The Effectiveness of Mindfulness-Based Art Therapy (MBAT) on Healthy Lifestyle in Iranian Menopausal Women.

BACKGROUND: The purpose of this study was to determine the effectiveness of mindfulness-based art therapy (MBAT) in promoting life style in Iranian menopausal women.
METHODS: This study was a quasi experimental study that was conducted on 104 menopausal women in Neyshabur,Iran 2018. One hundred and four menopausal women completed both the pre- and post-study measurements. The MBAT group demonstrated a significant decrease in symptoms of distress and significant improvements in key aspects of the health-related style of life (as measured by HPLPII questionnaire).
RESULTS: The MBAT interventions had a significant effect on improving lifestyle behaviors (p < 0.05). Among the dimensions of style of life, the highest mean score was for nutrition (35.14 ± 3.35), and the lowest score was achieved by the subdomains of physical activity (14.89 ± 3.55). The mean (standard deviation) scores of stress management, interpersonal relations and health responsibility were 21.54 ± 1.12, 26.00 ± 2.54 and 16.87 ± 4.10, respectively.
CONCLUSION: This investigation of MBAT provides initial encouraging data that support a possible future role for the intervention as a psychosocial option for decrease in symptoms of distress menopausal women and improve lifestyle.

INTRODUCTION

Menopause is a normal part of ageing. With increasing age, the risk of many common illnesses increases. Optimizing health at menopause may help to improve healthy physical and emotional health into older age. Lifestyle modifications are often relatively simple changes that can provide benefits to women with menopausal symptoms [1]. Techniques such as deep breathing, guided imagery, massage or progressive muscle relaxation can help you cope with and relieve some menopausal symptoms [2].

Different interventions in the field of individual and group treatment of menopause such as supportive therapies, cognitive and interpersonal psychotherapy to work gone [3].

Mental mindfulness-based art therapy (MBAT) is one of the interventions and therapies recently proposed for Cancer patients by integrating an Intervention mindfulness-based art therapy (MBAT) approach with a formulation of emotional support groups. Research evidence suggests the effectiveness of this method in reducing the number of disorders, irregularities, and improving the style of life of women with various types of cancer [4]. Art therapy combines the creative process and psychotherapy, facilitating self-exploration and understanding. Using imagery, color and shape as part of this creative therapeutic process, thoughts and feelings can be expressed that would otherwise be difficult to articulate. The main difference between mindfulness-based art therapy (MBAT) approach and the reduction of mental-based stress-based intervention is the awareness that it is based on the teaching of non-verbal components, such as creative expression of emotions and physical emotions in patients [5]. The effectiveness of art therapy in the treatment of mental disorders [6,7]. It seems that a group-based mental-based art-based approach to awareness of power has a greater effectiveness in the field of treatment and intervention in mental-psychiatric disorders [8]. This method is the result of the theoretical and therapeutic studies of gabazin [9,10], whose effectiveness has been confirmed by Monti et al. [5]. However, so far, no study has been done about the use of mind-focused art therapy to improve life style in menopausal women. The purpose of this study was to determine the effectiveness of MBAT in promoting life style in Neyshabur menopausal women.

MATERIALS AND METHODS

In this quasi-experimental study, according to the basic elementary study, with 95% confidence, a margin of error =0.05 and =10%, and an expected power of 90%, and a Z value of 1.28. The number for each group was 52 and a total of 104 were calculated.

In this study, cluster random sampling method was used. For this purpose, a list of all health centers in the health center of Neyshabur was prepared and were selected 104 samples of menopausal women were selected.

Inclusion criteria included women with ages ranging from 50 to 60 years, menopausal, having reading and writing skills and being able to answer questions, having a phone call to follow. Women were invited through research invitations to attend this research period. Exclusion criteria included any chronic medical illness; use of medications that influence mental. All of the participants provided informed consent to be involved in the study. Menopausal women into two groups of 52 intervention and 52 control and responded to the research tools. To conduct this research, the interventional group 12-week, twice a week, using a protocol of 90-120 min, underwent a mind-focused art therapy.

All participants were confident about the confidentiality of the research results. Before the enrollment, informed consent was obtained from all of the participants.

