Influence of Therapeutic Play Coloring Body Part On Anxiety inPreschool Age

Children, in Mitra Husada Hospital,Lampung Province, Indonesia

Yusnita
Muhammadiyah Pringsewu Lampung Indonesia School of Since.
umiyusnita@gmail.com

ABSTRACT
Based on the data from maternal and child health in 2010 showed that 33.2% of 1,425
children were hospitalized in Indonesia. The impact of hospitalization on children and
families is anxiety. Hospitalization is the most common situation in pre-school children,aged
3-6 years. Coloring body parts is one type of therapy for children aged between 4 - 7 years.
The aim of this study was to determine the effect of coloring body part therapy on anxiety in
pre-school children. This research was conducted in July 2017 in Mitra Husada Hospital. This
research was a quantitative research, Quasi-experimental design withone group pre-test –
post-test design.
Samples of this study were24pre-schoolchildrenin child care at in Mitra Husada Hospital
Pringsewu, using consecutive sampling technique.Data analysis was conducted using paired t-
testto analyze difference of anxiety score before and after intervention. The data collection
toolswere questionnaires. The results of the study showed that coloring body part
therapycould reduce anxiety in preschool-age children in RS.Mitra Husada with p value =
0.006.

Keywords: anxiety, coloring body part therapy

INTRODUCTION.
Having healthy children is a hope for every parent; however, sometimes in the developmental
stages,children have to be hospitalized (hospitalization) for further treatment. Hospitalization
is a crisis state for children that can cause trauma, anxiety, anger, sadness, fear and pain and
can interfere with the child's developmental phase (1).The The efect of Hospitalizati is stress
for parents and children. Children’s stress can come from hospital environments such as
hospitalization, medical devices, distinctive odors, surrounding with sick children,white
nurses' uniforms, or interactions with nurses and nurses’attitudes (22) .

Based on the data from World Health Organiation (WHO) in 2008, nearly 80% of children
were hospitalized (hospitalization). Data on maternal and child health in Indonesia showed
that 33.2% of 1,425 children were affected by hospitalization in 2010. The impact of
hospitalization on children and families is anxiety (23). Preschool children are childhood
experiencing an increased motordevelopment. The efect of hopitalization are anxiety, crying,
sadness and uncooperative.(22). The anxiety in children also can disrupt the child's growth
and healing process. Preschool-aged children describe the hospitalization as a frightening
experience, so it can increase children's anxiety(8).

Anxiety for hospitalization is common felt in pre-school children, aged 3-6 years. Preschool
children are childhood that is experiencing an increase in motor development. The reactions
of preschoolers to hospitalization anxiety are refusing to eat, often asking, crying, and
uncooperative (21). Hospitalization for children is a frightening experience and increases the
children’s anxiety. Playing is one way to overcome anxiety in children treated in the
hospital(8).

Play is one of a natural communication tool for children and a basic education in early
childhood education. Play can be as a therapeutic application to resolve anxiety in children
who are hospitalized (8).Play therapy is something that can be done by healthy and sick
children (1). Children who are undergoing hospitalization still need to play (9). Play therapy
is a medium of psycho therapy or treatment of children (22).Therapeutic play can improve
emotional disturbance and decrease anxiety during hospitalization. Playing in preschool is an
activity that is an important part of development in the early years of childhood. The child
can show what he felt during the hospitalization by doing the game. The child can forget the
pain using therapeutic play. Considerations ofcharacteristics and needs of preschool-aged
children during hospitalization, the limited number of pediatric patients for mobilization, cost,
special room and limited nursing personnel; playing with coloring can be an option to help
reducingthe children anxiety (25).

