Unlocking Limitations Through Arts: A Mixed Methods Study on the Effectiveness of an Expressive Arts-based Intervention on Psychosocial Wellbeing of Adults With Age-related Visual Impairment
Phase: NA
Conditions: Age-Related Macular Degeneration
Sponsor: The University of Hong Kong

 
Document creation date: 06 October 2023 Version 6 
Research Proposal 
Project Title 
Unlocking Limitations through Arts: A Mixed Methods Study on the Effectiveness of an 
Expressive Arts-based Intervention on Psychosocial Wellbeing of Adults with Age-related 
Visual Impairment 
 
Protocol Identifying Number 
RGC Ref No. 17611122 
 
Funding/Sponsor 
University Grant Council, General Research Fund 
 
Date 
30 October 2023 
 
Version 
2 
 
Investigators 
Principal Investigator: 
Prof Ho Tin Hung Rainbow, Professor, Faculty of Social Sciences, Department of Social 
Work and Social Administration, The University of Hong Kong 
Co-investigator: 
Dr. Cheong Ming Yan Allen, Associate Professor, School of Optometry, The Hong Kong 
Polytechnic University 
Dr. Wan Adrian Ho Yin, Lecturer, Faculty of Social Sciences, Centre on Behavioral 
Health, The University of Hong Kong 
Dr. Qing Li, Associate Consultant, Grantham Hospital, The University of Hong Kong 
 
Estimated Duration and Commencement Data 
Project start date: 31 March 2023 
Proposed study completion date: 31 December 2025 
Expected final report date: 30 June 2026 

 
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Document creation date: 06 October 2023 Version 6 
Project Objectives 
 
The primary objective of the present study is to investigate the effectiveness of an expressive 
arts-based intervention, with reference to a treatment-as-usual, waitlist control group, on 
persons with visual loss due to age-related macular degeneration (AMD) in the following 
domains: 
(i) 
Psychosocial adaptation, and; 
(ii) 
Vision-related quality of life; 
 
The secondary objectives of the proposed study also aim to investigate the potential 
effectiveness of an expressive arts-based intervention, with reference to a treatment-as-usual, 
waitlist control group on the followings:  
(iii) Symptoms of anxiety and depression; 
(iv) Resilience; 
(v) 
Social support; 
(vi) Imagination; 
 
While participants’ experiences as well as the process of the expressive arts-based intervention 
on other psychosocial wellness of persons with AMD will also be explored: 
(vii) The relationships of the psychosocial variables and intervention effectiveness (e.g. 
mediation, moderation, and other associations) 
(viii) The participants’ experiences in the intervention group (through qualitative inquiry), 
and; 
(ix) The factors that may contribute to or affect the intervention outcomes of the 
expressive arts-based group intervention (through both quantitative and qualitative 
inquiries). 
 
 
 

 
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Background of Research Study 
 
Age-related functional impairments, such as deafness, loss of speech, loss of limbs, dementia, 
and stroke-related paralysis impose tremendous stress on aging adults; evidence seemed to 
suggest that vision loss is one of the most prevalent and most-feared disabilities in old age [1, 
2], yet limited resources have been invested to help them. Vision loss triggers emotional 
reactions of extreme loss of confidence, sense of control, and independence in those affected 
by vision loss [3]. Amongst all, the age-related macular degeneration (AMD) is the most 
common cause of age-related, progressive, and irreversible vision loss. AMD occurs when the 
cells of the macula deteriorate, resulting in loss of central vision. Most people with AMD may 
be asymptomatic at the early stage of the disease, whereas when the disease progresses, they 
may experience blurring of central vision, distorted vision, empty spot appears in the centre of 
the visual field, colors appeared dull or washed out, and eventually become complete loss of 
central vision. Although the etiology of AMD is unknown, predisposing factors related to the 
development of AMD include heredity, ageing, smoking, obesity, and the gender of women 
[1].  As the most common form of vision disease, the prevalence rate of AMD is higher than 
glaucoma and diabetic retinopathy combined, accounting for 8.7% of all blindness of persons 
aged 65 or above worldwide. AMD is also the most common among individuals aged 60 or 
above, and the age of onset could be as early as 40; the prevalence rate of AMD surged from 
1% to 15% for persons aged between 55 and 80 [4, 5]. Given the trend of ageing worldwide, 
the disease and its sequels will increase the burden on society; despite the prevalence and the 
long duration of this progressive disease, limited interventions exist and there are currently no 
proven therapies for atrophic disease, a major type of AMD [2]. Most attention and resources 
have been allocated towards improving everyday functioning; psychosocial wellbeing that is 
equally important to rehabilitation and successful adaptation to vision loss is secondary and 
inadequate [6, 7].   
Psychosocial Needs of Persons with AMD 
Persons with AMD experience significant impairments in key aspects of daily life and require 
active adaption in response to the deteriorating vision ability and the consequences of the 
disease [8]. Research of psychosocial needs of adults with AMD is rare in Hong Kong. A 
qualitative study has been conducted by the project team to explore the psychosocial impacts 
of AMD in local Chinese adults; it was found that individuals with AMD faced the challenges 
of transitions of self-identity, psychological distress, as well as obstacles in social relationships 
and living in the community [9]. It was also documented, when compared with an age-matched 
cohort with chronic illnesses, persons with AMD experienced profound impairment in their 
daily life instrumental functions, quality of life, emotional wellbeing, and physical health 
status [10].  Depression is a common collateral diagnosis for this population [7]. In addition, 
literature also suggested that persons with AMD showed elevated signs of anxiety when 
compared with normal-vision peers and other adults with chronic diseases [11-13]. Research 
findings suggested that among persons with AMD, compromised mental health exacerbated 
difficulties in adjustment [14]. Horowtiz and colleagues suggested that treatment outcomes and 
life satisfaction were strongly and negatively associated with depressive symptoms [15].  
Research also showed that older adults with AMD-related vision loss were correlated with 
diminished social network, poor sense of self, and decreased perceived autonomy [16].  
Adults with vision loss are also at risk of poor quality of life [17, 18], which resulted from 1) 
reduced participation in social and vocational activities, 2) sense of hopelessness and 
depression from vision loss, and 3) the distress related to adjustment trajectory and prognosis 
of visual loss over time [19]. Even worse, the poor quality of life and risk of developing 
depression and anxiety elevated the suicide risks in this population, and the risk is greater than 

