JMIR Publications

ABSTRACT

Background:

The global elderly population is growing rapidly, posing significant social and economic challenges. In China, the one-child policy has exacerbated elder care difficulties, increasing reliance on institutional care. However, transitioning to elderly centers (ECs) often induces stress (Wang et al., 2021; Weaver et al., 2020; Wu & Rong, 2020), reduces psychological well-being (PWB) and can cause physical symptoms like insomnia and appetite loss (Levina et al., 2019), which lead to worsen health (Koppitz et al., 2017). In China, where historically home based care, relocation to ECs can heighten feelings of neglect and embarrassment (Wu & Rong, 2020), further compromising PWB. Inadaptation in older adults is more likely to occur in the first year of entry to ECs, as they face the loss of familiar surroundings and must adapt to a new environment (Sun et al., 2021). These phenomena may be of heightened concern in Chinese culture, where traditional values of filial piety emphasis children caring for their elderly parents. The admission to ECs for older adults may lead to feelings of abandonment and shame. Consequently, a decline in PWB is more common among new residents, especially in the Chinese context (Qi et al., 2023; Yao et al., 2020). Therefore, researching ways to improve the PWB of new residents is highly meaningful. Recent studies explore behavioral interventions, such as happiness therapy (Cantarella et al., 2017; Greenawalt et al., 2019), life review therapy (Lai et al., 2019; Viguer et al., 2017), cognitive behavioral therapy (Browne et al., 2017; Durgante & Dell’Aglio, 2019; Durgante et al., 2022) to improve PWB. A limitation of these interventions is that they are often perceived as uninteresting, which may promote disengagement among older adults (Rebok et al., 2014). Additionally, many interventions primarily target younger adult populations, further limiting their applicability (Aborass et al., 2025; Beraldo, 2025; Brown & Peter, 2025; Nci & Salam, 2025). Another significant drawback is that these studies often rely solely on subjective data, lacking support from objective measurements, which may affect the validity and reliability of the findings (Chen et al., 2019; Cheng et al., 2022; Li, 2021; Li, 2020). Therefore, it is essential to develop practical, effective, and easily accepted interventions specifically designed to improve PWB among older adults, while incorporating both subjective and objective data to ensure more robust and comprehensive results. Art activities and group-based interventions are widely recognized as effective methods for enhancing PWB (Wang & Wang, 2022). Some studies (KÖSe et al., 2024; Nie & Tsai, 2025; Oinas & Huhmarniemi, 2024; Zhenli et al., 2024) have incorporated group discussions or supplementary activities into art-based interventions to improve outcomes. While the combined intervention has potentially shown some effectiveness, this benefit comes with the drawback of a longer duration, which may inadvertently introduce negative effects like participant fatigue or reduced adherence (Northey et al., 2018). Therefore, it is critical to examine whether art activities alone or in combination with group discussions are more effective in boosting PWB among new elderly residents in Chinese elderly care centers. Conceptual framework The study is based on aesthetic theory and social support theory (Bavik et al., 2020; Brain, Beauty, and Art: Essays Bringing Neuroaesthetics into Focus, 2021; Wright), drawing from literature regarding the transfer of older adults to elderly care facilities. The Chinese art activity program was developed to include culturally significant aesthetic practices, whilst the peer Group Participation intervention was modified from evidence-based group support models. Outcome measures encompass psychological well-being, happiness, relaxation, loneliness, and salivary cortisol levels. Aesthetic theory underscores the significance of aesthetic experience in enhancing wellbeing via emotional and sensory reactions to art (Ivanov, 2023; Reiter & Geiger, 2023). Interaction with beauty is correlated with favorable emotional states, which neuroscience links to the release of neurotransmitters such as endorphins and serotonin, as well as a decrease in stress-related indicators, including cortisol (Brillenburg Wurth, 2023; Marino, 2023; Minhoto & Amato, 2023; Movlonova, 2023). The Chinese Art Activity intervention utilizes these pathways through culturally customized art engagement designed to elicit delight and confer physiological advantages. The social support theory emphasizes that interpersonal interactions mitigate stress and improve wellbeing by providing emotional, informational, and companionship support (Kort-Butler, 2018). The peer Group Participation intervention aims to reduce isolation and enhance self-efficacy through group cohesion and shared experiences (Bavik et al., 2020; Drageset, 2021; Haugan & Eriksson, 2021; Ngai et al., 2021), notions that coincide with Yalom's therapeutic group elements (Yalom, 2010).. The theory suggests that the art-based intervention yields neurophysiological advantages, while the peer group element offers social relational support (Aydın & Kutlu, 2021; Bradfield, 2021; Iwano et al., 2022). Collectively, they constitute a multifaceted strategy for improving psychological wellness in older persons during transitional phases. The concept structure of this study is shown as follows (Figure 1): Fig1:

Objective:

This study aims to evaluate the effects of Chinese art activities (CAA), both independently and in conjunction with Peer Group Participation (CAA+PGP), on the psychological well-being of newly old Chinese at ECs. The primary objectives are: (1) to investigate if participation in CAA significantly improves psychological well-being (PWB), happiness, relaxation, and reduces loneliness and salivary cortisol levels; (2) to examine if the combined CAA+PGP intervention significantly enhances PWB; (3) to assess if the combined CAA+PGP intervention produces superior outcomes compared to CAA alone; and (4) to evaluate the efficacy of salivary cortisol as a physiological biomarker reflecting changes in PWB.

Methods:

Feasibility Study Before the initiation of the full-scale RCT, a feasibility study was undertaken. This study was performed at a senior facility in Suzhou, China, separate from the primary study sites to enhance the intervention protocols. Twenty qualified older adults were recruited: ten underwent the CAA intervention, while the remaining ten engaged in the CAA+PGP intervention. Insights and evaluations from the pilot phase were utilized to enhance the intervention protocols. The revised protocol obtained official approval before its implementation in the primary study. Trial design This multicenter, randomized, assessor-blind trial, structured according to the Max.-Min.-Con. principle, has three parallel intervention groups: Group A (+CAA), Group B (+CAA+PGP), and Group C (regular care), with a 1:1:1 allocation ratio. The research is executed consecutively at three elderly residential residents. centers in Suzhou, China, with each site functioning as a randomization unit. Figure 2 delineates the implementation phase of the data collection techniques in the study. The intervention occurs over three sessions within a single week (Monday, Wednesday, Friday). Baseline evaluations of psychological well-being, loneliness, happiness, relaxation, and salivary cortisol levels are conducted before randomization. Outcome measures will be gathered 30 minutes prior to and following each intervention session to assess immediate effects. A concluding follow-up assessment occurs one week after the final session to examine enduring outcomes. Figure 3 illustrates research design within a single environment. The study protocol complies with the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) checklist (Table 1). The projected study duration is from May 9, 2025, to May 30, 2026. Participants Eligible participants were aged 60 to 85 years, residing in an elderly center (EC)e with a duration of stay not exceeding one year (Sun et al., 2020), and demonstrating normal cognitive function defined as a Mini-Mental State Examination (MMSE) score above 24 (Bourdon & Belmin, 2021). Additionally, participants were required to possess adequate literacy skills for basic reading and writing (Lan et al., 2019) and provide voluntary informed consent. Exclusion criteria encompassed severe medical conditions such as heart failure, asthma, cerebrovascular disease, or advanced malignancies, as well as planned or actual discharge from the facility during the study period. Figure 2. The Implementation Phase and the Data Collection Procedures Figure 3. CONSORT flow diagram. Table 1 SPIRIT standard protocol items with time schedule of enrolment, interventions and assessments ×*, This includes pre-test and post-test assessment Sample size The sample size of this randomized controlled trial study is calculated based on previous study. The effect size use formula d=(µ1-µ2)/σ (Cohen, 2013). Where d= effect size µ1= Mean of intervention group µ2= Mean of control group σ=√("SD" 1^2+"SD" 2^2 )/2 Based on a previous study (Piasai et al., 2018), the effect sizes for happiness and relaxation were calculated by the formula as 2.65 and 2.31, respectively. In another randomized controlled trial (Aydın & Kutlu, 2021), the effect size for loneliness was found to be 0.92. To calculate the required sample size, loneliness was selected as the reference due to its lowest effect size. Using a power chart (Lipsey, 1990), the sample size was determined based on an effect size of 0.92, a power of 0.80, and an alpha level of 0.05. The analysis indicated that a minimum of 25 participants per group would be required. This study will recruit 90 individuals to account for a potential dropout rate of 20%. The trial is scheduled at three independent institutions, each having three experimental groups with ten participants per group. Participant Enrollment Upon receiving formal authorization from the management of the ECs, the nursing director will act as the principal gatekeeper, enabling researcher access to the facility and aiding in the recruitment of prospective participants. Eligible participants will be determined by examining health records and the Mini-Mental State Examination (MMSE) in accordance with the inclusion criteria. Individuals who satisfy the requirements will be invited to participate and provided with a written information sheet detailing the study's aim, procedures, advantages, and their right to leave without repercussions. Written informed consent will be requested prior to enrollment. For group allocation, participants will obtain a group-specific information sheet and sign a corresponding consent form. Participant allocation The allocation sequence will be produced dynamically by an independent statistician throughout the recruiting phase utilizing the Minimization Randomization Program Version 2.01. This procedure will employ data on age and visit frequency for one month (refer to Table 2) from