A Pilot Intervention Study of Structured Art Therapy to Enhance Psychological Well-Being and Quality of Life in Older Adults

Umi Hani*, Maula Mar'atus Solikhah, Fitriyana Maharani, Layla Nur Fatihah

Department of Nursing, Faculty of Medicine, Universitas Diponegoro, Jl. Prof. Soedarto Gedung F, FK, Tembalang, Kec. Tembalang, Kota Semarang, Jawa Tengah 50275, Indonesia

*Corresponding Author’s Email: umi.hani.ners@gmail.com

ABSTRACT

Background: Aging leads to decreases in physical, mental, and social abilities, affecting the well- being of older people. Although art therapy is widely used, there is still little research on its specific methods and benefits for older adults. This study looked at the initial effects of organized art therapy on enhancing the Quality of Life (QoL) and Psychological Well-being (PWB) of older adults. Methods: This pilot study used a quasi-experimental design with pre- and post-tests without a control group. Art therapy, including drawing, coloring, making handicrafts, and collage activities, was conducted in one nursing home in Semarang, including 40 residents experiencing loneliness based on the University of California, Los Angeles (UCLA) loneliness scale. The World Health Organization Quality of Life - Bref (WHOQOL-BREF) questionnaire and the Ryff’s Psychological Well-Being Scale (RPWBS) were used. Since the data distributed normally, a paired t-test was used to examine the effects of art therapy; meanwhile, the QoL domains used the Wilcoxon signed rank test because the data did not distribute normally. Results: Post-intervention assessments indicated an improvement in both QoL and PWB scores, with the average QoL score increasing by 5.86 and the average PWB score rising by 4.35. Nevertheless, these results are preliminary and should not be construed as definitive evidence of effectiveness. Conclusion: Preliminary findings suggest that the intervention is feasible and may improve QoL and PWB. Nonetheless, the clinical utility of the intervention is not yet established, owing to the pilot study design, small sample size, and non-probability sampling. Consequently, larger controlled studies are necessary.

Keywords: Aged; Art Therapy; Feasible, Lonely, Mental Health

INTRODUCTION

Mental health problems are prevalent in older adults. The global prevalence rates for depression, anxiety, and stress in older people are 19.2%, 16.5%, and 13.9%, respectively. These rates are notably higher in certain regions and among specific groups, such as those in nursing homes (Jalali et al., 2024). Likewise, in Indonesia, depression is a common problem among seniors aged 75 and over, with a prevalence of 14.5% (Ministry of Health Republik Indonesia, 2018; Santoso et al., 2023). Other research indicates that 60.03% of seniors experience depressive symptoms (Susanty et al., 2024).

The major contributor to depressive symptoms in older adults, particularly among nursing home residents is loneliness (Isik et al., 2021; Zhao et al., 2018). It is up to 71% residents who report experiencing loneliness (Molas-Tuneu et al., 2023). Fear of death and comorbid diseases in addition to aging conditions often impact mental health problems that diminish QoL by impairing physical health, social relationships, and PWB (Bharti & Bharti, 2024; Koçak et al., 2025). Likewise, PWB, including personal growth, purpose in life, and emotional stability factors, is closely linked to increased emotional distress that is also associated with lower QoL (Lopez et al., 2024; Sadauskaitė et al., 2025).

The World Health Organization (WHO) states that the number of people aged 60 years or older is expected to exceed 2 billion by 2050, which will likely increase the prevalence of mental health issues in this demographic (Al-Mossawy et al., 2025; Fakhimi, 2025). The low level of QoL and PWB contribute to reduced independence and autonomy (de Mendonça Lima et al., 2019; Supasiri et al., 2019). It strains public health and social welfare systems through higher healthcare costs, hospitalizations, and demand for mental health services; therefore, the WHO emphasizes early diagnosis and comprehensive care to prevent poorer outcomes. (Fakhimi, 2025).

Pharmacotherapy is commonly employed to address mental health concerns in older adults. However, it is associated with adverse effects and potential drug interactions (Baron & Uno, 2019). Non-pharmacological interventions, including cognitive behavioral therapy, social engagement, and art therapy, present viable alternatives to enhance PWB and life satisfaction (Gunawan et al., 2025; Liang, 2024). Previous studies reported elderly activities that involve physical, emotional, and social activities showing many positive impacts on QoL and PWB (Lakshmanan et al., 2024; Liu et al., 2025).

Several studies have shown art therapy to address mental health issues in various age groups and conditions. Art therapy contributes to PWB by nurturing artistic identity, developing a sense of purpose, and facilitating social connections (Rossano & Cotter, 2024; Seo et al., 2021). It has been shown to effectively enhance cognitive functioning and provide emotional comfort for older individuals experiencing cognitive decline (Sahai & Tiwari, 2025) and alleviate anxiety and improve PWB and QoL in older adults (Emblad & Mukaetova-Ladinska, 2021; Putri et al., 2025). A study on creative and arts-based interventions such as engaging in poetry sessions has been shown to foster resilience and social connectedness, thereby enhancing PWB (Badawy et al., 2024; Choi, 2025).

Some studies have shown that art therapy can significantly improve QOL in pediatric (Zhou et al., 2025) and adult cancer patients, alleviating emotional symptoms and increasing mental resilience and self-esteem (Bosman et al., 2021; Elimimian et al., 2020). Seeing that art therapy demonstrated potential in enhancing the PWB and QoL of older adults by focusing on essential aspects of well- being such as self-acceptance (Haeyen & Wanten, 2024), life purpose, and positive relationships, the RPWBS Theory offers a comprehensive framework for comprehending and enhancing PWB through this therapeutic method (Laranjeira et al., 2019; Springer et al., 2011). The design and implementation of interventions vary greatly, including differences in duration, delivery format, and specific activities. This variability makes it difficult to compare results across studies and to draw clear conclusions about their effectiveness. Moreover, there is limited evidence of how feasible and acceptable a standardized intervention protocol is for the target population. Therefore, this pilot study was conducted to evaluate the feasibility and initial effects of a standardized intervention protocol.