 
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that associated with malignant disease and neurological disorders [20]. Overall, the above 
research and literature converged on one important point: it is crucial to address the 
psychosocial needs of persons suffering from AMD to support them to achieve optimal 
treatment benefits, better adjustment and adaptation to their lives to go beyond their vision 
limitation.  
 
Help is much needed to prevent a considerable impoverishment of life. Although the primary 
focus of rehabilitation in vision impairment is to learn ways to complete everyday activities, 
simply modifying physical performance does not necessarily yield adaptation [21]. Persons 
with vision loss may need to use different strategies at different times and in different 
situations to address the many difficulties they encounter. Hence the enhancement of psycho-
social flexibility in coping is the key to successful adaptation to vision loss. Persons with 
vision loss not only need to learn compensatory skills, but also the need to build resilience, 
renegotiate supportive relations, and maintain bio-psycho-social wellbeing [21]. Furthermore, 
a cross-sectional study suggested that intrapersonal factors, such as acceptance of loss and 
perceived social support played a pivotal role in mitigating depressive symptoms and eliciting 
adaptive coping among older adults suffering from vision loss [1].  
 
Why Expressive Arts-based Intervention (EXABI)  
A scoping review published by the World Health Organization suggesting that arts and arts 
therapies impact health and wellbeing is not particularly new [22]. Expressive arts-based 
intervention (EXABI)  integrates psychotherapeutic skills with the use of the intrinsic 
expressive and healing power of arts, and seeks to engage the client holistically across the 
physical, cognitive, emotional, social, aesthetic, and transpersonal domains [23, 24]. This 
approach uses different creative arts modalities (arts, dance/ movement, drama, music, and 
words) in an integrative way as a vehicle for establishing interpersonal connections (verbal or 
non-verbal), encouraging aesthetic appreciation with a non-judgmental attitude, and cultivating 
mutual understanding, support and appreciation [24]. EXABI takes a “low-skill high-
sensitivity approach”, as such, participants do not have to be proficient in any verbal or non-
verbal communication skills or arts ability; they would be facilitated to become sensitive to 
whatever they are experiencing so that they could engage creatively and meaningfully in 
different arts media and find way of working with the situation that feels “just right” to them 
[24]. The use of different elements from EXABI has attracted much attention in community 
settings due to its safe, engaging, enjoyable process, and its non-pharmacological and strength-
based orientation [25]. More importantly, the multimodality nature of EXABI can expand and 
complement each communication channel (via sound, images, movement and words) through 
the imaginative and creative power of the arts, creating unlimited possibilities in expression.  
A qualitative study on the potential benefits of a dance program for people with visual 
impairments showed promising physical benefits (such as coordination, balancing, body 
awareness, and increased physical activity) as well as interpersonal benefits (such as inclusion, 
friendship, and social support networks) [26]. While a music-based intervention also resulted 
in positive changes in personal wellbeing, tolerance of impairments, and social 
communication, at the same time, it helped building inner resources to tackle the challenges 
posed by vision loss [27]. A multimodal, expressive arts therapy for a senior adult with visual 
impairment suggested that the intervention has facilitated acceptance of physical weakness and 
promoted active coping in a residential setting [28]. Thus, the application of expressive arts 
intervention might facilitate the effective use of residual vision that might help enhance what 
sight remains, and keep contact with an external world. Moreover, EXABI offers a platform to 
uncover and express their anxieties by externalizing them onto a neutral object e.g. the paper 

 
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or sound, that would allow an individual to stay in the present moment. The non-judgmental 
environment emphasized during the process can also help participants experience an 
acceptance of whatever emerges through the art and the art-making process; and that would 
help preserve the sense of control over one’s own life and during adversity, leading to 
resilience [29]. Furthermore, through exploration in expressive arts intervention, one is more 
aware and getting in touch with previously unacknowledged feelings or needs; that would help 
individuals acquire better self-understanding as they face the challenges posited by vision loss.  
 