1. Instruments

HPLPII questionnaire (Health Promoting Lifestyle Profile-II questionnaire) is directed toward attaining positive outcomes and result in a positive health experience throughout the life span. This questionnaire comprised 52 items. Physical activity (8 items), nutrition (9 items), stress management (8 items), spiritual growth (9 items), interpersonal relations (9 items), health responsibility (9 items). The reliability of the questionnaire was 0.98. Cronbach’s alpha coefficient was calculated as 0.95, and its validity has already been confirmed [11].

2. Intervention

Participants were assigned to either the MBAT group or the control group. The educational needs of the groups were determined. Each group met for 90-120 min twice weekly, for 6 weeks and 12 sessions. One month was set aside for completion of the survey (pre-intervention and post-intervention). The curriculum focused art therapy in Monti et al. [12]. Therapy sessions, as follows:

First session: introduction to art making. “Draw a complete picture of yourself” self-picture assessment (SPA) task. Second session: mindful exploration of art materials (colored pencil, marker, pastel, watercolor crayon, and paint). Awareness of sensory stimulus and response. Body scan meditation, attitudinal foundations of mindfulness. Anchoring attention with the breath.

Session 3: exploring the mind-body relationship: pre–post assessment of mind/body relationship before and after gentle yoga. Fourth session: creative problem-solving/imaging self-care. Transforming mental, emotional and physical pain; introducing self-care imagery into the picture.

Session five: exploring meditation practice experience: art productions, using collage element, serve as the basis for increasing skills with mindfulness practice in the realm of thoughts and feelings. Session six: stressful and pleasant event pictures as introduction to the physiology of stress including stressful communication/non-reactive communication skills. Session seven: Open studio: free-art making. Session eight: Guided imagery to a place of healing. Session nine: drawing a complete and healthy picture of yourself based on this visualization of health; care of mind consciousness, focusing on your complete and healthy image. Session ten: SPA task. Sessions eleven and twelve: Group discussion and sharing of member experiences and summaries on the content of all sessions.

3. Statistical analysis

The age group was 60.75 ± 3.53 in the MBAT group and 60.35 ± 3.77 in the control group (Table 1). The majority of MBAT and control group has university (69.5%) and high school (29.5%) degree respectively and the education level of husband in MBAT and control group has been high school degree (50%) and university degree (40%) respectively. The job of majority of research units in both groups was housewife (75%). The husband’s job in MBAT and control group was freelance (62.5%). The income of the majority of research units (95%) was enough. The majority of research units (75.3%), in terms of housing status, had their personal home. In the present study, the hypothesis of naturalness in dimensions of the lifestyle score in both the MBAT and control groups was investigated by the Independent-Samples T Test and the results indicated that this hypothesis was established. Based on the results, both hypotheses were validated.

Table 1

Mean age, age of menopause in MBAT and control groups before of intervention

Variables	MBAT	Control	(Independent-Samples T Test)
	Mean ± SD*	Mean ± SD*
Age (year)	3.53 ± 60.75	3.77 ± 60.35	t = -0.352
			p = 0.802
			df = 104
Age of menopause	1.56 ± 51.15	1.47 ± 51.18	t = -0.04
			p = 0.784
			df = 104

*SD: standard deviation.

Table 2 shows, the average rates of physical activity, nutrition, stress management, spiritual growth, interpersonal relations, health responsibility in MBAT group was increased meaningfully (p < 0.05); these changes were not meaningful in control group (Table 2).

Table 2

The comparison among the average of studied variables in group of MBAT and control, before and after intervention

Groups	MBAT*		Control*		ANOVA with post-hoc comparisons
Variables	Before	After	Before	After
Physical activity	12.89 ± 3.55	14.89 ± 3.55	3.19 ± 11.47	11.72 ± 3.08	p = 0.120
					F = 11.40
Nutrition	1.35 ± 21.35	35.14 ± 3.35	6.46 ± 21.70	21.80 ± 5.98	p = 0.001
					F = 19.63
Stress management	17.24 ± 1.12	21.54 ± 1.12	9.35 ± 17.12	18.97 ± 8.84	p = 0.001
					F = 17.54
Spiritual growth	2.42 ± 15.05	19.10 ± 1.87	2.44 ± 15.15	2.17 ± 4.17	p = 0.002
					F = 20.48
Interpersonal relations	2.50 ± 17.50	21.34 ± 2.54	19.00 ± 19.00	19.30 ± 9.00	p = 0.001
					F = 20.43
Health responsibility	12.42 ± 3.05	16.87 ± 4.10	12.44 ± 3.15	13.17 ± 3.17	p = 0.006
					F = 18.49

*Mean ± Standard deviation.