METHODOLOGY

Study Design and Sample

This was a quantitative pilot study that employed a pre- and post-intervention evaluation without a control group. This study was conducted at a nursing home in Semarang City, Indonesia, with a total of 56 residents, 40 of whom were selected using a purposive sampling technique. Participants were selected based on several inclusion criteria, including functional status (Katz Index B), ability to understand instructions and communicate well, and experiences of loneliness (using the UCLA Loneliness Scale).

Participants unable to complete the full program were excluded. The sample was small because the study targeted lonely older adults in a limited number of nursing homes in Semarang. Nevertheless, as a feasibility study, it provides an important empirical foundation for larger studies by focusing on intervention feasibility and participants’ initial responses rather than broad population-level applicability (Li et al., 2021; Sim, 2021).

Research Tools

The UCLA loneliness scale consists of 20 items that have been translated into Indonesian and validated by expert judgment. This scale uses a Likert scale model with 4 alternative answers: Always (S), Often (S), Rarely (J) and Never (TP). There are positive (favorable) question items at numbers 2, 3, 4, 7, 8, 11, 12, 13, 14, and 17 as well as negative (unfavorable) question items at numbers 1, 5, 6, 9, 10, 15, 16, 19, and 20. The total score of the 20 question items will be interpreted into 4 categories, namely not lonely (20-34), mild loneliness (35-49), moderate loneliness (50-64), and severe loneliness (65-80).

This study investigated the feasibility of art therapy as a nursing intervention to enhance the PWB and QoL among older adults. PWB is a multifaceted construct that encompasses various aspects of mental health and QoL. It includes emotional, cognitive, personality, and social factors, playing a crucial role in overall mental health and life satisfaction (Pelagi et al., 2025). The 18-item RPWBS was used to measure PWB. The Indonesian version has six parts that make up PWB. PWB is determined by the total score obtained from self-assessments described through items in a Likert- style questionnaire. The questionnaire has excellent construct validity and high reliability (Muttaqin, 2022; Springer & Hauser, 2006).

Meanwhile, QoL can be understood as the way individuals view their lives in the context of society, which is influenced by existing culture and value systems (Vila et al., 2024). QoL was assessed using the WHOQOL-BREF, a 26-item questionnaire covering four main domains with high internal consistency, including the Indonesian version. Each domain is the sum of several questions, namely the physical domain (Q3, Q4, Q10, Q15, Q16, Q17), the psychological domain (Q5, Q6, Q7, Q11, Q19, Q26), the social domain (Q20, Q21, Q22), and the environmental domain (Q8, Q9, Q12, Q13, Q14, Q23, Q24, Q25). The scores from each domain (raw scores) will later be transformed into a value of 0-100 using transformed scores. The scores for each domain are accumulated and divided by 4, then categorized as follows: high QoL ≥ 67, moderate quality of life ≥ 33 and < 67 and low QoL < 33 (Goes et al., 2021; Sofiana et al., 2023). Both instruments are those that have been published openly and widely used in previous research.

Implementation Phase

Respondents completed six one-hour art therapy sessions. At the beginning of the program, social engagement, therapy ethics, and treatment goals were introduced to build trust (King et al., 2021). As outlined in Table 1, the sessions included handicrafts such as headbands, flowers, and key chains (Igreja et al., 2025; Pöllänen & Weissmann-Hanski, 2020), collage-making using old newspapers (Pramudito et al., 2023), and drawing and coloring (Turturro & Drake, 2022), with materials tailored to each activity. Each session comprised orientation, core activities, and reflection facilitated by nursing students and nursing home staff (Forchuk, 2024; Forchuk et al., 2021). Further activity details are presented in Table 1.

Data was analyzed using IBM SPSS statistical software version 2017, Chicago, USA. To assess statistical differences between pre- and post-intervention, a paired sample test was employed, given the normal distribution of the total score data. This analysis aimed to evaluate the significant impact of art therapy on respondents' QoL and PWB. Conversely, as the QoL data per domain did not follow a normal distribution, the Wilcoxon signed rank test was utilized. The significance level was established at α = 0.05.

Table 1: Art Therapy Activities

Ethical Considerations

The researchers obtained ethical approved from the Ethical Committee of the Faculty of Medicine, Universitas Diponegoro, Indonesia, with reference number 097/EC/KEPK/FK-UNDIP/IV/2025 on 24th April 2025.

RESULTS

Respondents Characteristic

Forty residents, aged 51–90, who experienced loneliness participated in the screening process. Most were female, aged 61-70, and had graduated from elementary school. All respondents experienced loneliness (Table 2).

Table 2: Characteristics of Older Adults (N=40)

Effect of the Structured Art Therapy

Respondents showed differences in QoL before and after art therapy intervention, as shown in Figure 1 and Table 3.

Figure 1: Changes in Quality of Life (N=40)

Figure 1 shows that the number of respondents with high and moderate QoL increased from 15% to 20% and from 58% to 68%, respectively, while low QoL decreased by 5% after the art therapy intervention was given. Respondents with moderate QoL still constitute the largest number. Meanwhile, this study evaluated the domains of QoL. The most significant improvement in average QoL was seen in the psychological domain, followed by the social, physical, and environmental domains (Table 2).

