Types of participants
Participants will be people aged 65 years or over, who are considered “healthy’” i.e. with no evidence or diagnosis of dementia or other cognitive disabilities. They will either be in nursing home care, community care, day care, residential, low-care, supported living or the medical home. They may have no family or other emotional support and be suffering from increasing introspection, which can have a profound impact on a person's physical and mental health.
Types of intervention(s)/phenomena of interest
The intervention of interest will be art therapy with a focus on the visual arts. All available techniques will be considered, including for example, art therapy sessions using a variety of tools, drawing, painting, computer manipulated imagery, photography and any other mode of visual expression. Art therapy techniques examined will be those used in the group situation or with the individual aged person. There will be no limitations as to who runs the art therapy program (i.e. artist, professional art therapist, general therapist), and the therapy can be self-directed. Duration and frequency of sessions can vary, depending on a person's health and stamina.
The phenomena of interest will be the experiences and meaning assigned to participating in art therapy by elderly people.
The comparator will be no intervention, that is, participants who experienced art therapy will be compared to those who did not.
Types of outcomes
Quantitative outcomes will look at physical and mental health outcomes and behavioral characteristics as measured by self-report or validated scales/instruments. Indicators will include measures of cognitive function, depression scales and frequency of participation in-group or individual art therapy activities. Changes in the participants' communication skills, social interaction, behavioral problems (e.g. stereotypic behavior, and attention and concentration skills) will be key outcome indicators of the intervention.
Qualitative outcomes will be subjective from the patient's point of view: how do they react to the feelings and emotions which they experience from the therapy sessions? Does the reminiscing help or make them feel sad for what they have lost, or happy for what they've had in their past? Does the person have an improved Quality of Life (QOL) because they are happier and feeling a sense of increased self-esteem by participating in group therapy, or achieving that painting they have always wanted to produce? As a result of the art therapy intervention, do they have improved cognitive abilities; do they cope with stress and adverse events more easily; has their outward demeanor changed all reflection their state of mental health?
Studies will be excluded if they have a focus on the performing arts - music, dance and drama. Participants will be excluded if they are under the age of 65 and if they have been diagnosed with dementia, Alzheimer's or other cognitive disorders. Editorials and opinion articles will be excluded.
Types of studies
Any quantitative, (e.g. comparative art therapy methodologies in the delivery of interventions) or qualitative study designs, (e.g. client self-evaluations or case progress notes) will be considered for this review. Each study will be classified according to the JBI levels of evidence (Appendix I) and preference will be given to those higher in the hierarchy of evidence such as randomized controlled trials (RCTs). Studies that are long term follow-up and observational cohorts will be included, as will guidelines from professional associations that are based on studies rather than expert opinion.
The search strategy will aim to identify both published and unpublished studies from 2004 to 2014. Although art therapy has existed as an intervention for some time, this review seeks to identify the best available, most up to date research. There have been a number of RCTs conducted in recent years, but to date, no systematic reviews on this topic has been published, and thus a time span of 10 years is deemed important to capture a substantive pool of research for the synthesis of this systematic review.
A three-step search strategy will be utilized in each component of this review. An initial limited search of MEDLINE and CINAHL will be undertaken, followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference lists of all identified reports and articles will be searched for additional studies. Only studies published in the English language will be considered for inclusion.
The databases to be searched include:
Cochrane Central Register of Controlled Trials (CENTRAL)
CSA Sociological abstracts
ISI Web of Knowledge
Health Source: Nursing/Academic Edition
The search for unpublished studies will include:
ProQuest Dissertations and Theses
Index to Theses
The Networked Digital Library of Theses and Dissertations (NDLTD)
Experts in the field will be consulted such as those registered with the Australian and New Zealand Art Therapy Associations (ANZATA), American Art Therapy Association (AATA), British Association of Art Therapy, as well as any other countries with credible associations, together with University lecturers and Art Therapists.
Additional searches will be conducted in specialist journals such as ‘The Arts in Psychotherapy’ to eliminate any excluded citations in the databases.
Initial keywords to be used are:
Concept 1: art therapy, art psychotherapy, art therapists, therapeutic arts, artistic expression, visual expression
Concept 2: aged care, aged, gerontology, elderly, healthy aging, older adults
Concept 3: self-esteem, social interaction, well-being, quality of life, self-concept, memory, hope, behavioral research
Assessment of methodological quality
Quantitative and qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using the appropriate standardized critical appraisal instruments, MASTARI (Meta Analysis of Statistics Assessment & Review Instrument) and QARI (Qualitative Appraisal & Review Instrument) from the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI-SUMARI, Appendix II). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.
Quantitative and qualitative data will be extracted from papers included in the review using the appropriate standardized data extraction tool from JBI-SUMARI (Appendix III).
For quantitative data all results will be subject to double data entry. Odds ratios (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed using the standard Chi-square. Where statistical pooling is not possible the findings will be presented in narrative form.
Qualitative research findings will be pooled where possible, using JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represents the aggregation through assembling the findings according to their quality and categorizing these findings on the basis of similarity in meaning. These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings.
Conflicts of interest
The authors have no conflicts of interest to declare.
Grateful thanks to Dr. Sarahlouise White, for her assistance in the revision of this protocol.
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Appendix I: Medline search strategy
Appendix II: Appraisal instruments
MAStARI appraisal instrument
QARI appraisal instrument
Appendix III: Data extraction instruments
MAStARI data extraction instrument
QARI data extraction instrument