Theoretical Basis of Expressive Arts-based Intervention for Vision Loss 
Rested on the assumption that all art disciplines engage to some extent with sensory and 
communicative modalities when being created or observed, Roscher proposed the 
Polyaesthetic Theory [24] which has been adopted as the theoretical basis for expressive arts 
therapy. The theory is also recognized as having the essence of Chinese arts [28, 30] as images 
and poems always go together in traditional Chinese paintings. The theory asserts that all art 
modalities embrace a variety of sensory channels and imagination modalities. For instance, 
engaging visual arts involves not only visual perception, but also sensorirmotor and tactile 
senses as we paint; musicing does not only rely on auditory sensory modality, but also other 
forms of senses. Through imagination, one can even add sound and movement to an image. 
The art-making process allows persons with visual impairment to convey explicit and implicit 
visual images through non-visual forms, and thus the use of arts can bypass or breakthrough 
the limitations of communicating through visual cues [31]. The intermodal transfer of art 
modality from one to the other could help enhance persons with vision loss to perceive and 
expand their experiences in a multimodal way. Thus, the multimodal expressive arts-based 
intervention could help tap into different sensory channels for communication, expression, 
perception and interactions, and satisfy the different preferences of expressive channels that 
individuals may have, while offering opportunities for them to explore new ways of knowing 
and interacting with others [32]. Intervention strategies that help to facilitate communication 
and coping for persons with AMD would help improve quality of life, buffer against 
psychological complications, instill a sense of control and resilience that is instrumental to 
active participation in treatment and rehabilitation [8, 33]. On the other hand, such initiatives 
would help buffer against caregiver stress, prevent caregiving burden, which would in turn 
further enhance the overall wellness of the individual and the family caregivers [33].  
The EXABI emphasizes the process of exploration with arts and imagination, which 
encourages individuals to try out new strategies to communicate, relate to each other, and in 
problem-solving. Such exploration and reliance on creativity will allow the individuals more 
room to express, more flexibility to manage the disabilities and impairments due to vision loss; 
open new ways that enable adaptive daily functioning [26]; and facilitate the improvements of 
wellbeing and resilience for persons with vision loss [1, 6]. Expressive arts-based group 
intervention allows social support to emerge between the group members synergistically, 
whereas the experiences of one member could provide the avenue for other members to model 
alternative copings [26, 29]. When participants use arts to share what they normally cannot 
verbalize, they open up possibilities for unexpected common themes for discussion and 
exploration [6]. The arts-based group also allows the participants to connect more with the 
program content, display attention and appreciation of the self, others, and the external 
environment, rather than only learn practical skills to manage issues arising in daily living [3]. 
Although evidence is accumulating on the use of arts-based approaches to help individuals 
with vision loss, existing evidence on the use of arts among persons with vision impairments 
is rather limited and is plagued by the following limitations: (i) small sample; (ii) inclusion of 
participants with various vision loss conditions; (iii) interventions with single art modality; (iv) 

 
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without post-intervention data collection time points to explore the sustainability of changes. 
To address the above limitations and knowledge gaps, this study may generate rigorous 
research evidence to support the use of expressive arts-based intervention, which puts equal 
emphasis on creativity, multi-sensory integration, and cultivation of inner coping resources for 
people with visual impairments.  
 
Work Done by the Team 
The current research team comprises experienced and well-known researchers and clinical 
experts in expressive arts therapy, ophthalmology, optometry, psychiatry, mental health, and 
outcome research in behavioural health. All of them have works done related to the population, 
the arts-based intervention, and the health and wellbeing issues related to this study. Prof. 
Rainbow Ho (PI) has rich experiences in clinical practice and research (RCT, mixed methods) 
in expressive arts-based interventions, including its cultural adaptation, mechanism, and 
psycho-physiological outcomes [34, 35]. She has also supervised trainees in using expressive 
arts for the wellbeing of persons with different clinical conditions, including visual impairment 
[28], hearing impairment, depression, dementia, stroke and cancer, etc. Dr. Allen Cheong is an 
experienced researcher-practitioner in optometry and rehabilitation for persons with visual 
impairments. She has collaborated with the PI and the project team in a study on exploring the 
psychosocial needs of adults with visual impairments [9]. She is collaborating with HKU and 
HKSB on projects using non-invasive brain stimulation and perceptual learning to improve 
functional vision in patients with AMD and glaucoma. Dr. Adrian Wan is a researcher on 
holistic wellness, mindfulness, expressive arts-based intervention, and social work practices in 
patients with chronic illnesses and caregiver supports [36, 37]. Dr. Qing Li is associate 
consultant in Grantham hospital. The experiences in research and clinical practices of the 
project team will ensure proper implementation of the project components, its scientific rigor, 
as well as translation of the research findings to practical wisdom locally and internationally.  
 
Research Plan and Methodology 
Study Hypotheses. The proposed study attempts to explore the following hypotheses: 
1. The Expressive Arts-based Intervention Group is more effective than the treatment-as-usual 
waitlist control in (i) psychosocial adaptation, (ii) vision-related quality of life, (iii) anxiety 
and depressive symptoms, (iv) resilience, (v) social support, and (vi) imagination of persons 
with AMD. 
2. Changes observed/ reported by participants in the expressive arts-based intervention group 
are sustainable at 3-month and 6-month post-intervention follow-up time points. 
Exploratory Questions. The proposed study will also attempt to explore the potential 
mechanism and process of the interventions: 
3. The relationships of the psychosocial variables and intervention effectiveness (e.g. 
meditation, moderation and other associations)  
4. The participant’s experiences in the expressive arts-based intervention group. 
5. The potential factors and conditions that may affect how and why the expressive arts-based 
intervention works or does not work for the participants, and real-life application of the 
experiences that the participants have in the intervention groups.  
 