registered participants to guarantee equitable baseline characteristics among all groups. Age data will be gathered during the collection of participants' demographic information. Each institution will record visitors, enabling the verification of the older adults’ visitation frequency throughout one month through the institution's visitor registration data. The monthly visit count should remain variable; therefore, we will compute the average monthly visits for older adults since their relocation, without surpassing one year. Table 2. The categories of confounding variables for using minimized randomization program Confounding variables Category 1 Category 2 Age 60-75 over 75 One-month visitation frequency 1-2 times per month more or equal 3 times per month The researcher will recruit thirty participants from each institution, resulting in a total of ninety older people (aged 60–85, new residents with ≤1 year of residency), introduced by through health providers. In each institution, the 30 participants will be allocated into three groups—A, B, and C—comprising 10 participants each group. Group A will be administered +CAA, Group B will be administered +CAA+PGP, and Group C will receive routine care. Blinding A double-blind design will be impractical due to the characteristics of the art-based intervention with the exception of outcome assessors and data analysts will remain blinded to guarantee an objective review. Research assistants responsible for pre- and post-intervention data collection will remain uninformed of group assignments and will not engage in the delivery of the intervention. Unblinded study personnel will manage randomization and intervention delivery but will be excluded from data collection tasks. Data analysts will obtain solely anonymized participant codes, devoid of any information regarding group allocation. All blinded staff are will not be able to obtain information on group assignments. Intervention Chinese Art Activities (CAA) A systematic, structured protocol guides will be followed for the implementation of the Chinese art intervention at all research settings (Ciasca et al., 2018; Huang et al., 2022; Tong et al., 2021). The program will begin with a 10-minute instructional introduction presented through a pre-prepared PowerPoint exhibited on a wide screen. These sessions will focus on the historical development, philosophical underpinnings, and essential brush-and-ink techniques of traditional Chinese landscape painting and calligraphy. Exemplary artworks will be displayed on the screen throughout the relevant instructional segment to demonstrate aesthetic principles and improve participants' visual literacy. A three-minute instructional movie will subsequently be screened. iPad will be supplied and positioned on the desks of older participants who indicate difficulties with clearly reading the screen. The movie will systematically illustrate the formation of a meticulously chosen landscape scene, utilizing novice-friendly brush techniques and color modification methods. Participants will thereafter be allocated 25 minutes to reproduce or modify the exemplar on xuan paper (rice paper) utilizing traditional implements (wolf-hair brush, pine-soot ink, mineral pigments). Personalization by color variation or the incorporation of supplementary natural elements (e.g., bird patterns, floral designs) will be deliberately promoted to enhance individual creative expression. The ensuing calligraphic element will necessitate those participants create a brief lyric or aphorism thematically congruent with their completed image. After initial drafting on practice sheets, the final text will be inscribed in calligraphy onto the artwork within a 15-minute timeframe, thus merging poetry inscription with visual imagery in line with classical Chinese creative traditions. A detailed summary of the interventional strategy for CAA is provided in Table 3. Table3. The Details of CAA Program Activities appliance procedure Time (minutes) Traditional Chinese landscape painting and calligraphy pens, ink, paper, inkstones, pigments Preliminary understanding and familiarity 10 Creation of Traditional Chinese Landscape Painting 25 Chinese Calligraphy Creation 15 CAA combined with Peer Group Participation (PGP) Intervention Program The CAA+PGP intervention, supported by previous studies (Aydın & Kutlu, 2021; Hermann, 2021), consists of an 80-minute integrated session led by a single researcher (RA1). Based on established recommendations that at least four participants are necessary for effective group interventions (Levine, 1979), the 10 participants in this arm will be randomly divided into two groups of five, each facilitated by one trained peer volunteer, resulting in six individuals per group including the peer volunteer. The intervention commences with the CAA (Chinese Art Intervention) segment, which will be executed in accordance with the established CAA protocol. After the art creation phase, the PGP (Peer-Guided Sharing) phase will be continued. Volunteers will organize the exhibition of artworks and promote reciprocal appreciation by facilitating group conversation in accordance with established protocols. The group's active involvement and accomplishments will initially be officially recognized, followed by an invitation for each member to sequentially articulate the positive significance of their artwork. Participants will then be encouraged to give their artwork as gifts, accompanied by gestures of mutual appreciation, such as handshakes or embraces. Ultimately, peer volunteers will conclude the program by sharing personal stories highlighting adaptation to life