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)) (BRT MCA)

Examination of the Effect of Mandala Coloring Activity Applied to Caregivers in the Palliative Care Clinic Along With Benson Relaxation Exercise on Stress, Anxiety and Mental Well-Being

This study aimed to examine the effects of mandala coloring activities, applied in conjunction with Benson relaxation exercises, on the stress, anxiety, and mental well-being of caregivers in a palliative care clinic.

Accordingly, the hypotheses of the study are as follows:

H0a: The combined application of Benson relaxation exercises and mandala coloring activities has no effect on the stress levels of caregivers in a palliative care clinic.

H0b: The combined application of Benson relaxation exercises and mandala coloring activities has no effect on the anxiety levels of caregivers in a palliative care clinic.

H0c: The combined application of Benson relaxation exercises and mandala coloring activities has no effect on the mental well-being of caregivers in a palliative care clinic.

H1a: The combined application of Benson relaxation exercises and mandala coloring activities has an effect on the stress levels of caregivers in a palliative care clinic.

H1b: The combined application of Benson relaxation exercises and mandala coloring activities has an effect on the anxiety levels of caregivers in a palliative care clinic.

H1c: The combined application of Benson relaxation exercises and mandala coloring activities has an effect on the mental well-being of caregivers in a palliative care clinic.

Study Overview

• Status: Completed
• Conditions: Mandala Coloring; Benson Exercise; Informal Palliative Caregiver
• Intervention / Treatment: Behavioral: mandala coloring activity; Behavioral: Benson relaxation exercises

Detailed Description

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.

• Study Type: Interventional
• Enrollment (Actual): 68
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Turkey (Türkiye)
  • Trabzon, Turkey (Türkiye)
    • Karadeniz Technical University

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: Yes

Description

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

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
No Intervention: control group (n=34); Caregivers in the control group received no intervention. Before the study, they completed pretest questionnaires administered face-to-face by the researcher in a quiet clinic environment. The control group was given the "Palliative Caregiver Introduction Form (Appendix 1)" and the pretests: "Perceived Stress Scale (Appendix 2)", "Anxiety Assessment Scale (Appendix 3)", and "Warwick-Edinburgh Mental Well-being Scale (Appendix 4)". At the end of the study, materials were shown and given to control group caregivers who wished to participate in mandala coloring or Benson relaxation exercises. After eight days, all caregivers in the control group completed posttest questionnaires administered by the researcher, consisting of the same three scales (Appendices 2, 3, and 4), and their answers were recorded on the relevant forms.
Experimental: intervention group (n=34); Before the study began, caregivers in the intervention group completed face-to-face pretests administered by the researcher in a quiet environment, and their responses were recorded on the relevant forms. The intervention group was administered the "Palliative Caregiver Introduction Form (Appendix 1)" and the pretests: "Perceived Stress Scale (Appendix 2)", "Anxiety Assessment Scale (Appendix 3)", and "Warwick-Edinburgh Mental Well-being Scale (Appendix 4)". Each caregiver was given a mandala coloring book, a set of colored pencils, an eraser, a pencil sharpener, and an eye mask to use during the Benson relaxation exercises. The Benson relaxation exercises and mandala coloring activities were first demonstrated practically by the researcher. For eight days, 20 minutes of Benson relaxation exercises and 30 minutes of mandala coloring were applied daily under the researcher's supervision. At the end of the study, posttests were administered, responses were recorded, and the materials w	Behavioral: mandala coloring activity; Mandala coloring is an art therapy method that allows individuals to express their inner world by coloring circular and symmetrical patterns. According to Carl Jung, the mandala represents the subconscious and symbolizes an individual's inner integrity, with drawings reflecting a person's self-perception and mood. Structured mandalas are accessible and low-threatening in clinical settings. The activity is typically conducted in short sessions where participants choose the patterns and colors they wish to use. The coloring process promotes meditation and awareness, providing mental calmness and helping individuals recognize their emotions and values while offering a sense of control and accomplishment during chaotic situations. As a safe, time-efficient, and self-management tool requiring no special skills, mandala coloring contributes to reducing stress and anxiety, making it an effective complementary practice for palliative caregivers.; Other Names: art therapy; mandala coloring; colored therapy; Behavioral: Benson relaxation exercises; The Benson Relaxation Technique (BRT) is a behavioral intervention designed to elicit a "relaxation response" through breath regulation, cognitive focus, and the repetition of words or phrases. This response, which is the physiological opposite of the stress reaction, reduces heart rate, respiration, blood pressure, and muscle tension while lowering stress hormones and promoting mental calmness. BRT is practiced in a quiet environment, in a comfortable position with eyes closed, for 10 to 20 minutes. Participants focus on their breath, repeat a chosen word silently, and acknowledge and release distracting thoughts. Clinical studies have demonstrated that BRT reduces anxiety, depression, perceived stress, and fatigue, while improving sleep quality and contributing to overall quality of life. It is a safe, low-cost, and accessible stress management method for palliative caregivers.; Other Names: exercises; relaxation; relaxation exercises; breathing exercises