Coloring is one type of therapy play in preschoolers. Coloring is an easy and inexpensive
therapeutic play applied in hospitals to reduce the impact of hospitalization onpreschoolers,
and it does not require a large space in its implementation. Coloring helps childrento express
their feelings and gives pleasure, because preschool children are very active and like to
imagine (15). In a previous study conducted by Elza Sri Pratiwi and Deswita entitled
Differences Effect of Coloring Therapy Drawing by Playing Puzzles Against Anxiety
Preschoolers in IRNA hospital Dr.M.Djamil Padang obtained results that coloring therapy is
more effective at reducing children's anxiety than play puzzle therapy
Coloring body part/s is one type of therapy play for children aged 4 to 7 years. According to
Peaget's theory, preschoolers have egocentric characteristics and more self-oriented;
therefore, coloring body part is the most appropriate therapy for preschool children.In this
activity, children are introduced to their bodies, for example, members of the body parts.Body
parts for preschoolers are the first thing taught inpreschool curriculum. The coloring body
part also can increase pre-school children's knowledge about body functions, as well as, pre-
treatment of hospitalization, namely introducing body parts treated or performed surgery (6).

A study conducted by Katinawati (2011) on anxiety of preschoolers experiencing

hospitalization,showeddifferences of anxiety levels in children before and after play therapy.
Before being given play therapy,80% of children experienced moderate anxiety and 20% of
them experienced severe anxiety; but after being given playtherapy, 86.7% of them
experienced mild anxiety and 13.3% of them experienced moderate anxiety. The results of
this study were also supported by Ikbal (2014) study on the effect of wax playing therapy on
decreasing anxiety level in preschool-aged children who experienced hospitalization.
Soedarso Pontianak explained that there was significant difference between the levels of
anxiety before and after the therapy of playing candles. Related research supported the effect
of coloring therapy to play image was done by Doni Septyana (2013) that playingandcoloring
pictures made the child feel happy, thus stimulating the nerves of the brain (synapses) to
connect each other, thus forming a beautiful new memory and reducing anxiety as long as the
child was hospitalized.

The preliminary study was conducted in 74 children (patients) aged 3-6 years, staying in
economic room and data were obtained during the last 3 months from September to August
2016. The Researcher found that many children cried, especially during treatment. In addition
to crying, pediatric patients also did not want to be separated from parents/guardians and
avoided to get treatment. Mitra Husada hospital did not have adequate play space for play
therapy.Based on the phenomenon above, the researchers were interested to do research on
the influence of playing with Coloring body part on anxiety in pre-school children (3-6 years
old) who were hospitalized in Mitra Husada Hospital. The purpose of this study was to
determine the effect of play therapy (Coloring body part)on the anxiety level of pre-school
children at Mitra Husada Hospital, PringsewuLampung.

MATERIAL and METHODS

The research design of this study was Quasi-experimental, one group pre-test – post-test
design without controlgroup. The samples of this study were 27 children with inclusion
criteria as pre-school age children who undergoing 1-6 day treatment, be able tocommunicate
andthe first hospitalization. The number of participants in this study wasdetermined using
simple random sampling,consecutive sampling. Data were analyzedusing paired sample t-
test. The researcher used three instruments namely: 1) The demographic data, 2) anxiety score
with before and after given preferential treatment, 3) sheets of paper containing complete
human body pictures and stationery, and colored / crayon pencils.
Questionnaire B was used to measure anxiety scores of children before and after treatment.
The researcher usedmodifiedQuestionnaire:Preschool Anxiety Scale Revised (PASR) (
Edwards et al, 2010).This instrument consisted of 4 categories including 28 items with 5
scales as : not at all (score 0), rarely (score 1), sometimes (score 2), often (score 3), very
often (score 4). The categoriesof anxietyscore, obtained by summing the score of each
category item,weredividedinto 4 groups as follows: 0 (0-28 scores) = not anxious, 1 (29-
56scores) = light anxious , 2 (57-84scores) = moderately anxious,3 (85-112 scores) =
anxiously heavy.

RESULTS
There were 24 respondents and most of them were male (62.5%). Most of them were 3 years
old (37.5%) and were cared for 5 days (37.5%).
Most of the respondents (62.5%). had moderate anxiety before doing coloring body part
treatment (Table 1).

