative behavioral changes including general anxiety, apathy and withdrawal, separation anxiety, sleep disturbances, aggression towards authority, and eating disturbances.10

Kaine and co-workers stated that negative behavioural response in 54.0% children (2 to 10 years) after 2 weeks, 20.0% after six months and 7.3% after one year of surgery.11

Material and Methods:

Research Design

In this study Quasi-experimental, pre-test post-test control group design was used to assess the effect of art therapy versus bubble breaths on anxiety among children undergoing surgery in selected hospitals.

Setting

The setting of the study was Dr. D. Y. Patil Hospital.

Sample

The sample selected for present study comprised of the children undergoing surgery from 6 to 12 years of age admitted in Dr. D. Y. Patil Hospital.

Instrument

In this study, the tool consisted of following:-

  • Demographic Variables: This includes 12 questions which obtain information regarding demographic data such as age, gender, religion, education of the child, father’s education, father’s occupation, mother’s education, mother’s occupation, family income, presence of caregiver with child, duration of hospitalization, and play activities of the child during hospitalization.

  • Modified Short State-Trait Anxiety Inventory: The Modified Short State-Trait Anxiety Inventory has 10 elements related to anxiety, with score 0, 1, 2, 3. In that Not at all is rated as score 0, somewhat is rated as score 1, moderately is rated as score 2 and very much is rated as score 3.

Scoring Key:

0 -10: Severe anxiety

11 – 20: Moderate anxiety

21 – 30: Mild anxiety

  • Art Therapy Profile

  • Bubble Breaths Profile

Intervention

The samples were selected considering inclusion & exclusion criteria. The researcher introduced herself to the subjects and their parents, assurance of confidentiality was given to the subjects and their parents and consent/assent was obtained from subjects. Socio-demographic data was collected from each subject. Pre-test was conducted for all three the groups using Modified Short State Trait Anxiety Inventory. On the same day 2 times art therapy was given for 30 – 40 minutes to children in experimental group 1 once in morning & then in evening. Bubble breaths were given 2 times to children in experimental group 2 for 15 – 20 minutes once in morning & then in evening. Post-Test data was collected following each intervention. Data collection from control group was also done.

Ethical consideration

The research study was carried out after obtaining permission of Sub Ethical Committee (DYPV / CON/ 523/ 2020), Research& Recognition Committee (DPU / 656 / - 15 / 2020) of Dr. D. Y. Patil Vidyapeeth Pune.

Data Collection

After obtaining administrative permissions from hospital authorities the actual data was collected from 14.12.2020 to 23.01.2021

Figure 1 depicts the step by step procedure followed during the study for collection of data.

Schematic Diagram

Population

Data Analysis:

Descriptive and analytical statistics were done. The data is represented in mean and standard deviation. The association of the level of anxiety with selected socio-demographic variables was analysed by Fisher’s exact test.  The independent sample t-test and paired sample t-test were used to check to mean differences. The level of significance was kept at p<0.05. The software used was R Software.

Results:

                                                                                                                                                                                                                                                                                                                                     Table 2 shows that, in the control group, 23.3% of the children undergoing surgery had mild anxiety (score 21-30), 70% of them had moderate anxiety (Score 11-20) and 6.7% of them had severe anxiety (Score 1-10). In Art therapy group, 90% of them had moderate anxiety (Score 11-20) and 10% of them had severe anxiety (Score 1-10). In Bubble breaths group, 3.3% of them had mild anxiety (score 21-30), 93.3% of them had moderate anxiety (Score 11-20) and 3.3% of them had severe anxiety (Score 1-10). 

Figure 2 shows that, in art therapy, 90.0% of the children undergoing surgery had moderate anxiety (Score 11-20) and 10.0% of them had severe anxiety (Score 1-10) in first observation. In second observation, 23.3% of them had mild anxiety (Score 21-30) and 76.7% had moderate anxiety (Score 11-20). In third observation, 30.0% of them had mild anxiety(Score 21-30) and 70.0% had moderate anxiety (Score 11-20). This indicates that the anxiety among children undergoing surgery reduced remarkably after art therapy.