Study Design and Methods of Data Collection 
Study Design. This proposed study adopts a randomized controlled trial with mixed methods 
design. To address the research objectives, data collected will be triangulated and interpreted 

 
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simultaneously to address the research questions. Appendix A depicts the CONSORT flow 
diagram of the present study. Outcome measures will be assessed on four time-points (T0: Pre-
intervention at baseline; T1: Post-intervention; T2: 3-month post-intervention and; T3: 6-month 
post-intervention) to assess the immediate and sustained effects of the expressive arts-based 
intervention on psychosocial wellbeing of the participants. Qualitative interviews will be 
conducted with a random subsample of 30 participants from the expressive arts group at T1 and 
T3 to collect fine-grained, information to explore their overall experience of participation in the 
intervention and how the experience has shaped their coping experience in terms of stress 
management, self-care challenges, and to reestablish severed social connections. Results of the 
qualitative interviews will be used to enhance the interpretation and understanding of the 
quantitative findings [38]. Appendix B summarizes the conceptual framework of the study. 
Participants.  Although the prevalence of AMD is most common at 60 or above, there has 
been a decreasing trend in the onset age of the disease; individuals aged 50 or above or even 
younger are at risk of the disease, depending on their exposure to lifestyle-related risk factors 
[2]. As suggested by the clinical experts in the team, we intend to recruit community-dwelling, 
Chinese-speaking adults aged between 50 and 80, with diagnosis of age-related macular 
degeneration in one or both eyes of all different etiologies[39]. Inability to understand the 
Chinse language, as well as a diagnosis of total blindness, presence of other significant 
physical, psychological, and cognitive comorbidities that would hinder the participant from 
completing the study will be excluded. 
Recruitment. The recruitment will be facilitated by our collaborative partners in the 
community (including the Vision Rehabilitation Clinic at The Hong Kong Polytechnic 
University and The Hong Kong Society of the Blind), and in the hospital (including the 
Department of Psychiatry of Queen Mary Hospital and the Department of Ophthalmology of 
Grantham Hospital), as well as referral from medical and mental health professionals working 
in the field of geriatric, psychiatry, clinical psychology, social work, and other related fields. 
Promotion will be arranged on the website/social media platform of the Department of Social 
Work and Social Administration and Centre on Behavioural Health, HKU, the Optometry 
Clinic at PolyU, Department of Psychiatry of Queen Mary Hospital, and the Department of 
Ophthalmology of Grantham Hospital. Screening will be conducted by the researcher or 
referral professionals who have attended briefing sessions offered by the research team. In 
view of their visual conditions, computer-assisted methods and research assistant(s) will be 
available to assist data collection by face to face/phone follow up. To encourage participation 
in the multi time-points study, incentives in forms of cash vouchers will be given to 
participants of both the experimental group and the control group. Each of participants will be 
given a case voucher of HKD$50 at each data collection time point. 
Sample Size: We expect a moderate effect size of 0.5 for the primary outcomes based on 
previous studies on expressive arts intervention [40]. Power analysis was conducted using the 
Gpower 3.1 software. Assuming a 20% attrition rate, a total sample of 154 participants with 77 
participants for each arm will offer a statistical power of 80% to detect the moderate effect size 
in the 2-arm RCT with 4 measurement time points at a significance level of 0.05. For the 
qualitative data, a random subsample of 25 - 30 from the intervention arm will be invited to 
join individual and in-depth interviews at post-intervention (T1) and 6-month follow-up (T3). 
Based on the guidelines for mixed-methods study design, a sample of 25 participants should 
suffice data saturation. More participants will be recruited into the study if data saturation is 
not reached until no new findings emerge [41].  
Group Allocation. Eligible participants will be randomly assigned into one of the two study 
conditions on a 1:1 basis using a randomization table and a computer-assisted random number 

 
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generator. The allocation list will be produced by an independent researcher and concealed 
from other researchers and participants until assignment. 
(a) The Expressive Arts-based Group Intervention: The 8-session intervention group (weekly 
session, 90 minutes each, with 6-8 participants in 1 group) will be delivered by a registered 
Expressive Arts Therapist, or a therapist trainee/ mental health professional trained supervised 
by a qualified expressive arts therapist or the PI. Each session is structured based on the basic 
architecture of Intermodal Expressive Arts Therapy composing of the basic processes in 
EXAT: check-in, warm-up, core arts-making, sharing, and closure [30, 42]; and focuses on a 
specific theme related to the psychosocial needs of persons with AMD: communication, 
expression, flexibility, relationship, coping with uncertainties, confidence, creativity, and 
resilience. A similar program has been adopted for people with deteriorating chronic illness 
[40, 43, 44], and has been refined to integrate the cultural-relevant components (e.g. Chinese 
festivals, Chinese arts and music, etc.) [2, 3], and used by the team in previous studies, student 
practicums and community workshops [45, 46] and fine adjustment has been made to suit 
people with visual adjustment [28]. Appendix C summarizes the structure of the session. 
(b) The Wait-list Control Group: This study aims to show whether people benefit from 
receiving the EXABI as a treatment package compared with those who are not receiving it, i.e. 
the absolute effect of the intervention [47], thus a waitlist control group that continues with 
usual routine healthcare (e.g. existing functional, rehabilitation services, etc.) will be adopted. 
The controls will be invited to attend the expressive arts-based group intervention upon 
completion of the study period.  
Treatment fidelity. Group facilitators of the program will receive training on the protocol and 
safety precautions. Treatment fidelity will be assessed by the PI in the form of on-site or 
video-reviewing supervisions during the 2nd or 3rd session upon informed consent in Chinese 
by the participants; and off-site supervision to support the facilitators. Assessment will be 
conducted using a pre-constructed observation checklist of program pedagogy and expected 
goals.   
Research ethics. Ethical approval will be obtained from the Institutional Review Board and 
Human Research Ethics Committee prior to data collection, and consent in Chinese will be 
obtained from all recruited participants prior to assessment. The study will be registered in the 
HKU Clinical Trials Registry and the ClinicalTrials.gov under the National Institutes of 
Health. All procedures performed in studies involving human participants were in accordance 
with the ethical standards of the institutional and/or national research committee and with the 
1964 Helsinki Declaration and its later amendments or comparable ethical standards. 
 