Table 1: Frequency Distribution of Respondents Based on Anxiety Before Performing

Coloring Body Part Therapy at Mitra Husada Hospital

Anxiety Before
Performing Frequency Percentage (%)
anxiously heavy 4 16.7
moderately anxious 15 62.5
light anxious 5 20.8
not anxious 0 0
Total 24 100

Table 2: Respondent Frequency Distribution by Anxiety After Coloring Body Part Therapy at
Mitra Husada Hospital

Anxiety After
Performing Frequency Percentage (%)
anxiously heavy 4 16.7
moderately anxious 3 12.5
light anxious 13 54.2
not anxious 4 16.7
Total 24 100

Most of the respondents(54.2%)experienced mild anxiety after coloring body part therapy.

Table 3: Anxiety Score Changes Before and After Coloring Body Part in Preschoolers at
Partner Husada Hospital

P
Anxiety Mean Difference n
Value
Pretest 1.96
0.65 0.006 24
Posttest 1.29

The average anxiety score before the coloring body part therapy was equal to 1.96 and the
average score of anxiety after coloring body part therapy was 1.29. The difference in the
decrease in anxiety score before and after the coloring body part treatment was 0.65. The
result of statistical test of dependent t-test got p value = 0.006 with significance limit 95% (α
= 0.05), so it was concluded that anxiety levels were reducedin pre-school children after
performing coloring body part

DISCUSSION
Gender
From the statistical test results,15 children (62.5%) were boys and the rest was girls (9
children, 37.5%). This finding was similar to previous finding conducted by Diah in 2014
where most of the respondents were boys. According to Diah (2014), there were more male
children admitted in the hospital compared to female children. This meant that boys were
more often sick than girls, but the exact cause was not known (Soetjiningsih, 1995;
Ngastiyah, 2005). Boys were more commonly hospitalized than girls.

Age
From the study results, most ofthe respondents were age 3 years(9 children, 37.5%). At the
age of pre-school children is the time for children to explore into the environment and tend to
spend more time outside the house to socialize. Consequently, children will adapt to the new
environment. Santrock (2011) saidthat preschool children are an initiative stage according to
Erikson's psychosocial theories in which children enter the wider social world, they face more
challenges than when they are babies and learn to actively engage in activities that are aimed
at meeting those challenges .
In the new environment it is undeniable that the child will be exposed to various things in the
environment that may cause the child to get illness. The three year olds child will be much
more active than 4 or 5 year olds. Children aged 3 years have the highest activity in the life
span of human life (Santrock, 2011). While the immune system of children aged 3 years, will
be weaker than children aged 4-5 years. The physical endurance of children tends to be more
vulnerable and physiological process is not yet mature. In this case children who tend to be
active in new environments with weaker immune systems will be more exposed to the
environment and eventually fall ill if the immune system is not immune (Hidayat, 2009).
According to research conducted by Widiyono in 2012, 3-year-olds were most hospitalized
comparing to children aged 4, 5, and 6 years.Therefore, children aged 3 years were more
hospitalized because at that age the children were more active, but had a weak immune
system.

Length of day care

In this study,most of the days of treatmentwere 5 days (9 children 37.5%), because of the
parents' habit that they would take the child to a hospital after 2 -3 day of illness. Child care
would be done at home first. Wong (2004) said that direct family involvement to sick children
was part of the family role as an open system. The family served as a child protector,
fulfilling children's needs, and sustaining child survival. Widiyono(2012) found that long
treatment during the hospitalization was for 5-6 days because pre-school children had long
healing period.

Coloring Body Part Therapy

The results of this study indicated that 24 respondents (100%) performed coloring body part
therapy. Coloring is the activity of giving color to drawings or imitations of goods made with
pencil or dye stencils on paper (Sudaryat, 2011). Coloring pictures is a creative game therapy
to reduce stress and anxiety and improve communication in children. Coloring provides an
opportunity for children to be free of expression and very therapeutic. Color is also a media
therapy for reading emotions and can relieve stress (Farida, 2009). A study conducted by
Novan in 2012, found that coloring body part therapy had a strong influence to decrease
anxiety in children.