Figure 3 shows that, in bubble breaths group 3.3% the children undergoing surgery had mild anxiety (Score 21-30), 93.3% had moderate anxiety (Score 11-20) and 3.3% had severe anxiety (score 1-10) in first observation. In second observation, 53.3% of them had mild anxiety (Score 21-30) and 46.7% had moderate anxiety (Score 11-20). In third observation, 86.7% had mild anxiety (Score 21-30) and 13.3% had moderate anxiety (Score 11-20). This indicates that the anxiety among children undergoing surgery reduced remarkably after bubble breaths therapy.

Table 3 shows that in art therapy group Average anxiety score in first observation was 17.1 which increased to 19.1 and 20.1 in second and third observation with 29 degrees of freedom. T-values for this test were 4.7 and 5.6 on second and third observations respectively. In bubble breaths group, average anxiety score in first observation was 17.6 which increased to 20.7 and 22.1 in second and third observations respectively. T-values for this test were 9.7 and 12.7 on second and third observations with 29 degrees of freedom.  Corresponding p-values were small (less than 0.05), therefore the null hypothesis was rejected. It was evident that the anxiety among the children undergoing surgery reduced significantly in both the experimental groups.

Table 5 shows data analysis related to association of level of anxiety among children undergoing surgery with selected socio-demographic variables, since all the “p-values”were large (greater than 0.05), therefore none of the demographic variables were found to have significant association with anxiety among children undergoing surgery.

STATISTICAL ANALYSIS

Descriptive and analytical statistics were done. The data is represented in mean and standard deviation. The association of the level of anxiety with selected socio-demographic variables was analysed by Fisher’s exact test.  The independent sample t-test and paired sample t-test were used to check to mean dif­ferences. The level of significance was kept at p<0.05. The software used was R Software.

DISCUSSION

A hospital-based comparative study was conducted in Capital Hospital. The study was carried out in pre-school children aged 3 to 6 years who were admitted in paediatric ward of Capital Hospital. Questionnaire was used for demographic details and measurement of severity of anxiety. Two different experimental groups were instructed to undergo art therapy and play therapy consecutively for 3 days, 30 minutes each day. Post-test was performed on 4thday; the questionnaire measured level of anxiety. Self-structured hospitalization anxiety scale was developed to measure the severity of anxiety symptoms. Assessment of anxiety level was done before and after the test. T-test, ANOVA and Chi-square test were performed to find an association between the variables. Play therapy was significantly more effective (“p-value” 0.025) than art therapy.12

Similarly in present study, the samples were 90 children who were undergoing surgery. 30 children were allotted to art therapy group. Self-structured interview on demographic variables & Modified Short State-Trait Anxiety Inventory were used. The T values were 4.7 and 5.6 after first and second intervention with 29 degrees of freedom. Corresponding “p-value” was small (less than 0.05). So, it was evident that art therapy was effective in reducing anxiety.

A study was conducted to assess the effect of soap bubbles as a distraction technique for anxiety management, fear, and pain in children waiting for a medical examination at the paediatric emergency room. 74 children (M = 9.30; “S.D.” = 1.10; 50.0% female) were randomly assigned to either a control group or experimental group. The children in the experimental group were provided soap bubble protocol while waiting for a medical examination at the paediatric emergency room. Anxiety, fear, and pain were assessed by self-report administered to the children. ANCOVA analyses were run using CAM.13

In present study the 30 children were allotted to bubble breaths group. The T values were 9.7 and 12.7 after first and second intervention with 29 degrees of freedom. Corresponding “p-value” was small (less than 0.05) Therefore it was evident that bubble breaths were effective in reducing anxiety. Children who had severe anxiety, it was reduced to mild or moderate levels. Therefore it shows bubble breaths were effective in reducing anxiety.

To compare levels of anxiety in children from bubble breaths with art therapy two sample t-test was used. Average change in anxiety score in art therapy group is 2 and 3 on second and third observations respectively which were 3.1 and 4.5 for bubble breaths group. T-values for this comparison were 2 and 2.3 on second and third observations with 58 degrees of freedom. Corresponding p-values were small (less than 0.05). Average reduction in anxiety among children in bubble breaths group was significantly higher than art therapy group therefore bubble breaths were significantly more effective in reducing the anxiety among children undergoing surgery than art therapy.

