Art Therapy to Improve Quality of Life of Cancer Patients and Their Carers in Bangladesh

Objective: Art as a therapy helps in reparation and recovery. The aim of this study was to see the response of the cancer patients and their carers residing in Bangladesh towards art therapy and the perceived effect of art therapy on their physical and psychological condition. Method: The study was a record review study conducted through a cross-sectional descriptive method from July to November 2018. Along with the cancer patients, their immediate carers were enrolled in this study since patients and their carers both suffer from the distress that comes with the diagnosis of cancer. In-depth interviews and focused group discussions of art therapy were conducted with our study popu-lation at BPSCF and BSMMU. Findings: After art therapy, there was an improvement in sensory perception and self-perception, physical and psychological condition, communication and social skills and helped in more personal integration and built stronger insight among the patients and carers. Majority of the participants of art therapy felt good and wanted to continue art therapy. Significance of results: The results of this study will help to create awareness among the community about the importance of psychotherapies like art therapy in the life of the cancer patients and their carers. Introducing the concept of art therapy will also help the public health practitioners to improvise palliative care services in Bangladesh in a very cost-effective approach.

lows expressing positive feelings like hope, beauty or tenderness [4]. In simple words, art therapy can help to nurture positive feelings and also reflect on negative or difficult thoughts [5].
AT can help to explore deeper feelings and also helps in dealing with their cancer experience [5]. In 2015, 8.8 million people died because of cancer making it a second leading cause of death globally [6]. In low-and middle-income countries, approximately 70% of deaths occur from cancer [6]. In Bangladesh, 12.7 million deaths accounted for cancer leading to a need for palliative care to reduce suffering and disability worldwide [6]. The total estimated economic cost of cancer was approximately US $1.16 trillion in 2010 showing an increase in the economic burden [6]. As a psychosocial palliative care intervention, art-making projects can foster positive interaction between patients and nurses [7]. Art-making projects when exposed to the children suffering from childhood cancer can give an opportunity to the parents to get involved with their child in art making and can ease the situation during oncology treatments [7].
AT is considered as a health profession which is state registered in countries like Canada, United States, Australia, United Kingdom and other European countries [4]. In UK, a recent survey showed that in the palliative phase, over 50% of the art therapists have been working with adult cancer care people [4]. A study done in 2011 with art therapists and service users in UK showed that among 55 service users (adults with cancer), 92% of which agreed that it benefited coping, provided new perspectives, facilitated expression of feelings and assisted distraction from worries [8].
A study done in Taiwan shows that during art therapy, 53% of the patients felt much better or very much better physically, whereas 70% of the terminal cancer patients felt much relaxed or very much relaxed emotionally [9]. Within a pallia-R. Dowla which included symptoms like pain, anxiety, ill-being, depression, sadness and tiredness [10]. This study was conducted with 28 patients who participated in 63 sessions of art therapy [10].
In Bangladesh, Canadian activist Fahmida Urmi Hossain has introduced art as a therapy to heal trauma to improve the mental health condition of women. 11 Acid Survivors Foundation organized a three-day-long art therapy workshop conducted by Fahmida Urmi Hossain, where 8 acid survivors attended for their mental and emotional well-being [11]. In Bangladesh in 2016 doctors without borders introduced art therapy among the Sexual and Gender-based Violence (SGBV) survivors in Kamrangirchar slums [12].
There is little empirical evidence that shows the efficacy of AT and there has not been much discussion on the sole effects of AT [3] [13]. Moreover, the detailed description of art therapy was not provided by many studies [13]. AT has been practiced in Bangladesh recently but no literature exists to show the benefits of art therapy except few newspaper articles [11] [12].
The aim of this study is to understand how patients and carers responded to art therapy and explore their unexpressed emotion. The objective of this study was also to understand the perceived effects of AT on the physical and psychological condition of the participants. In addition to the existing literatures, this study could give a complete image about the benefits of AT among the cancer patients and their carers. This study will help to increase awareness about such psychotherapies in Bangladesh among the community and public health practitioners. Moreover, this study will give a lead to the theoretical formation of art therapy in Bangladesh context.