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Stress levels of palliative caregivers (Perceived Stress Scale)	Changes in palliative caregivers' Perceived Stress Scale scores were measured before and 8 days after the implementation of the BRT combined with the MCA.	Before intervention (day 0) and after intervention (day 8)

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Anxiety levels of palliative caregivers (Anxiety Assessment Scale)	Changes in palliative caregivers' Anxiety Assessment Scale scores were measured before and 8 days after the implementation of the BRT combined with MCA.	Before intervention (Day 0) and after intervention (Day 8)

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Palliative caregivers' mental health score (Warwick-Edinburgh Mental Health Scale)	Changes in Warwick-Edinburgh Mental Well-being Scale scores were measured in palliative caregivers before and 8 days after the implementation of the BRT combined with MCA.	Before intervention (Day 0) and after intervention (Day 8)

Collaborators and Investigators

• Sponsor: Karadeniz Technical University

Publications and helpful links

General Publications

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Study record dates

Study Major Dates

• Study Start (Actual): March 29, 2025
• Primary Completion (Actual): May 10, 2025
• Study Completion (Actual): September 27, 2025

Study Registration Dates

• First Submitted: February 27, 2026
• First Submitted That Met QC Criteria: March 4, 2026
• First Posted (Actual): March 5, 2026

Study Record Updates

• Last Update Posted (Actual): March 5, 2026
• Last Update Submitted That Met QC Criteria: March 4, 2026
• Last Verified: March 1, 2026

More Information

Terms related to this study

• Keywords: palliative care; exercise; muscle relaxation; nursing; Art therapy
• Additional Relevant MeSH Terms: Behavior; Motor Activity; Motor Activity; Movement; Musculoskeletal Physiological Phenomena; Musculoskeletal and Neural Physiological Phenomena; Therapeutics; Mind-Body Therapies; Complementary Therapies; Exercise Movement Techniques; Physical Therapy Modalities; Patient Care; Psychotherapy; Behavioral Disciplines and Activities; Rehabilitation; Aftercare; Continuity of Patient Care; Sensory Art Therapies; Exercise; Breathing Exercises; Art Therapy
• Other Study ID Numbers: KTU-SBE-HEM-BGE-MND-2025-01; TYL-2025-16411; BAP06 (Other Grant/Funding Number: Republic of Turkey, Black Sea Technical University, Scientific Research Projects Coordination Unit)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: Participant confidentiality was strictly maintained throughout the study. All personal and clinical data were anonymized by assigning unique identification codes to each participant, and no identifying information was included in the data collection forms or analysis. Study data were accessible only to the research team and were stored securely in accordance with institutional and ethical guidelines. The results were reported in aggregate form to ensure that individual participants could not be identified.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No