A study was conducted to assess prevalence and factors having association with preoperative anxiety in children between 5-12 years of age. Study involved 210 selected children undergoing inguinal and umbilical hernia repair. Socio-demographic and clinical variables were taken into consideration for analysis.Study results indicated that the male children were more prevalent, 7-12 years of age and were from lower socioeconomic status. In bivariate analysis, the factors associated with preoperative anxiety included 5-6 years age group and lower socioeconomic status was constantly associated with preoperative anxiety. Existence of these characteristics increased chances of developing preoperative anxiety. 14

However in this study, the analysis related to level of anxiety among children undergoing surgery with selected socio-demographic variables revealed that all "p-values” were large(> 0.05), therefore none of the demographic variables were found to have significant association with anxiety among children undergoing surgery.

CONCLUSION

The results of the study revealed that art therapy & bubble breaths, both are effective in reducing preoperative anxiety. However bubble breaths were more enjoyable & convenient for children of all ages. Bubble breaths are cost effective and can be included as preoperative routine for reducing anxiety among children.

ACKNOWLEDGEMENT

Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors/ editors/publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.

Source of Funding: None

Conflict of Interest: None

Authors’ Contribution: All the authors have contributed to the planning, implementation and analysis of the research study and its presentation in the form of the manuscript.

References:

1. Ahmed MI, Farrell MA, Parrish K, Karla A. Preoperative anxiety in children -risk factors and non-pharmacological management. Middle East J Anaesthesiol 2011;21(2):153-64

2. Definitions of Children. www.kathyeugster.com

3. Kain ZN, Cicchetti DV, Mayes LC, O’Connor TZ. Preoperative anxiety in children: predictors and outcomes. Arch Pediatr Adolesc Med 1996; 150:1238–45.

4. Anxiety in Children, Teen Stress and Teenage Depression. www.lifepositive.com

5. India Population (2021) - Worldometerwww.worldometers.infoworld-population/india-population/

6. Mc Cann ME, Kain ZN. The management of preoperative anxiety in children: An update.Anesth Analg 2001; 93(1):98-105

7. Aikaterini C, Gregory T, Vasiliki M, Georgios V, Christos I, Pelagis C. Preoperative anxiety in Greek children and their parents when presenting for routine surgery. Anesthesiol Res Pract 2018;2018:5135203.

8. Vaughn F, Wichowski H, Bosworth G. Does preoperative anxiety level predict postoperative pain. AORN J.2007; 85 (3):589-604

9. Agnieszka T, Beata B. Anxiety and need for information in parents of children prepared for surgery under general anesthesia. PMID: 313105593

10.  Zuwala R, Barber KR. Reducing anxiety in parents before and during pediatric anesthesia induction. AANA J 69(1):21-5

11. Wright Kristi D, Stewart Sherry H, Allen Finley G, Buffett-Jerrott Susan E.Prevention and intervention strategies to alleviate preoperative anxiety in children: a critical review Behav Modif. 2007; 31(1):52-79.

12. Dalei SR, Nayak GR, Pradhan R. Effect of art therapy and play therapy on anxiety among hospitalized preschool children. J. Biomed. Sci.2020;7(2):71-76

13. Longobardi C, Prino Laura E. Soap bubbles as a distraction technique in the management of pain, anxiety, and fear in children at the paediatric emergency room: A pilot study. Child Care Health Dev. 2019;45(2):300-305.

14. Louise Amália de M, Iohanna Maria Guimaraes D, Lilian Varanda P. Prevalence and factors associated with preoperative anxiety in children aged 5-12 years. Rev Lat Am Enfermagem. 2016; 24: e2708.

Announcements

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Awards, Research and Publication incentive Schemes by IJCRR

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One article from every issue is selected for the ‘Best Article Award’. Authors of selected ‘Best Article’ are rewarded with a certificate. IJCRR Editorial Board members select one ‘Best Article’ from the published issue based on originality, novelty, social usefulness of the work. The corresponding author of selected ‘Best Article Award’ is communicated and information of award is displayed on IJCRR’s website. Drop a mail to editor@ijcrr.com for more details.

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This award is instituted to encourage women researchers to publish her work in IJCRR. Women researcher, who intends to publish her research work in IJCRR as the first author is eligible to apply for this award. Editorial Board members decide on the selection of women researchers based on the originality, novelty, and social contribution of the research work. The corresponding author of the selected manuscript is communicated and information is displayed on IJCRR’s website. Under this award selected women, the author is eligible for publication incentives. Drop a mail to editor@ijcrr.com for more details.