Table 3: Improvement Score of the Quality of Life in Every Domain

a: standard deviation

Table 3 presents the minimum, maximum, mean, and standard deviation values of QoL and PWB, showing that structured art therapy significantly affected and was associated with changes in both outcomes.

Table 4: Comparison of Difference of Quality of Life and Psychological Well-being before and after Structured Art Therapy

a: Standard Deviation; Sig=Significance; d= Cohen’s dz; df=Degree of Freedom

Table 4 results showed a paired-samples t-test on QoL and a significant difference between pre- and post-treatment scores, t (39) = −12.71, p < 0.001, with a very large effect size (Cohen's dz = 2.01). For PWB, t (39) = −15.74, p < 0.001, with a very large effect size (Cohen's dz = 2.49), indicating the treatment had a very strong impact on changes in respondents' scores.

DISCUSSION

The results of the study showed the shift in QoL and PWB levels after structured-art therapy (QoL 52.76 to 58.62 and PWB 44.03 to 48.37). Most participants showed consistent score improvements, with confidence intervals favoring improvement and suggesting intervention-related rather than coincidental changes. This is consistent with a previous systematic review reporting significant benefits of art therapy for QoL and cognitive and emotional functioning (de Souza et al., 2022). Another study by Shoesmith et al. (2021) found that a six-week, person-centred art intervention may improve QoL and social functioning in people with dementia, choice and socialization supporting its acceptability.

Art therapy activities are related to the opportunity for the elderly to express their emotions and thoughts in each art therapy session (Lachnit & Rastogi, 2023; Putri et al., 2025), which can help stabilize the emotions of older adults and create a comfortable environment (Albañil-Delgado et al., 2020; Putri et al., 2025). During reflection sessions, participants reported comfort, peace, and enjoyment, suggesting that art activities provided relaxing sensory stimulation during leisure time. From a biopsychosocial perspective, improvements across all QoL domains, particularly social and psychological well-being, may reflect the benefits of psychosocial stimulation, social engagement, and participant choice rather than biomedical changes alone (Bolton, 2023; Ngamwongwiwat et al., 2023).

Peplau’s Interpersonal Relations Theory assumes that structured art therapy leverages preserved capacities and facilitates therapeutic communication through nonverbal expression (Culligan et al., 2025; Durocher et al., 2022). Therefore, activities like drawing, painting, and other forms of creative expression can be soothing and help manage and alleviate anxiety symptoms and depression (Abbing et al., 2019; Koltz & Koltz, 2022) and improve cognitive functions from painting activities, which are particularly effective in impacting QoL among older adults (Masika et al., 2020; Putri et al., 2025).

Crafting in art therapy provides calming tactile stimulation, maintains sensory engagement, and helps mental health by reducing stress and anxiety (Koltz & Koltz, 2022; Vasudevan et al., 2025). Art activities allow older adults to express their creativity, cultural values, and personal interests, thereby enhancing life satisfaction and a sense of purpose. Furthermore, the use of fine motor skills and hand-eye coordination can maintain physical mobility and QoL (Albañil-Delgado et al., 2020; Kalma et al., 2019). Improvements in the physical and environmental domains showed indirect positive effects, such as increased self-efficacy, sense of meaning, and comfort in social settings during sessions. Another study testing art therapy in the form of the Art, Colors, and Emotional Treatment (ACE-t) showed significant improvements in general cognition, language, and executive functions among participants (Savazzi et al., 2020).

Older adults who experience psychological and mental disorders need to receive the right intervention (Kertapati et al., 2022). Clinically, structured art activities may enhance social interaction, emotional expression, meaning in life and reduce psychological distress, supporting their use as a psychosocial nursing intervention for older adults. Art therapy may also improve cognitive well-being through greater neural plasticity and emotional engagement (Sahai & Tiwari, 2025). Another study highlighted the effectiveness of art therapy in reducing depressive symptoms and increasing self-esteem in elderly people in nursing homes, thus having a positive impact on PWB (Ching-Teng et al., 2019).

From a gerontological perspective, structured art therapy aligns with the concept of successful aging and the theory of selective optimization with compensation, where the elderly are encouraged to use the capacities, they still have while also finding new ways to maintain psychological function (Moeller & O’Brien, 2024). Psychologically, the increase in PWB suggests that art can be a medium for self-reflection and meaning construction, which is particularly important in the final stages of life for older adults (Koltz & Koltz, 2022; Stephenson, 2021). This relationship is theoretically grounded in the RPWBS model, which assumes that opportunities for emotional expression, reflection, and meaning making facilitated through art activities support self- acceptance and purpose in later life (Darewych, 2022).

The variety of forms of arts interventions and the lack of standards make research findings diverse (Lee et al., 2019). One study explained that the activities, which are readily accessible, have demonstrated improvements in mood and self-esteem among older adults (Fraser & Ostby, 2022). Art therapy like Arts on Prescription has shown positive impacts on mental well-being, creativity, and social relationships among older adults because it serves as a means of self-reflection and meaning making, which are important in the aging process (Malhotra et al., 2024; Poulos et al., 2019).

The adherence and acceptability of art therapy among elderly participants suggest that these individuals are willing to engage in such interventions (Savazzi et al., 2020). Therefore, group- based community activities offer holistic support for cognitive, emotional, and social well-being. Craft groups strengthen social connections, reduce isolation, foster belonging and mutual support, affirm individual and collective strengths, and promote continued learning and development (Schnittka, 2021). Also, Keisari et al. (2024), supports these findings, noting consistent modest gains in well-being indicators across various art therapy interventions, which prioritize participant engagement and implementation fidelity over causal inference.