Measurements 
Primary Outcomes 
1. Psychosocial Adaptation Scale for Visual Impairments. The 38-item Psychosocial 
Adaptation Questionnaire (PSAQ) for visual impairment in Chinese [48] is a self-report 
measure of visual impairment-related psychosocial adaptation. It is rated on a 4-point Likert 
Scale, and yields 7 domains of attitude, self-acceptance, self-esteem, anxiety/ depression, 
sense of belonging, self-efficacy, and self-control. Higher scores indicate a higher level of 
endorsement in specific domain. 
2. Quality of life. Vision-specific quality of life is measured by the 13-item Vision-Related 
Quality of Life Scale in Chinese taken from NEI-VFQ-25. The scale measures vision-
related social function, as well as mental health symptoms, role limitations, ocular pain, and 
dependency on others due to vision impairment, using on a continuous scale ranging from 0 
to 100, with higher score indicates the best possible outcome. The scale has been adopted to 

 
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assess vision-specific quality of life among Chinese adults with visual impairments [49]. 
Secondary Outcomes 
3. Symptoms of depression and anxiety. To better assess the severity of depressive symptoms 
and anxiety, the 14-item Hospital Anxiety and Depression Scale in Chinese will be used to 
measure anxiety and depressive symptoms, with higher scores indicated higher level of 
anxiety and depressive symptoms perceived by the participants [50]. 
4. Resilience. The Chinese version, 14-item, self-report Resilience Scale-14 (RS-14 is a 
reliable and valid instrument of resilience of Chinse; it measures resilience on a 7-point 
Likert Scale, with higher scores indicate higher levels of resilience [51] . 
5. Social support. Perceived social support is captured by the Chinese version of the 
Multidimensional Scale of Perceived Social Support [52]. The 12-item scale composes of 
subscales for perceived social support from the family, friends, and significant others, rated on a 
7-point Likert scale. Higher score denotes a higher level of support in specific domain. 
6. Imagination. The 25-item Self-Descriptive Imagination Questionnaire (SIQ) [53] with five 
factors: expressive imagination, openness to variations, instrumental imagination, past/future 
mindedness, and conventionality, and 21-item Fantastic Reality Ability Measurement 
(FRAME) [54] with four features: coping, transcendence, playfulness, and control. These two 
scales in Chinese will be used to measure participants’ imagination. 
7. Demographics. Participant profiles including age, gender, education level, income, 
employment status, religiosity, marital status, and family composition will be recorded. 
Clinical information (time since onset/ diagnosis, vision status, medical treatment record, 
psychiatric history, comorbidity (physical disabilities, hypertension, diabetes mellitus, or 
other cognitive disturbance) and rehabilitation services utilization will be documented in 
Chinese. The vision status of the participants will be documented by the 15-item Functional 
Vision Screening Questionnaire (FVSQ) [55]. 
In-depth Interviews: About 25-30 participants in the intervention group will be invited to 
attend two individual in-depth interviews in Chinese at post-intervention (T1) and 6-month 
follow-up (T3). The first interview focuses on the immediate post-intervention changes 
perceived by the participants upon program completion, while the second interview focuses on 
the sustainability of these changes at 6-month follow-up and explores additional changes that 
would be observed between the follow-up windows. The interviews will be conducted by 
members of the research team, assisted by a research assistant, using an interview guide (see 
Appendix D) [56, 57]. 
 
Data Analysis: Analyses of the outcomes will be conducted according to the standard intent-
to-treat principle to address the effects of crossover and attrition. The emerging themes from 
the qualitative analysis will be reviewed for resonance with the quantitative findings, and 
triangulated to identify the potential pathways for the therapeutic effect of the intervention. 
1. Effectiveness of the expressive arts-based intervention group (Hypothesis 1 – 2). 
Descriptive statistics will be used to summarize the socio-demographic profiles of the 
participants at the baseline upon recruitment. Chi-square tests and independent t-tests will 
be performed to examine whether there are significant differences in the demographic 
factors and baseline outcomes between groups. The primary analysis of treatment outcomes 
will be conducted using mixed-effects regression models using Mplus 8.3. Mixed-effects 
models analyze the repeated measurements between groups to obtain the group x time 
effect as the intervention effect. Missing data in the sample will be handled using full 
information maximum likelihood method [58] according to the intention-to-treat principle. 
Effect size of the intervention will be evaluated using Cohen d [59], with 0.2, 0.5, and 0.8 