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A Study by Sudha Ramachandra & Vinay Chavan entitled "Enhanced-Hybrid-Age Layered Population Structure (E-Hybrid-ALPS): A Genetic Algorithm with Adaptive Crossover for Molecular Docking Studies of Drug Discovery Process" is awarded Best article for Vol 12 issue 15
A Study by Varsha M. Shindhe et al. entitled "A Study on Effect of Smokeless Tobacco on Pulmonary Function Tests in Class IV Workers of USM-KLE (Universiti Sains Malaysia-Karnataka Lingayat Education Society) International Medical Programme, Belagavi" is awarded Best article of Vol 12 issue 14, July 2020
A study by Amruta Choudhary et al. entitled "Family Planning Knowledge, Attitude and Practice Among Women of Reproductive Age from Rural Area of Central India" is awarded Best Article for special issue "Modern Therapeutics Applications"
A study by Raunak Das entitled "Study of Cardiovascular Dysfunctions in Interstitial Lung Diseas epatients by Correlating the Levels of Serum NT PRO BNP and Microalbuminuria (Biomarkers of Cardiovascular Dysfunction) with Echocardiographic, Bronchoscopic and HighResolution Computed Tomography Findings of These ILD Patients" is awarded Best Article of Vol 12 issue 13 
A Study by Kannamani Ramasamy et al. entitled "COVID-19 Situation at Chennai City – Forecasting for the Better Pandemic Management" is awarded best article for  Vol 12 issue 12
A Study by Muhammet Lutfi SELCUK and Fatma entitled "Distinction of Gray and White Matter for Some Histological Staining Methods in New Zealand Rabbit's Brain" is awarded best article for  Vol 12 issue 11
A Study by Anamul Haq et al. entitled "Etiology of Abnormal Uterine Bleeding in Adolescents – Emphasis Upon Polycystic Ovarian Syndrome" is awarded best article for  Vol 12 issue 10
A Study by entitled "Estimation of Reference Interval of Serum Progesterone During Three Trimesters of Normal Pregnancy in a Tertiary Care Hospital of Kolkata" is awarded best article for  Vol 12 issue 09
A Study by Ilona Gracie De Souza & Pavan Kumar G. entitled "Effect of Releasing Myofascial Chain in Patients with Patellofemoral Pain Syndrome - A Randomized Clinical Trial" is awarded best article for  Vol 12 issue 08
A Study by Virendra Atam et. al. entitled "Clinical Profile and Short - Term Mortality Predictors in Acute Stroke with Emphasis on Stress Hyperglycemia and THRIVE Score : An Observational Study" is awarded best article for  Vol 12 issue 07
A Study by K. Krupashree et. al. entitled "Protective Effects of Picrorhizakurroa Against Fumonisin B1 Induced Hepatotoxicity in Mice" is awarded best article for issue Vol 10 issue 20
A study by Mithun K.P. et al "Larvicidal Activity of Crude Solanum Nigrum Leaf and Berries Extract Against Dengue Vector-Aedesaegypti" is awarded Best Article for Vol 10 issue 14 of IJCRR
A study by Asha Menon "Women in Child Care and Early Education: Truly Nontraditional Work" is awarded Best Article for Vol 10 issue 13
A study by Deep J. M. "Prevalence of Molar-Incisor Hypomineralization in 7-13 Years Old Children of Biratnagar, Nepal: A Cross Sectional Study" is awarded Best Article for Vol 10 issue 11 of IJCRR
A review by Chitra et al to analyse relation between Obesity and Type 2 diabetes is awarded 'Best Article' for Vol 10 issue 10 by IJCRR. 
A study by Karanpreet et al "Pregnancy Induced Hypertension: A Study on Its Multisystem Involvement" is given Best Paper Award for Vol 10 issue 09

List of Awardees

A Study by Ese Anibor et al. "Evaluation of Temporomandibular Joint Disorders Among Delta State University Students in Abraka, Nigeria" from Vol 13 issue 16 received Emerging Researcher Award


A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" from Vol 13 issue 06 received Emerging Researcher Award


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International Journal of Current Research and Review (IJCRR) provides platform for researchers to publish and discuss their original research and review work. IJCRR can not be held responsible for views, opinions and written statements of researchers published in this journal

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