This study evaluated the initial findings of an art therapy model that integrates drawing, coloring, crafting, and collage. The primary aim of a pilot study is often to identify potential challenges, refine methodologies, and assess the practicality of the intervention protocol. This preliminary phase helps ensure that subsequent research is well-designed and adequately powered to test hypotheses rigorously. Consequently, any observed effects or trends in the pilot study should be interpreted with caution and validated through more comprehensive trials before informing clinical practice or policy decisions (Adams-Price & Morse, 2018; Beets et al., 2020). Collectively, these studies support art therapy’s feasibility and acceptability across diverse cultural and clinical

settings, but further research is needed to confirm its efficacy as a psychosocial intervention for older adults.

Art therapy has important implications for gerontological nursing and can be integrated into assessment, diagnosis, planning, implementation, and evaluation across healthcare settings (Ho et al., 2019). Nurses also serve as educators and facilitators, enabling caregivers and social institutions to sustain interventions (Srolovitz et al., 2022). Through therapeutic communication, consistent with Peplau’s phases of orientation, identification, exploitation, and resolution, nurses can create a supportive environment in which older adults feel valued and confident expressing themselves. Using art as a communication medium may enhance openness and strengthen the nurse–patient relationship (Hall & Shearer, 2025).

As a pilot study, this research primarily serves to explore the feasibility, design, and initial outcomes of the intervention rather than to provide definitive evidence of its effectiveness (Beets et al., 2020). Pilot studies are typically conducted on a smaller scale with limited sample sizes and shorter durations, which restricts the generalizability and statistical power needed to draw firm conclusions about the intervention’s impact. Therefore, while the findings may offer valuable insights and guide the development of future, larger-scale studies, they should not be used as a conclusive reference for the intervention’s efficacy (Teresi et al., 2022).

Limitations

This feasibility study is limited by its small sample, lack of a control group, limited applicability to broader populations, and potential self-report bias; therefore, findings on feasibility, acceptability, and possible benefits should be interpreted cautiously. Future research should use adequately powered randomized controlled trials and longitudinal designs to establish causal effectiveness, assess long-term sustainability, examine moderator and mediator variables, and develop a standardized art therapy protocol for older adults.

Future Scope

Future research should further validate art therapy as a structured component of gerontological nursing care for older adults experiencing loneliness. Larger, fully powered randomized controlled trials and longitudinal studies are needed to assess its sustained effects on PWB and QoL, identify potential side effects, and develop appropriate management strategies. Further investigation should also clarify the most effective forms and structures of art therapy to support standardized, holistic nursing practice for aging populations.

CONCLUSION

Structured art therapy positively influences the QoL and PWB of isolated older adults. Enhancements in QoL across all four domains suggest that activities prompting seniors to their emotions and thoughts can stabilize emotions and foster a comfortable environment. Structured art therapy contributes to successful aging by encouraging older individuals to employ their existing skills and explore new methods to maintain cognitive function. Psychologically, the increase in PWB indicates that art engagement facilitates self-reflection and the search for meaning, which is crucial in later life stages. Participation in art activities provides opportunities for emotional expression, introspection, and meaning-making, promoting self-acceptance and a sense of purpose in later years.

Integrating artistic activities into social work care may guide long-term care towards a more diverse, unique, and innovative approach. Despite the evident benefits of art therapy, challenges

exist in its implementation, including the necessity for more rigorous scientific studies to thoroughly evaluate its efficacy and effectiveness. Additionally, research on art therapy with older adults often encounters challenges related to the specific needs and conditions of this demographic.

CRediT Authorship Contribution Statement

U.H.: Conceiving and designing the study, supervising the research process, collecting and interpreting data, drafting and revising the manuscript, and serving as the corresponding author. M.M.S.: Interpreted the research findings and enhanced the discussion to provide a more comprehensive interpretation of the results. F.M. and L.N.F: Data analysis and interpretation under the supervision of U.H. and M.M.S. All four authors significantly contributed to the manuscript's development, engaging collaboratively in essential tasks such as conceptualization, data analysis, drafting, and critical revision.

AI Assistance Declaration

Generative AI supported language editing, grammar improvement, idea generation, and discussion framing. All authors reviewed, revised, and approved the final manuscript and take full responsibility for its content.

Conflict of Interest

The authors declare that they have no competing interests.

ACKNOWLEDGEMENT

The authors thank Pucanggading Nursing Home, Indonesia, for supporting the therapy and all participants for their involvement. This research was funded by Universitas Diponegoro in the Young Lecturer Research Scheme Grant No. 222-140/UN7.D2/PP/IV/2025.

REFERENCES

Abbing, A., de Sonneville, L., Baars, E., Bourne, D., & Swaab, H. (2019). Anxiety reduction through art therapy in women. Exploring stress regulation and executive functioning as underlying neurocognitive mechanisms. PLoS ONE, 14(12). https://doi.org/10.1371/journal.pone.0225200

Adams-Price, C. E., & Morse, L. W. (2018). Crafts as serious hobbies: Impact and benefits in later life. Craft Research, 9(1), 93–102. https://doi.org/10.1386/crre.9.1.93_1

Albañil-Delgado, S., Aguilar Machain, P., & Guerrero-Castañeda, R. F. (2020). Home art therapy techniques as nursing care for older adults in contingency by covid-19. Cogitare Enfermagem, 25, 1–8. https://doi.org/10.5380/ce.v25i0.73883

Al-Mossawy, D. A., Radhi, O. A., Khudair, F. W., Al-Amarei, H. M., & Albandar, I. (2025). Mental health and death anxiety among community- dwelling elderly: A cross-sectional study. The Malaysian Journal of Nursing (MJN), 17(Supplementary 1), 131–138. https://doi.org/10.31674/mjn.2025.v17isupp1.013