 
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denoting cut-off of small, moderate, and large magnitudes respectively. Demographic and 
clinical variables will be controlled in the analysis. Statistical significance is set at 0.05. 
2. Process and mechanism of the treatment group (Exploratory research question 3). 
Correlation analysis will be conducted to explore the relationships between the primary and 
secondary measures, and other demogrphics and clinical variables. Path modeling will be 
performed to examine the mediating role of adaptive functioning and social support on the 
effect of EXAT on quality of life, emotional distress, and overall health condition. The path 
model will be built for the EXAT intervention group as the predictor variable at baseline 
(T0). Mediation effects will be assessed through the significance of the indirect effects from 
EXAT to outcome variables (quality of life, and emotional distress) at T3 via the mediators 
(adaptive functioning and social support) at post-intervention (T1) and 3-month follow-up 
(T2). Given the likely non-normal distribution of the indirect effects, confidence intervals 
will be estimated using the bootstrapping approach. Themes related to processes and factors 
related to changes will be identified from the qualitative analysis to supplement and explain 
the quantitative findings. Although a sample size of 150 – 200 is normally recommended 
for conducting path analysis in the form of structural equation modeling (Kline, 2005). Our 
team has successfully conducted path analysis on data of previous projects with smaller 
sample sizes (N = 121–151) and published several papers in international journals [60-62]. 
Potential moderating effects would be explored by examining the interaction effects 
between the EXABI treatment and demographic factors such as gender and clinical factors 
such as clinical classification of AMD on the outcome variables.  
3. Process and experience of the treatment (Exploratory research question 4-5). Qualitative 
data from the open-ended questionnaires will be converted into electronic text file for data 
analysis. The interviews will be audio-taped, and transcriptions will be produced by a 
research staff who is not involved in the interventions. All data will be input, managed, and 
analysed using NVivo 12.0 or above. Analysis will be performed using inductive thematic 
analysis method. Transcripts will be coded, and the codes will be put into categories and 
subcategories; and recurrent themes and patterns will be explored. A team member who is 
experienced in qualitative data analysis will conduct the analysis. Audit trial will be 
conducted to ensure data credibility; while the trustworthiness of the analysis will be 
ensured through member checks, triangulation and interrater reliability (helped by another 
research staff). The qualitative analysis will identify themes related to processes and factors 
related to changes to supplement and explain the quantitative findings. 
 
 
 
 
 
 
 
 
 
 
 
 

 
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Gantt Chart (Study Period: 3 years) 
 
 

 
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Appendix A: CONSORT diagram for the proposed study 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
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Appendix B: Conceptual Framework of the proposed study 
 
Appendix C: Sessions Outline & Structure of an Expressive Arts-Based Intervention 
Group Session (EXABI) [30] 
 
 

 
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Appendix D:  Interview Guide for Qualitative Interview 

 
 
 
1. 
Tolman, J., et al., Psychosocial adaptation to visual impairment and its relationship to 
depressive affect in older adults with age-related macular degeneration. The 
Gerontologist, 2005. 45(6): p. 747-753. 
2. 
Wong, W.L., et al., Global prevalence of age-related macular degeneration and 
disease burden project for 2020 and 2040: A systematic review and meta-analysis. The 
Lancent, 2014. 2: p. e106-16. 
3. 
Szubielska, M., People with sight impairment in the world of visual arts: does it make 
any sense? Disability & Society, 2018. 33(9): p. 1533-1538. 
4. 
Health, D.o. Age-related macular degeneratioin. 2020 7 Feburary 2020 [cited 2021 30 
September]; Available from: 
https://www.elderly.gov.hk/english/common_health_problems/others/amd_factsheet.ht
ml. 
5. 
You, Q.S., et al., Prevalence and causes of visual impairment and blindness among 
adult Chinese in Hong Kong - The Hong  Kong Eye Study. Ophthalmic Epidemiology, 
2020. 27(5). 
6. 
Van Der Aa, H.P., et al., Psychosocial interventions to improve mental health in adults 
with vision impairment: systematic review and meta‐analysis. Ophthalmic and 
Physiological Optics, 2016. 36(5): p. 584-606. 
7. 
Demmin, D.L. and S.M. Silverstein, Visual impairment and mental health: unmet 
needs and treatment options. Clinical Ophthalmology 2020. 14: p. 4229-4251. 
8. 
Ueda, Y., Psychosocial adaptation to visual impairment. Causes and coping with 
visual impairment and blindness, 2018: p. 93-108. 
9. 
Ho, R.T.H., et al., Living with low vision: Perspectives of patients with retinal 
degenerative disease in Hong Kong, in Society of Behavioral Medicine 43rd Annual 
Meeting & Scientific Sessions. manuscript in progress: Baltimore, MD. 
10. 
Williams, R.A., et al., The psychosocial impact of macular degeneration. Archives of 
ophthalmology, 1998. 116(4): p. 514-520. 
11. 
Augustine, A., J.-A. Sahel, and F. Bandello, Anxiety and depression prevalnce rates in 
age-realted macular degeneration. Invest Opthalmol Visual Sci, 2007. 48(4): p. 1498. 
12. 
Eramudugolla, R., J. Wood, and K.J. Anstey, Co-morbidity of depression and anxiety 
in common age-related eye diseases; A population-based study of 662 adults. Aging 
Neuroscience, 2013. 5. 
13. 
Kempen, G.I.J.M., et al., Erratum to: The impact of low vision on activities of daily 
living, symptoms of depression, feelings of anxiety and social support in community-
living older adults seeking vision rehabilitation services. Quality of Life Research, 
2012. 21(8): p. 1413. 
14. 
Rovner, B.W. and R.J. Casten, Neuroticism predicts depression and disability in age-
realted macular degeneration. American Journal of Geriatric Psychiatry, 2001. 10: p. 
305-310. 