at the elderly center. Table 4 contains information pertaining to the CAA+PGP interventional procedures. Table 4. Details of CAA + PGP Program Activities appliance procedure Time (minutes) Traditional Chinese landscape painting and calligraphy and peer group participant pens, ink, paper, inkstones, pigments Preliminary understanding and familiarity 10 Creation of Traditional Chinese Landscape Painting 25 Chinese Calligraphy Creation 15 Display and appreciate art works 5 Discuss ongoing art activities 25 End intervention Routine care Both the intervention and control groups in all 3 settings will get the same routine care, which includes daily activities such as basic limb exercises being specified activity hours from 8:30 am to 10:30 am and 2:00 pm to 4:00 pm each day. The interventions for CAA and CAA+PGP are planned from 2:00 pm to 4:00 pm, during which the experimental groups will engage in intervention activities, while the control group will adhere to the original activity schedule of the elderly center. All other everyday management and activities for the three groups will continue as normal. Outcomes This research used a repeated-measures design. In addition to the measurements obtained concurrently with the PWB assessment at baseline and one-week post-intervention, further pre- and post-intervention evaluations will be performed for happiness, relaxation, loneliness scores, and salivary cortisol levels. The schedule of evaluations is outlined in Table 1 The PWB score will be assessed using the 18-item, Chinese version of Ryff’s PWB scale (Li, 2014). This scale consists of 18 questions, with 3 questions per dimension, covering a total of six dimensions: Self-Acceptance, Positive Relations with Others, Autonomy, Environmental Mastery, Purpose in Life, Personal Growth. Happiness score, Relaxation score, Loneliness score will be measured by specific 10 cm VASs. After a decision is made, the record value will be measured in millimeters (from left to right) using a ruler to assign a numerical value to the subjective evaluation, possible scores ranged from 0 to 10. Thirty minutes prior to and following the intervention, the saliva will be collected. A saliva tampon collecting tube will be used to gather saliva. After collecting the saliva samples will be put on wet ice right away, brought to the lab within three hours, and frozen below -80°C. Following the collection of all the samples, measurements will be requested from the laboratory's qualified personnel. The Jiangsu Provincial Department of Science and Technology has accredited the lab, which possesses significant proficiency in measuring salivary cortisol levels. Statistical methods This study will utilize computer-based data analysis with the following statistical procedures. Dependent variables include PWB score, loneliness, happiness, relaxation, and salivary cortisol levels, compared at pretest and posttest across intervention groups (CAA, CAA+PGP) and the control group (routine care), with the independent variable being the type of intervention. Preliminary data analysis will assess normality and homogeneity of variance assumptions using histograms, skewness, and kurtosis, while descriptive statistics will identify missing values, out-of-range data, and accuracy. Demographic and characteristic data will be summarized, with normality tests determining data distribution. Normally distributed data will be presented as mean ± standard deviation for visual scale values and salivary cortisol levels, while non-normal data will be reported as median (interquartile range). Inferential statistics will employ repeated measures ANOVA and paired t-tests for normally distributed data to compare group differences and pre-post intervention changes, respectively. For non-normal data, non-parametric tests (Friedman test, Wilcoxon signed-rank test, and Mann-Whitney U test) will be used for group comparisons and pre-post intervention analysis. Ethical Considerations This study protocol has been reviewed and approved by the Institutional Review Board of Prince of Songkhla University (Approval No: PSU IRB 2024-St-Nur 048). The trial is registered at ClinicalTrials.gov (NCT06841133). Any modifications to the protocol will be promptly submitted to the IRB for review and approval. Before participation, all eligible individuals will receive detailed information regarding the study objectives, procedures, potential risks, and benefits. Written informed consent will be obtained from each participant after thing been provided with full explanation of the study requirements. For participants with visual or literacy challenges, the consent form will be read aloud verbatim by trained research assistant and obtaining written signature. To ensure confidentiality, all collected data will be deidentified using unique participant codes. Electronic data will be stored on encrypted, password-protected servers, and physical documents will be kept in locked cabinets accessible only to authorized investigators. Biological specimens (saliva samples) will be processed for cortisol analysis immediately after collection and destroyed thereafter to prevent unauthorized use or retention. All research personnel have completed training in ethical data handling and participant privacy protection according to international standards (Association, 2013). In this study, the experimental group will receive supplemental entertainment activities as interventions alongside routine activities, while the control group will receive only routine activities. Post-trial, the control group will be offered the same interventions if interested, without follow-up requirements.