Materials and Methods
The study was conducted through a cross-sectional descriptive approach, which included a record review from July to November 2018. were included in this study.
Exclusion criteria: Patients who were less than 18 years of age, could not consent, or had a performance status of 4 were excluded from this study.
The session "Healing through Art" was an hour art therapy session where the participants were given art supplies like drawing books, crayons, pencil and eraser by BPSCF. Through purposive sampling data was collected from a total of 27 participants. Guest, Bunce and Johnson (2006) founded with their data set that data saturation can be obtained within first 12 interviews for a particular group [14]. With reference to this, our study focused data of 12 patients and 12 carers but data collection continued until data saturation.
Documents and photographs of their art were collected from the stored soft copies from electronic devices of BPSCF. The data of our study were collected from semi-structured questionnaires, in-depth interviews (IDIs) and focused group discussion (FGDs) guidelines which were used by BPSCF in the interview with the participants. Mobile devices were used to scan the pictures that the participants' had drawn.
To check the reliability, the study tools were reviewed among the peers. Any issues found in the questionnaire and guidelines was edited and corrected accordingly by the research investigators. Prior permission was taken from BPSCF and BSMMU authority before data collection to conduct the study with their records. This study was ethically approved by Bangladesh Medical Research Council (BMRC).
The collected data were reviewed by the research investigators to ensure the accuracy of data. After data familiarization, data displays and data memos were developed for qualitative data. A-priori codes and inductive codes were developed and modified while coding after collecting the data of January to February 2018. After coding data, clustering and comparing, patterns and themes identification was done. This was an iterative process and involved multiple analysis and repetitions. Peer review was done throughout the procedure to minimize the errors. Conclusions were drawn following that along with verification and triangulation where other literatures were used as sources to ensure the reliability of the study. The data entry and descriptive analysis of the socio-demographic data were done through STATA version 13. The majority (51.9%) of participants were homemakers ( Figure 1) as most (59.3%) of the participants were female (Table 1) whereas around 14.8% of them were farmers (Figure 1). Among the carers 16.7% were health counselors and 16.7% were nurses but the majority (60%) of carers were homemakers displayed in Figure 1. The majority (41.7%) of the patients were homemaker who did household chores mostly and around 6.7% of them were unemployed as they had to leave their jobs because of the disease. 8.3% had private jobs which included business, tutoring and private company jobs. Table 2 shows the condition of the patients who participated in the art therapy

Effects of Art therapy
The majority (80%) of the patients and almost all the carers mentioned after art therapy (AT) that they felt good during the therapy (Figure 1). Only a few (13.3%) patients mentioned that they felt really good but 6.7% of the patients did not feel good during the therapy AT ( Figure 2). "Well, most of them said that they did not have that much difficulty. But some mentioned that the crayons were a bit hard for them to hold for their weak hands." (IDI 21, a 34-year-aged female, Nurse)

Improved Sensory Perception and Self Perception
A study with patients diagnosed with personality disorders showed that participants perceived that working with art can lead to more physical and emotional awareness. [3] Our study also showed that patients were able to understand their physical and emotional responses.

Improved Health
Health concerns the state of complete physical and psychological well-being experienced by the participants. While few patients felt weak, participants responded that there was a contribution of AT towards the physical condition of the patients and reduction in mental distresses of both the patients and carers.
After drawing and talking about the drawn pictures, the majority (13 out of 25 participants) stated that it helped in reducing distresses like stress, tension, anger and anxiety which comprises the psychological distresses of the patient and carers that comes with cancer. AT helped to forget physical and emotional distresses for a while, one of the participants having cancer mentioned, "I felt good in this art session. I was very tired. But I did not feel that tiredness while I was drawing. It made me think about the things I like and draw the pictures of those things." (IDI 04, a 65-year-aged female, Homemaker) Both formal and informal carers were able to bring forward their emotions through art and hence mentioned that drawing pictures helps them to reduce their stress and worried thoughts. On the other hand, 1 patient out of total 25 participants mentioned that it helped in improving the existing physical condition. One of the carers also mentioned about her patient, "He had fever from last two days…Although it was difficult for him to draw as he had less strength in his hand but he drew the art seeing me. I think drawing helped him to recover from fever faster." (IDI 16, a 40-year-aged female, Homemaker) However, in the study conducted in Taiwan showed that the majority of patients (53.1%) mentioned that there was an improvement in physical condition [9]. In a pilot study done in a hospital's oncology unit, participants reported improvement in tiredness, anxiety, pain, depression consistent to our study along with other symptoms like drowsiness, lack of appetite, wellbeing and shortness of breath [15]. Creative art interventions also reduce stress, lowers anxiety and negative emotions consistent with our findings [16].