 
 
 
15. 
Horowitz, A., R. Leonard, and J.P. Reinhardt, Measuring psychosocial and functional 
outcomes of a group model of vision rehabilitation services for older adults. Journal of 
Visual Impairment and Blindness, 2000. 94: p. 30-41. 
16. 
Cherry, K.E., M.J. Keller, and W.N. Dudley, A needs assessment of persons with visual 
impairments: Implication for older adults and service providers. Journal of 
Gerontological Social Work, 1991. 17: p. 99-123. 
17. 
Boerner, K., S. Wang, and V.R. Cimaroli, The impact of functional loss: Nature and 
implications of life changes. Journal on Loss and Trauma, 2006. 11: p. 265-287. 
18. 
Vu, H.T.V., J.E. Keeffe, and C.A. McCarty, Impact of unilateral and bilaterial vision 
loss on quality of life. British Journal of Ophthalmology, 2005. 89: p. 360-363. 
19. 
Lau, J.T.F., The Hong Kong Adult Vision Study: a cross-sectional epidemiological pilot 
study of eye diseases in the population aged 40 years and over in Hong Kong. Hong 
Kong Med J, 2007. 13: p. S4-6. 
20. 
Cosh, S., et al., Sensory loss and suicide ideation in older adults: Findings from the 
Three-City cohort study. International Psychogeriatrics, 2019. 31(1): p. 139-145. 
21. 
Smith, T.M., Adaptation to low vision caused by age-related macular degeneration: a 
case study. Journal of Visual Impairment & Blindness, 2008. 102(11): p. 725-730. 
22. 
Fancourt, D. and S. Finn, Health Evidence Network Synthesis Report 67: What  Is the 
Evidence of the Role of the Arts in Improving Health and Well-being? 2019, World 
Health Organization: Copenhagen, Denmark. 
23. 
Roger, N., The Creative Connection for Groups: Person-centered expressive arts for 
healing and social change. 2011, Palo Alto, California: Science & Behavior Books. 
24. 
Knill, P.J., Foundations for a theory of practice, in Principles and practice of 
expressive arts therapy: Towards a therapeutic aesthetics, P.J. Knill, E.G. Levine, and 
S.K. Levine, Editors. 2005, Jessica Kingsley Publishers: London. 
25. 
Mossey, J.M., et al., Effectiveness of a psychosocial intervention, interpersonal 
counseling, for subdysthymic depression in medically ill elderly. Journal of 
Gerontology, 1996. 51A(4): p. M172-M178. 
26. 
Seham, J. and A.J. Yeo, Extending our vision: access to inclusive dance education for 
people with visual impairment. Journal of Dance Education, 2015. 15(3): p. 91-99. 
27. 
Park, H.Y., The Meaning of Musicing in the Post-traumatic Growth of Individuals With 
Adventitious Visual Impairment: Applying the Life History Method by Mandelbaum. 
Frontiers in Psychology, 2021. 12. 
28. 
Cheung, I.P.Y., Expressive Arts Therapy (EXAT) with a Visually Impaired Female 
Senior Adult, in Department of Social Work and Social Adminsitration. 2019, The 
University of Hong Kong: Hong Kong. p. 63. 
29. 
DiGiulio, D., The use of art therapy with the blind to impact a sense of capability, in 
Art Therapy Department 2017, Long Island University. 

 
 
 
30. 
Levine, E., P. Knill, and S. Levine, Principles and Practice of Expressive Arts 
Therapy: Toward a Therapeutic Aesthetics. . 2004, London: Jessica Kingsley 
Publishers. 
31. 
Cho, J.D., A Study of Multi-Sensory Experience and Color Recognition in Visual Arts 
Appreciation of People with Visual Impairment. Electronics, 2021. 10(4): p. 470. 
32. 
Got, I.L.S. and S.T. Cheng, The effects of art facilitation on the social functioning of 
people with developmental disability. Art Therapy: Journal of the American Art 
Therapy Association, 2008. 25(1): p. 32-37. 
33. 
Dev, M.K., et al., Psycho-social impact of visual impairment on health-related quality 
of life among nursing home residents. BMC health services research, 2014. 14(1): p. 1-
7. 
34. 
Ho, R.T.H., et al., Pssychophysiological effects of Dance Movement Therapy and 
physical exercise on older adults with mild dementia: A randomized controlled trial. 
Journal of Gerontology: Psychological Sciences, 2020. 75(3): p. 560-570. 
35. 
de Witte, M., et al., From therapeutic factrs to mechanisms of change in creative arts 
therapies: A scoping review. Frontiers in Psychology, 2021. 12(678397). 
36. 
Ho, R.T.H., et al., The "Playful" path to parent-child wellbeing: A randomized-
controlled study of a creative arts-based group, in 40th Annual Meeting & Scientific 
Sessions. 2019, Society of Behavioral Medicine: Washington, DC. p. S725-725. 
37. 
Wan, A.H.Y., et al., Factors associating with caregiver identity within the family 
dyads: A cross-sectional study of Chinese cancer caregiving spouse, in Annual Mental 
Health Conference. 2013: Hong Kong. 
38. 
Ivankova, N.V., J.W. Creswell, and S.L. Stick, Using mixed-methods sequential 
explanatory desgin: From theory to practice. Field Methods, 2006. 18: p. 3-20. 
39. 
Organization, W.H., International Classification of Impairments, Disabilities, and 
Handicaps: A Manual of Classification Relating to the Consequences of Disease. 1980: 
Geneva. 
40. 
Ho, R.T.H., et al., Effects of Expressive Arts-based Interventions on Adults with 
Intellectual Disabilites: A Stratified Randomized Controlled Trial. Froniters in 
Psychology, 2020. 11: p. 1286. 
41. 
Saunders, B., J. Sim, and T. Kingstone, Saturatio in qualitative research: Exploring its 
conceptualization and operationalization. Quality & Quantity, 2018. 52: p. 1893-1907. 
42. 
Cassidy, S., S. Turnbull, and A. Gumley, Exploring core processes facilitating 
therapeutic change in dramatherapy: a grounded theory analysis of published case 
studies. Arts Psychotherapy, 2014. 41: p. 351-365. 
43. 
Li, I.M.Y., The effectiveness of an Attachment-based Expressive Arts Therapy 
Parenting Programme for Parents with Special Needs Children (Unpublished Thesis). 
2017, The University of Hong Kong: Hong Kong. 

