The effectiveness of mandala coloring on the psychological and physiological symptoms in adult hospitalized patients: a meta-analysis

BACKGROUND: Hospitalization often imposes significant psychological and physiological demands on patients. Mandala coloring may help reduce these challenges. This meta-analysis aimed to evaluate the effectiveness of mandala coloring interventions across psychological and physiological symptoms in adult hospitalized patients. METHODS: A comprehensive search was conducted using nine databases. Randomized controlled and controlled studies comparing mandala coloring with control groups were included. Data extraction was performed independently by two authors, and risk of bias was assessed using the Cochrane RoB tool. GRADE Pro software was used to assess the quality of the evidence. Standardized mean differences (SMD) with 95% confidence intervals (CIs) were pooled using RevMan (version 5.4). Subgroup analyses were performed by session frequency and duration. RESULTS: Seventeen studies with a total of 987 participants were included. Mandala coloring significantly reduced anxiety (SMD = - 2.16, 95% CI [-3.38, - 0.95]) and stress (SMD = - 2.45, 95% CI [-3.06, - 1.85]). Improvements were also observed in well-being (SMD = 4.51, 95% CI [0.81, 8.21]) and hope (SMD = 0.42, 95% CI [0.09, 0.75]). No significant effects were found for resilience, pain, fatigue, nausea, comfort, or vital parameters. Subgroup analyses indicated that brief (≤ 30 min) and multiple-session interventions were especially effective in alleviating anxiety. The level of evidence, as assessed using GRADE, was, however, low. CONCLUSION: Mandala coloring provides nurses and healthcare professionals with an inexpensive, low-resource, and patient-friendly method to enhance psychological well-being during hospitalization. Incorporating short, repeated sessions into routine care may strengthen resilience and patient comfort. Further large-scale and high-quality trials are required to establish standardized protocols and clarify effects on physiological symptoms. TRIAL REGISTRATION: PROSPERO meta-analysis registration: CRD420251130565.