Anxiety Before Giving Therapy Coloring Body Part Pre-School Children

There were 15 respondents (62.5%) who experienced moderate anxiety before the coloring
body part therapy. Anxiety occuring in children is actually normal, as revealed by Miller in
2011 that the anxiety is a normal reaction to stressful situations and is in a new situation.
According to Supartini (2004), anxiety increases when children lose control of physical
weakness, pain, and fear of death. Based on observations made by researchers, the active role
of parents was still less in relation to reduce anxiety children. This was in connection with the
limited time family waiting in the hospital, because it had to be alternate with other family
members, so it would cause a protest to the child due to lack of attention. Parents were more
likely to work closely with nurses in terms of implementing nursing action procedures. The
results of observations by researchers and nurses at the time of the nurse getting into the room
and approaching the child, the reaction always appearedas the calm facial expression, holding
or approaching parents, and siblings. While at the time of the nurse performing the inspection,
or performing painful actions (injection, treating wounds, putting in an IV) the most frequent
reactions of the child were tense facial expressions, a sad child, holding tightly, or calling
parents when the parents wereleaving,and struggling. While nurses fed, medicated, and
engaged in conversation,children’s reactions appeared to be quiet and uncooperative.

Anxiety After Coloring Body Body Therapy Part Pre-School Children

(1) After coloring body part therapy, most of the respondents had mild anxiety (15 children,
54.2%). Coloring is the activity of giving color to drawings or imitations of goods made
with pencil or dye stencils on paper. Coloring pictures is a creative game therapy to
reduce stress and anxiety and improve communication in children. Coloring is a
therapeutic play, a healer game, and a way of communicating without using words to
express feelings (Tedjasaputra, 2008). Color is also a media therapy to read one's
emotions and can alleviate stress in children (Elza Sri Pratiwi & Deswita,2017).
With the play therapy of drawing the limbs can reduce anxiety in children because children’s
fear are reduced. Children become familiar with the hospital environment and will not be
saturated because of drawing and coloring activities of their limbs. This finding was in
accordance with Wong’s study in 2004 where play therapy was very effective and served to
meaningful hospital environment.With coloring body part therapy, when the nurse entered the
room and approached the child, the child's reaction was no longer uncooperative response.
They wanted to work with nurses and no longer tobe silent or crying. With the therapy of
coloring body part, anxiety in children could be reduced and minimized the effect of
hospitalization. This was supported by research conducted by Kiche and Almeida (2007)
entitled "Theraupetic Toy: Strategy For Pain Management and Tension Relief During
Dressing Change In Children".
Anxiety Changes Before and After Done Coloring Body Part In Preschoolers

The effect of coloring body part on anxiety reduction in preschool children, at Mitra Husada
Hospital, based on statistical test, obtained p-value <0.05, was very effective and significant.
Coloring body part is a form of play therapy where the child is given knowledge about the
body parts, then the child is given the opportunity to choose which body part will be drawn or
colored, then the child is asked to color the picture. After that ask the child to mention the
colored body part and function. Furthermore, the child can describe the part of his body.

IMPLICATIONS
Nurses working in hospitals are expected to apply play therapy such as coloring body parts to
decrease anxiety in children who are in the hospital and provide information to parents about
the benefits of play therapy when children are treated in the hospital. Researchers can then
conduct research on various factors that influence the application of hospital play therapy.

Conclusion
There was a significant change of preschool children's anxiety before and after doing coloring
body part therapy.

ACKNOWLEDGEMENT
Acknowledgments to all parties who had helped and supported the completion of this research
especially STIKes Muhammadiyah Pringsewu Lampung and Mitra Husada Pringsewu
Hospital Lampung. We also convey our thanks to all Mitra Husada Hospital nurses especially
in the Children's Room.
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