 
 
 
44. 
Ho, R.T.H. and C.C. Wong, Joint Painting for understanding the development of 
emotional regulation and adjustment between mother and son in expressive arts 
therapy, in Arts-based Research, Resilience and Well-being Acoss the Lifespan, L. 
McKay, et al., Editors. 2020, Palgrave Macmillan: Switzerland. p. 127-146. 
45. 
Kong, C.K.W., A case study on the positive effects of Expressive Arts Therapy with 
Mindful Self-Compassion Intervention for a Mother of Pre-School Child with 
Developmental Difficulties (Unpublished Thesis). 2018, The University of Hong Kong: 
Hong Kong. 
46. 
Ho, R.T.H. and C.K.P. Chan, Expresssive Arts Therapy Program for Parent-Child 
Relationship. 2018, Yan Chai Fong Kong Fai Kindergarten: Hong Kong. 
47. 
Karlsson, P. and A. Bergmark, Compared with what? An analysis of control-group 
types in Cochrane and Campbell reviews of psychosocial treatment efficacy with 
substance use disorders. Addiction: Methods and Techniques, 2014. 110: p. 420-428. 
48. 
Zhang, X.J. and A.P. Wang, Development of a psychosocial adptation questionnaire 
for Chinese patients with visual impairments. Journal of Clinical Nursing, 2011. 20: p. 
2822-2829. 
49. 
Wang, C.W. and C.L.W. Chan, Psychosopcial adaptation status and health-realted 
quality of life among older Chinsee adults with visual disorders. Quality of Life 
Research, 2009. 18: p. 847-851. 
50. 
Leung, C.W., et al., Validation of the Chinese-Cantonese version of the Hospital 
Anxiety and Depression Scale and comparison with the Hamilton Rating Scale of 
Depression. Acta Psychiatr Scand, 1999. 100(6): p. 456-461. 
51. 
Chung, J.O.K., et al., Psychometric evaluation of the traditional Chinese version of the 
resilience Scale-14 and assessment of resilience in Hong Kong adolescents. Health 
Qual Life Outcomes, 2020. 18(33). 
52. 
Zimet, G.D., et al., The Multidimensional Scale of Percevied Social Support. Journal of 
Personality Assessment, 1988. 52: p. 30-41. 
53. 
Feng, Z., et al., A cross-cultural exploration of imagination as a process-based 
concept. Imagination, Cognition and Personality, 2017. 37(1): p. 69-94. 
54. 
Rubinstein, D., et al., Development and validation of fantastic reality ability 
measurement (FRAME) to measure use of imagination in response to stress and 
trauma. Journal of Creativity in Mental Health, 2021. 16(4): p. 412-427. 
55.  
Horowitz A, Teresi J, Cassels LA. Development of a vision screening questionnaire for 
older people. J Gerontol Soc Work 2021;17:37-56. doi:10.1300/J083v17n03_04 
56. 
Elliot, R. Client Change Interview protocol. 2001  [cited 2020 5 October]; Available 
from: http://experiential-researchers.org/instruments/elliott/change.html. 
57. 
Sou, C.S.W., The effects of expressive arts therapy on parent of children with special 
education needs (Unpublished Thesis). 2020, The University of Hong Kong: Hong 
Kong. 

 
 
 
58. 
Enders, C.K. and D.L. Bandalos, The relative performance of full information 
maximum likelihood estimation for missing data in structural equation models. 
Structural Equation Modeling, 2001. 8(3): p. 430-457. 
59. 
Cohen, J., Statistical power analysis for the behavioral sciences. 2nd ed. 1988, 
Hillsdale, NJ: Lawrence Erlbaum Associates. 
60. 
Fong, T.C.T. and R.T.H. Ho, Mindfulness facets predict quality of life and sleep 
disturbance via physical and emotional distresses in Chinese cancer patients: A 
moderated mediation analysis. Psycho-Oncology, 2020. 29(5): p. 894-901. 
61. 
Fong, T.C.T., et al., Psychiatric symptoms mediate the effects of neurological soft signs 
on functional outcomes in patients with chronic schizophrenia: A longitudinal path-
analytic study. Psychiatry Research, 2017. 249: p. 152-158 
62. 
Ho, R.T.H., T.C.T. Fong, and P.S.F. Yip, Perceived stress moderates the effects of a 
randomized trial of dance movement therapy on diurnal cortisol slopes in breast 
cancer patients. Psychoneuroendocrinology, 2018. 87: p. 119-126.