Badawy, W. B. M., Mohamed, A. H., & Shaban, M. (2024). Effectiveness of a resilience-building nursing intervention on psychological well-being in Arab community-dwelling older adults. Geriatric Nursing, 60, 338–347. https://doi.org/10.1016/j.gerinurse.2024.09.024

Baron, D., & Uno, J. (2019). Biopsychosocial approaches to depression in the older adults. In Primary Care Mental Health in Older People: A Global Perspective (pp. 189–198). https://doi.org/10.1007/978-3-030-10814-4_16

Beets, M. W., Weaver, R. G., Ioannidis, J. P. A., Geraci, M., Brazendale, K., Decker, L., Okely, A. D., Lubans, D., van Sluijs, E., Jago, R., Turner-McGrievy, G., Thrasher, J., Li, X., & Milat, A. J. (2020). Identification and evaluation of risk of generalizability biases in pilot versus efficacy/effectiveness trials: A systematic review and meta-analysis. International Journal of Behavioral Nutrition and Physical Activity, 17, 19. https://doi.org/10.1186/s12966-020-0918-y

Bharti, A., & Bharti, D. A. (2024). Impact of death anxiety on psychological well-being and successful aging of older adults with chronic illness. Omega (United States). https://doi.org/10.1177/00302228241272543

Bolton, D. (2023). A revitalized biopsychosocial model: Core theory, research paradigms, and clinical implications. Psychological Medicine, 53(16), 7504–7511. https://doi.org/10.1017/S0033291723002660

Bosman, J. T., Bood, Z. M., Scherer-Rath, M., Dörr, H., Christophe, N., Sprangers, M. A. G., & van Laarhoven, H. W. M. (2021). The effects of art therapy on anxiety, depression, and quality of life in adults with cancer: a systematic literature review. Supportive Care in Cancer, 29(5), 2289– 2298. https://doi.org/10.1007/s00520-020-05869-0

Ching-Teng, Y., Ya-Ping, Y., & Yu-Chia, C. (2019). Positive effects of art therapy on depression and self-esteem of older adults in nursing homes. Social Work in Health Care, 58(3), 324–338. https://doi.org/10.1080/00981389.2018.1564108

Choi, J. (2025). Impact of elderly participation in poetry therapy programs on psychological well- Being and successful aging. Journal of Poetry Therapy, 1–12. https://doi.org/10.1080/08893675.2025.2487130

Culligan, J., Tasnim, N., Winter, P., Upthegrove, T., English, D. F., & Basso, J. C. (2025). Methods for measuring interpersonal behavioral and neural synchrony during group music therapy for individuals with dementia and their caregivers: A case series study. Journal of Alzheimer’s Disease, 105(4), 1097–1113. https://doi.org/10.1177/13872877251334406

Darewych, O. H. (2022). Cultivating psychological well-being through arts-based interventions. In The Oxford Handbook of the Positive Humanities (pp. 114–128). https://doi.org/10.1093/oxfordhb/9780190064570.013.8

de Mendonça Lima, C. A., Ivbijaro, G., Kumar, S., & Roy, J. (2019). Advocating for better mental health care for older adults. In Primary Care Mental Health in Older People: A Global Perspective (pp. 145–157). https://doi.org/10.1007/978-3-030-10814-4_12

de Souza, L. B. R., Gomes, Y. C., & de Moraes, M. G. G. (2022). Os impactos da arte-terapia visual para idosos com transtorno [The impacts of visual Art Therapy for elderly with Neurocognitive disorder: A systematic review]. Dementia e Neuropsychologia, 16(1), 8–18. https://doi.org/10.1590/1980-5764-DN-2021-0042

Durocher, E., Njelesani, J., & Crosby, E. (2022). Art activities in long-term care: A scoping review. Canadian Journal of Occupational Therapy, 89(1), 36–43. https://doi.org/10.1177/00084174211064497

Elimimian, E. B., Elson, L., Stone, E., Butler, R. S., Doll, M., Roshon, S., Kondaki, C., Padgett, A., & Nahleh, Z. A. (2020). A pilot study of improved psychological distress with art therapy in patients with cancer undergoing chemotherapy. BMC Cancer, 20(1). https://doi.org/10.1186/s12885-020-07380-5

Emblad, S. Y. M., & Mukaetova-Ladinska, E. B. (2021). Creative art therapy as a non- pharmacological intervention for dementia: A systematic review. Journal of Alzheimer’s Disease Reports, 5(1), 353–364. https://doi.org/10.3233/ADR-201002

Fakhimi, M. M. (2025). Smart-home innovation for older adults’ mental health: Reimagining usability and accessibility. Preventing Chronic Disease, 22. https://doi.org/10.5888/pcd22.250113

Forchuk, C. (2024). Peplau and therapeutic relationships. In The Nurses’ Guide to Psychotherapy: A Reference Book for Nurses Providing Psychotherapy (pp. 27–39). Springer Nature Singapore. https://doi.org/10.1007/978-981-97-4738-2_3

Forchuk, C., Westwell, J., Martin, M.-L., Azzopardi, W., Kosterewa-Tolman, D., & Hux, M. (2021). The developing nurse-client relationship: Nurses’ perspectives. In From Therapeutic Relationships to Transitional Care: A Theoretical and Practical Roadmap (pp. 45–51). https://doi.org/10.4324/9781003000853-96

Fraser, K. D., & Ostby, J. (2022). Collage: An often-neglected art form for use in health research- A Canadian exemplar. In Arts Based Health Care Research: A Multidisciplinary Perspective (pp. 137–153). https://doi.org/10.1007/978-3-030-94423-0_10