DISCUSSION

Overall, the results of the study provide preliminary support for the hypotheses that the MBAT intervention can help improve style of life. Results of this study are consistent with those of other mindfulness studies of groups and cancer patients [13].

Although we note that this is the first mindfulness-based study reporting significant outcomes for menopausal women. In addition, the results indicate a possible advantage over standard support, when comparing HPLP II-52 results of a recent study by Helgeson et al. [14]. Clearly, further testing is required to assess whether the synergy of the proven techniques incorporated in the MBAT protocol provides an advantage for menopausal women over any one of these techniques alone.

It is noteworthy that two of the three endpoints we chose for the study did not demonstrate the greatest therapeutic effect as compared to other measured endpoints. For example, changes in the stress management subscale of the HPLP II-52 were significant. Certainly, the most sensitive indicator of change on the HPLP II-52 for this study group was the GSI, which is considered to be the best single indicator of current level of emotional distress [14].

The results revealed statistically significant improvements on four of eight HPLP II-52 subscales and to a lesser degree on the mental composite summary scale.

Statistical significance was not demonstrated on the physical composite summary score as hypothesized. One possible explanation is that symptoms that comprise the physical composite score, such as bodily pain and physical functioning, were not significantly moderated by the intervention. This would be surprising for the pain aspect, given that relaxation is part of the intervention.

Other possible explanations are that the study period was not sufficient for newly acquired skills to affect those variables or that the receipt of food supplements. It was not surprising that the mental health subscale was highly significant, since, like the HPLP II-52, it is an indicator of psychological distress.

The high statistical significance on the general health subscale of the HPLP II-52, an indicator of perception of wellness or illness, may reflect the intervention is success at helping menopausal women focus on a life perspective. In the MBAT intervention, participants receive support to develop tools for observing and assessing their experiences. MBAT is intended to facilitate a sense of control in participants through knowledge that they have the choice to hold their illness experience as is or alter them relationship to particular aspects and events.

In the MBAT model, this goal is accomplished by learning self-awareness through directed observation (mindfulness practices) and creative expression of internal thoughts and emotions (art therapy) and by enhancing self-acceptance through verbal and nonverbal bonding and social support (group therapy).

The high statistical significance on the vitality subscale of the HPLP II-52 was of interest given that there was also a significant improvement on the sleep items embedded in the “additional items” dimension of the HPLP II-52. Together, these data strongly suggest that women in the experimental intervention felt more rested, and perhaps, less fatigued. This is noteworthy because fatigue is a well-documented problem among women with menopausal [13]. It negatively affects style of life by limiting participation in activities of daily living. Other parameters of fatigue might be explored in future studies. There were several limitations to the study. First, this was a pilot study that had an inactive control group (wait list). Since MBAT is a multimodal intervention, the control group for the next level of investigation should be an active component of the MBAT intervention, such as a support group without the other components. This also would control for contact time with study personnel. The post intervention HPLP II-52 data are encouraging, but not sufficient to predict long-term effects of the intervention. The results of the study cannot be generalized to all women with breast cancer. In summary, this randomized, controlled investigation of MBAT provides encouraging initial data regarding the intervention is potential for reducing symptoms of distress and improving key aspects of style of life in women with breast cancer. Currently, there are few randomized, controlled, clinical trials on standardized alternatives to the usual supportive-expressive women with breast cancer group model. Although there are some study limitations, the results provide support for further investigation of this novel intervention.

CONCLUSION

According to the findings of this research and similar studies, it is suggested to the prenatal healthcare providers that along with the use of strategies for promoting physical health, the mental esthetic program should be considered as one of the undesirable beneficial interactions with the aim of increasing the mental health of this women are benefited; therefore, knowledge-based art therapy is effective as a new method, which improve the style of life menopausal women. Therefore, widespread use of this method in such populations is suggested.