Results:

The experiment was funded in September 2024. The study protocol received approval from the Institutional Review Board of Prince of Songkhla University (Approval No: PSU IRB 2024-St-Nur 048). The initial participant was enrolled on May 9, 2025, and by August 20, 2025, a cumulative total of 90 participants has been recruited. Data collection will continue until October 2025. The data analysis has not commenced, and the results are anticipated to be released in late 2025. Discussion Summary The globally aging phenomenon, along with China's one-child policy, has markedly heightened dependence on institutional elder care. However, shifting to geriatric facilities frequently diminishes psychological well-being (PWB) owing to stress and cultural shame. Current studies on therapies, including well-being therapy and cognitive-behavioral therapy, are frequently hindered by inadequate participant involvement, excessive dependence on professional guidance, and undue focus on subjective data, which collectively diminish their overall effectiveness (Durgante et al., 2022; Tam, 2021). Art activities and group-based interventions are recognized for their capacity to improve PWB. Nonetheless, the amalgamation of various methodologies, although potentially more efficacious, frequently extends the period of intervention, so augmenting the burden and tiredness experienced by older adults and eliciting ethical dilemmas. Consequently, it is imperative to examine whether art activities alone or in conjunction with group talks are more efficacious in enhancing psychological well-being among newly elderly residents in Chinese residential facilities. The study seeks to enhance psychological well-being by integrating traditional Chinese art, offering a culturally pertinent and engaging approach. The research design comprises three intervention sessions within a week period, with assessments administered before and following each session to measure immediate effects. A follow-up evaluation one-week post-intervention is essential to ascertain if the effects endure beyond the immediate results. The incorporation of quantifiable metrics like salivary cortisol levels, with subjective evaluations, strengthens the study's rigor, mitigating the shortcomings of prior research that depended exclusively on self-reported data. Strengths and Limitations To account for confounding variables and improve internal validity, this study will use a strict multicenter randomized controlled trial (RCT) design with restricted randomization techniques. The intervention creates a multifaceted and comprehensive framework to enhance psychological well-being (PWB) among older adults in assisted elderly centers by creatively combining culturally adapted Chinese art activities (CAA) with peer group participation (PGP). A thorough evaluation approach that combined objective and subjective markers will be used as the methodology. The outcomes of the study are considerably more constructed and ecologically valid because of applying multi-method measurement technique

Conclusions:

This project has the potential to yield significant insights for the delivery of aged care and policies. The findings could inform the creation of practical guidelines for enhancing psychological well-being in aged care institutions by demonstrating the efficacy of culturally customized art-based interventions. The study emphasizes the significance of incorporating cultural traditions into contemporary care systems, presenting a scalable approach that may be applied to other aged care cultural contexts. Clinical Trial: Trial registration ClinicalTrials.gov NCT06841133. Registered on Feb 21, 2025