Goes, M., Lopes, M., Marôco, J., Oliveira, H., & Fonseca, C. (2021). Psychometric properties of the WHOQOL-BREF(PT) in a sample of elderly citizens. Health and Quality of Life Outcomes, 19(1), 146. https://doi.org/10.1186/s12955-021-01783-z

Gunawan, J., Aungsuroch, Y., & Montayre, J. (2025). A qualitative study of coping strategies for loneliness among Indonesian older adults: Implications for nursing practice. International Journal of Mental Health Nursing, 34(2). https://doi.org/10.1111/inm.70033

Haeyen, S., & Wanten, F. (2024). Effectiveness of trauma-focused art therapy (TFAT) for psychological trauma: A mixed method single case study. Arts in Psychotherapy, 91. https://doi.org/10.1016/j.aip.2024.102218

Hall, S., & Shearer, K. (2025). Applying Peplau’s interpersonal relations theory to enhance older adults’ health literacy through nursing care: A theory analysis. Journal of Holistic Nursing. https://doi.org/10.1177/08980101251345027

Ho, A. H. Y., Tan-Ho, G., Ngo, T. A., Ong, G., Chong, P. H., Dignadice, D., & Potash, J. (2019). A novel mindful-compassion art therapy (MCAT) for reducing burnout and promoting resilience for end-of-life care professionals: A waitlist RCT protocol. Trials, 20(1). https://doi.org/10.1186/s13063-019-3533-y

Igreja, S., Teles, S., & Paúl, C. (2025). Perceived health, quality of life and happiness among older professional artisans in a UNESCO Creative City of crafts and folk art. Frontiers in Psychology, 16. https://doi.org/10.3389/fpsyg.2025.1536447

Isik, K., Başoğul, C., & Yildirim, H. (2021). The relationship between perceived loneliness and depression in the elderly and influencing factors. Perspectives in Psychiatric Care, 57(1), 351–357. https://doi.org/10.1111/ppc.12572

Jalali, A., Ziapour, A., Karimi, Z., Rezaei, M., Emami, B., Kalhori, R. P., Khosravi, F., Sameni, J. S., & Kazeminia, M. (2024). Global prevalence of depression, anxiety, and stress in the elderly population: A systematic review and meta-analysis. BMC Geriatrics, 24(1). https://doi.org/10.1186/s12877-024-05311-8

Kalma, A., Ploderer, B., Sitbon, L., & Brereton, M. (2019). Probing yarns about ageing and making. ACM International Conference Proceeding Series, 173–183. https://doi.org/10.1145/3369457.3369472

Keisari, S., Orkibi, H., & Lang, F. R. (2024). Arts therapies and arts-based interventions for older adults. GeroPsych, 37(1). https://doi.org/10.1024/1662-9647/a000336

Kertapati, Y., Sahar, J., Nursasi, A. Y., & Mutyah, D. (2022). The effect of chair yoga with spiritual intervention on the life satisfaction of older adults. The Malaysian Journal of Nursing (MJN), 14(2), 60–66. https://doi.org/10.31674/mjn.2022.v14i02.011

King, G., Chiarello, L. A., Ideishi, R., Ziviani, J., Phoenix, M., McLarnon, M. J. W., Pinto, M., Thompson, L., & Smart, E. (2021). The complexities and synergies of engagement: an ethnographic study of engagement in outpatient pediatric rehabilitation sessions. Disability and Rehabilitation, 43(16), 2353–2365. https://doi.org/10.1080/09638288.2019.1700562

Koçak, F. Ö. K., Karapınar, A., Yılmaz, M., Eryuva, H., Ergin, I., & Akçiçek, S. F. (2025). The quality of life and loneliness among older adults in Third Age University: Case-control study. Aging Medicine and Healthcare, 16(2), 102–109. https://doi.org/10.33879/AMH.162.2023.04040

Koltz, R. L., & Koltz, D. J. (2022). Eco-art activities for older adults: Reducing stress and reframing aging. Family Journal, 30(3), 268–273. https://doi.org/10.1177/10664807211063196

Lachnit, I., & Rastogi, M. (2023). Online group art therapy: Encouraging creative healing in the virtual space. In The Virtual Group Therapy Circle: Advances in Online Group Theory and Practice (pp. 191–203). https://doi.org/10.4324/9781003248606-18

Lakshmanan, J., Gopalakrishnan, B., & Rajendran, S. S. (2024). Impact of mind-body interventions on psychosocial and bio physiological markers among elderly. Journal of Pharmacy and Bioallied Sciences, 16(Suppl 3), S2883–S2885. https://doi.org/10.4103/jpbs.jpbs_577_24

Laranjeira, C., Campos, C., Bessa, A., Neves, G., & Marques, M. I. (2019). Mental health recovery through “Art Therapy”: A pilot study in Portuguese acute inpatient setting. Issues in Mental Health Nursing, 40(5), 399–404. https://doi.org/10.1080/01612840.2018.1563255

Lee, R., Wong, J., Lit Shoon, W., Gandhi, M., Lei, F., EH, K., Rawtaer, I., & Mahendran, R. (2019). Art therapy for the prevention of cognitive decline. The Arts in Psychotherapy, 64, 20–25. https://doi.org/https://doi.org/10.1016/j.aip.2018.12.003

Li, G., Wu, D., Zhang, Y., Zhang, J., Li, Z., & Shang, H. (2021). Introduction to pilot and feasibility studies in medical research. Chinese Journal of Evidence-Based Medicine, 21(5), 617–620. https://doi.org/10.7507/1672-2531.202011065

