The Effect of Benson Relaxation Exercise and Mandala Coloring Activity on Stress, Anxiety, and Mental Health of Palliative Caregivers (Benson Relaxation Technique (BRT), Mandala Coloring Activity (MCA))

This randomized controlled trial, employing a pretest-posttest experimental design, investigated the effects of mandala coloring activities combined with Benson relaxation exercises on the stress, anxiety, and mental well-being of caregivers in a palliative care clinic. The study population consisted of palliative caregivers hospitalized in Palliative Care Ward-1 and Ward-2 at Trabzon Akçaabat Haçkalı Baba State Hospital. The study included two groups: an intervention group and a control group.

The G*Power 3.1 power analysis program was used to determine the sample size. To achieve a power greater than 95%, a total of 40 individuals were required, with 20 in each group (intervention and control), at a 5% significance level and an effect size of 1.198 (df=38; t=2.024). Given the high power of the test and the potential for participant attrition, the study aimed to reach a total of 60 individuals, with 30 in each group. The final study sample consisted of 68 individuals who met the inclusion criteria and participated in the research: 34 in the intervention group and 34 in the control group.

A single-blind randomization method was used to prevent data bias. The computerized randomization program CalculatorSoup was used for this process. The program defined the groups as an intervention group (Benson relaxation exercises and mandala coloring activity group) and a control group, and determined the assignment of participants to these groups.

Before the start of the study, caregivers in both the intervention and control groups completed pretest questionnaires administered face-to-face by the researcher in a quiet environment at the relevant clinic, and their answers were recorded on the relevant forms. The study sample was administered the "Palliative Caregiver Introduction Form" and the pretests: "Perceived Stress Scale", "Anxiety Assessment Scale", and "Warwick-Edinburgh Mental Well-being Scale".

Each caregiver in the intervention group was given a mandala coloring book, a set of colored pencils, an eraser, and a pencil sharpener by the researcher. Additionally, each participant in this group was given an eye mask to use during the Benson relaxation exercises. At the end of the study, these materials were given to the caregivers as gifts. The mandala coloring activity was first demonstrated practically by the researcher to the caregivers in the intervention group in conjunction with the Benson relaxation exercises. For eight days, in a quiet room in the clinic under the researcher's supervision, the caregivers in the intervention group participated in 20 minutes of Benson relaxation exercises and 30 minutes of mandala coloring activity once a day. Caregivers in the control group received no intervention. At the end of the study, the materials were shown and given to caregivers in the control group who wished to participate in mandala coloring activities or Benson relaxation exercises.

Eight days later, all caregivers in the sample completed posttests administered by the researcher. The Statistical Package for Social Sciences (SPSS) 25.0 program was used for coding and statistical analysis of the data obtained from the study. Before applying the tests, the normality of the data distribution was examined using the Kolmogorov-Smirnov test and was considered normal at a 95% confidence interval and p > 0.05 level. Percentage, mean, and standard deviation calculations were performed to describe the demographic characteristics of palliative caregivers and patients. Chi-square and Fisher's Exactness tests were used in analyses based on the nominal data of the caregivers. To compare the pretest and posttest mean scores of the intervention and control groups, independent t-tests and Mann-Whitney U tests were applied for independent samples, while paired t-tests, Wilcoxon tests, and Chi-square tests were applied for dependent samples.

In the analyses, the statistical significance of the effect size was evaluated using Cohen's d and r values. According to Cohen's interpretation of effect size, a d value below 0.2 indicates a small effect, 0.5 a moderate effect, and 0.8 a large effect. Effect size calculations were performed using data from an online calculator. For non-parametric tests, effect size was determined using the r value, and regardless of the r sign, 0.10 was interpreted as a small effect, 0.30 as a moderate effect, and 0.50 as a large effect. In addition, the explained variance of the dependent variable on the independent variable was evaluated using the R² value.

Iİnclusion Criteria:

• Aged 18 years and older
• Serving as the sole informal caregiver for a palliative care patient
• Possessing sufficient cognitive level and language proficiency to answer questions
• Having provided continuous care in a palliative care clinic for at least one week (7 days)
• Having no vision or hearing problems
• Being able to use their hands actively
• Having no allergy to colored pencils
• Being literate
• Not using any other non-pharmacological approaches (e.g., herbal treatments, massage, reflexology, meditation, breathing exercises, relaxation exercises, yoga, or acupuncture) during the research period
• Volunteering to participate in the study

Exclusion criteria

• Under 18 years of age
• Having a diagnosed illness that could affect cognitive level or language proficiency
• Not being the sole informal caregiver of a palliative care patient
• Having visual or hearing problems that would prevent participation in mandala coloring
• Having a physical disability in the upper extremities
• Having advanced COPD, asthma, bronchitis, or upper respiratory tract infections