Improved Communication and Social Skills
Communication involves verbal and non-verbal way of expressing the emotions and which brought a change in the behavior of the patients towards themselves and also towards others. Cooperating with one another through social interaction the participants helped out each other to come up with art and openly discuss their feelings that they felt during the journey of the disease. 2 out of 25 participants mentioned that they helped the patients to draw some pictures while they explained verbally or non-verbally what they wanted to draw since they were feeling weak. A number of participants (13 out of 25 participants) stated that they shared their stories of disease with one another during the AT session which helped them to related with each other. Indications were there that patients and their carer learned to find social support from the fellow participants. While sharing their stories of the disease they developed building self-respect to accept their condition. One of the respondents mentioned,

R. Dowla et al. Journal of Cancer Therapy
"After coming to this art session, I have seen that I am not alone with this disease. There are people like me who are also facing the same situation. We have all talked about our condition during the art session." (FGD 01, a 20-year-aged male, Home Tutor) Few patients stated that they changed their behavior and started drawing after seeing others draw which worked as a motivation for them. Not only patients but also carers got motivated by seeing others and started drawing apart from motivating patients to draw. One of the carers stated, "I started drawing pictures so that the patients could see me drawing and feel motivated enough to start drawing. I have seen that it actually works." (FGD 15, a 60-year-aged female, Nurse) While in our study some carers helped patients to draw, another pilot study also showed when patients found the art materials difficult to use, the therapists helped them to form the art [15]. The study with personality disorder patients showed that they got social support from other participants of AT, looked for a solution together and learned to change their behavior patterns [3]. Art was regarded as a communication tool as it improved the way of communication of cancer patients [17]. Art creation process helps a patient to develop ideas and express his/her feelings [18] [19]. Figure 4 shows an example of this. In a study of Taiwan, patients mostly drew pictures of landscape which is consistent with our study too [9].   My mother used to love me a lot. As flower spreads love, my mother used to love me like that…When I was a child during sickness she used to take care of me and pamper me, but now in this condition of mine I miss her." (IDI 02, a 52-year-aged male, Unemployed).

More Personal Integration
struggles and traumatic experiences from past through their art [3].  demonstrates this. One of the carers reflected patient's inner struggles that were observed in the following quotes.

Stronger Insight and Comprehension
Both the patients and carers after AT were able to draw conclusions on their emotions, process and on the art materials as well. 19 out of 25 participants mentioned that they want to continue the AT session whereas some also suggested other psycho-therapies and some entertainment programs should also be conducted for them in the future programs. One of the carers mentioned, "We can arrange some entertainment programs to improve their physical and psychological well-being for the patients and the cares. Programs like 'Healing through art' helped them a lot to express their feeling and also gave them a mode of entertainment." (IDI 27, a 25-year-aged male, Health Counselor) Through AT patients learned to express their non-verbal experiences into words. A similar finding was showed in the qualitative study with personality disorder [3]. Our study showed the majority of both patients and carers want to continue AT, while an interdisciplinary research team conducted a study and also showed that majority of their participants appreciated the sketchbooks and pencils and wanted to continue AT continue drawing or painting [20].

Limitations
Since this study is a record review study, there might be some information bias as information was not collected via direct observation and functional analysis.
The information obtained might not be complete to be generalizable. Another limitation of this study is that it did not consider the treatment phase of the patients who were undergoing frequent chemotherapies that might create a hurdle in receiving the AT properly. It is difficult to determine through this study whether art therapy benefitted the patients or they have been distracted temporarily from the distresses since AT as an intervention may have a placebo effect.

Conclusion and Recommendation
This study offers an overview of the potential benefits of AT in the life of cancer Health practitioners should be aware of the fact that AT as a psychotherapy can be beneficial for the cancer patients and can help to add life to their days.