Liang, L.-Y. (2024). The impact of social participation on the quality of life among older adults in China: A chain mediation analysis of loneliness, depression, and anxiety. Frontiers in Public Health, 12. https://doi.org/10.3389/fpubh.2024.1473657

Liu, L., Li, J., Tang, Y., Chen, C., Yu, C., Li, X., Peng, L., & Zheng, D. (2025). The impact of life events on health-related quality of life in rural older adults: the moderating role of social support. Frontiers in Public Health, 13. https://doi.org/10.3389/fpubh.2025.1587104

Lopez, J., Perez-Rojo, G., Noriega, C., Sánchez-Cabaco, A., Sitges, E., & Bonete, B. (2024). Quality-of-life in older adults: its association with emotional distress and psychological wellbeing. BMC Geriatrics, 24(1). https://doi.org/10.1186/s12877-024-05401-7

Malhotra, B., Jones, L. C., Spooner, H., Levy, C., Kaimal, G., & Williamson, J. B. (2024). A conceptual framework for a neurophysiological basis of art therapy for PTSD. Frontiers in Human Neuroscience, 18. https://doi.org/10.3389/fnhum.2024.1351757

Masika, G. M., Yu, D. S. F., & Li, P. W. C. (2020). Visual art therapy as a treatment option for cognitive decline among older adults. A systematic review and meta-analysis. Journal of Advanced Nursing, 76(8), 1892–1910. https://doi.org/10.1111/jan.14362

Ministry of Health Republik Indonesia. (2018). Laporan Nasional Riset Kesehatan Dasar [National Report on Basic Health Research]. Kementerian Kesehatan RI, 1–582. https://www.badankebijakan.kemkes.go.id/repositori/id/eprint/3514/1/Laporan%20Riskesdas%20 2018%20Nasional.pdf

Moeller, M., & O’Brien, W. H. (2024). Integrating acceptance and commitment therapy with selective optimization with compensation to predict wellbeing. Clinical Gerontologist, 1–13. https://doi.org/10.1080/07317115.2024.2432912

Molas-Tuneu, M., Jerez-Roig, J., Minobes-Molina, E., Coll-Planas, L., Escribà-Salvans, A., Farrés- Godayol, P., Yildirim, M., Rierola-Fochs, S., Goutan-Roura, E., de Souza, D. L. B., Skelton, D. A., & Naudó-Molist, J. (2023). Social and emotional loneliness among older people living in Nursing Homes in Spain: A cross-sectional study. Anales de Psicologia, 39(3), 465–477. https://doi.org/10.6018/analesps.530641

Muttaqin, D. (2022). Internal structure evaluation on the Indonesian version of psychological well- being scales. Psympathic Jurnal Ilmiah Psikologi, 9, 1–16.

https://doi.org/10.15575/psy.v9i1.10710

Ngamwongwiwat, B., Kongsuwan, V., & Songwathana, P. (2023). Interventions for Improving mental health and quality of life of older adults with mental illness in long-term care: A systematic review and meta-analysis. Pacific Rim International Journal of Nursing Research, 27(4), 671–693. https://doi.org/10.60099/prijnr.2023.261505

Pelagi, A., Camastra, C., & Sarica, A. (2025). Social, emotional, and personality factors shape four psychological well-being profiles: A clustering approach in young adults with affinity propagation algorithm. Applied Psychology: Health and Well-Being, 17(5). https://doi.org/10.1111/aphw.70072

Pöllänen, S. H., & Weissmann-Hanski, M. K. (2020). Hand-made well-being: Textile crafts as a source of eudaimonic well-being. Journal of Leisure Research, 51(3), 348–365. https://doi.org/10.1080/00222216.2019.1688738

Poulos, R. G., Marwood, S., Harkin, D., Opher, S., Clift, S., Cole, A. M. D., Rhee, J., Beilharz, K., & Poulos, C. J. (2019). Arts on prescription for community-dwelling older people with a range of health and wellness needs. Health and Social Care in the Community, 27(2), 483–492. https://doi.org/10.1111/hsc.12669

Pramudito, A., Barbareschi, G., & Sato, C. (2023). Enhancing Self-reflection in older adults through collage making. ACM International Conference Proceeding Series, 236–239. https://doi.org/10.1145/3627050.3631568

Putri, N. R. I. A. T., Cahyaningrum, E. D., Wurdaningsih, T. K., Syangadah, Z., & Mesayu, S. F. (2025). Evaluation of coloring therapy as an anxiety reduction strategy in the older adults in the community area. BIO Web of Conferences, 152. https://doi.org/10.1051/bioconf/202515201032

Rossano, J. M., & Cotter, K. N. (2024). Thriving through the arts: Pathways to social well-being for older women. Women and Therapy, 47(4), 485–502.

https://doi.org/10.1080/02703149.2024.2391242

Sadauskaitė, R., Šimulionienė, R., & Gedutienė, R. (2025). The relationship of psychological well- being with adaptive and maladaptive functioning among older adults in Lithuania. Health Psychology Report, 13(1), 55–66. https://doi.org/10.5114/hpr/194437

Sahai, S., & Tiwari, P. (2025). Art Therapy as a promising approach for cognitive rehabilitation in the elderly: A meta-analysis. In Health Psychology in Integrative Health Care. https://doi.org/10.4324/9781003596806-26

Santoso, P. M. A., Turana, Y., Handajani, Y. S., & Suryani, E. (2023). The relationship of diabetes mellitus, cognitive impairment, sleep disturbance, and sleep impairment on depression among elderly 75 years old and over in Indonesia. Aging Medicine and Healthcare, 14(3), 122–129. https://doi.org/10.33879/AMH.143.2022.01004

Savazzi, F., Isernia, S., Farina, E., Fioravanti, R., D’Amico, A., Saibene, F. L., Rabuffetti, M., Gilli, G., Alberoni, M., Nemni, R., & Baglio, F. (2020). “Art, Colors, and Emotions” treatment (ACE-t): A pilot study on the efficacy of an art-based intervention for people with Alzheimer’s disease. Frontiers in Psychology, 11. https://doi.org/10.3389/fpsyg.2020.01467

Schnittka, C. G. (2021). Older adults’ philanthropic crafting of face masks during COVID-19. Craft Research, 12(2), 223–245. https://doi.org/10.1386/crre_00051_1

Seo, J. H., Sungkajun, A., & Garcia, B. (2021). Developing the art-technology intergenerational community program for older adults’ health and social connectedness. Frontiers in Public Health, 9, 589589. https://doi.org/10.3389/fpubh.2021.589589

Shoesmith, E., Charura, D., & Surr, C. (2021). Acceptability and feasibility study of a six-week person-centred, therapeutic visual art intervention for people with Dementia. Arts & Health, 13(3), 296–314. https://doi.org/10.1080/17533015.2020.1802607

Sim, J. (2021). Distinctive aspects of consent in pilot and feasibility studies. Journal of Evaluation in Clinical Practice, 27(3), 657–664. https://doi.org/10.1111/jep.13556

Sofiana, L., Adi, M. S., Martini, M., & Raharjo, M. (2023). Psychometric attributes of WHOQOL- BREF among tuberculosis patients: Rasch model analysis. International Journal of Public Health Science, 12(4), 1402–1412. https://doi.org/10.11591/ijphs.v12i4.23024

Springer, K. W., & Hauser, R. M. (2006). An assessment of the construct validity of Ryff’s Scales of psychological well-being: Method, mode, and measurement effects. Social Science Research, 35(4), 1080–1102. https://doi.org/https://doi.org/10.1016/j.ssresearch.2005.07.004

Springer, K. W., Pudrovska, T., & Hauser, R. M. (2011). Does psychological well-being change with age? Longitudinal tests of age variations and further exploration of the multidimensionality of Ryff’s model of psychological well-being. Social Science Research, 40(1), 392–398.

https://doi.org/10.1016/j.ssresearch.2010.05.008

Srolovitz, M., Borgwardt, J., Burkart, M., Clements-Cortes, A., Czamanski-Cohen, J., Ortiz Guzman, M., Hicks, M. G., Kaimal, G., Lederman, L., Potash, J. S., Yazdian Rubin, S., Stafford, D., Wibben, A., Wood, M., Youngwerth, J., Jones, C. A., & Kwok, I. B. (2022). Top ten tips Palliative Care Clinicians should know about music therapy and art therapy. Journal of Palliative Medicine, 25(1), 135–144. https://doi.org/10.1089/jpm.2021.0481

Stephenson, R. C. (2021). Art therapy and creative aging: Reclaiming elderhood, health and wellbeing. In Art Therapy and Creative Aging: Reclaiming Elderhood, Health and Wellbeing. Routledge. https://doi.org/10.4324/9780429352751

Supasiri, T., Lertmaharit, S., Rattananupong, T., Kitidumrongsuk, P., & Lohsoonthorn, V. (2019). Mental health status and quality of life of the elderly in rural Saraburi. Chulalongkorn Medical Journal, 63(2), 95–101. https://doi.org/10.14456/clmj.1476.14

Susanty, S., Mujahid, E. H., Suyanto, J., Sudayasa, I. P., & Chuang, Y.-H. (2024). Older adults with predictors factors of depressive symptoms in the community of Indonesia: a cross sectional study. Advances in Gerontology = Uspekhi Gerontologii, 37(5), 525–531. https://doi.org/10.34922/ae.2024.37.5.006

Teresi, J. A., Yu, X., Stewart, A. L., & Hays, R. D. (2022). Guidelines for designing and evaluating feasibility pilot studies. Medical Care, 60(1), 95–103.

https://doi.org/10.1097/MLR.0000000000001664

Turturro, N., & Drake, J. E. (2022). Does coloring reduce anxiety? Comparing the psychological and psychophysiological benefits of coloring versus drawing. Empirical Studies of the Arts, 40(1), 3–20. https://doi.org/10.1177/0276237420923290

Vasudevan, M. K., Besevli, C., Madapura Nagaraj, P., Zhong, S., Muniyandi, M., & Obrist, M. (2025). Co-producing mindful tactile technologies for healthy ageing: Cross-cultural insights from India and the UK. Digital Health, 11. https://doi.org/10.1177/20552076251349909

Vila, T. D., Lopes, M. C., & Liberato, D. (2024). The importance of cultural context in the quality of life of senior tourists. In A Research Agenda for Senior Tourism (pp. 193–212). https://doi.org/10.4337/9781035312993.00014

Zhao, X., Zhang, D., Wu, M., Yang, Y., Xie, H., Li, Y., Jia, J., & Su, Y. (2018). Loneliness and depression symptoms among the elderly in nursing homes: A moderated mediation model of resilience and social support. Psychiatry Research, 268, 143–151. https://doi.org/10.1016/j.psychres.2018.07.011

Zhou, S., Li, H., Yang, Y., Qi, Y., Liu, W., Mo, L., & Wong, C. L. (2025). Effects of art therapy on psychological outcomes among children and adolescents with cancer: a systematic review and meta-analysis. BMC Complementary Medicine and Therapies, 25(1). https://doi.org/10.1186/s12906-025-04866-2