Effects of a puppet-assisted house-tree-person test on fear and anxiety in children receiving chemotherapy and associated influencing factors: A projective, quasi-experimental study

Abstract

Objectives: This study investigated the effect of the puppet-assisted House-Tree-Person Test (HTP-T) on fear and anxiety levels in children undergoing chemotherapy treatment and the factors influencing these outcomes. Methods: The study employed a one-group pretest-posttest quasi-experimental design combined with HTP-T analysis. The study was conducted with 29 children aged 5-12 years receiving chemotherapy at the pediatric hematology-oncology outpatient clinics of a university hospital in the Eastern Black Sea Region of T & uuml;rkiye during the 2022-2024 years. Data were collected using "the Demographic Information Form for Children and Parents, the Children's State Anxiety Scale (CSA), the Children's Fear Scale (CFS), and HTP-T". Data analysis was performed using descriptive statistics, repeated measures ANOVA, and HTP-T analysis. Results: Statistically significant differences were observed in children's mean CSA (F = 3.898, p = 0.026, eta 2 = 0.122) and CFS (F = 5.313, p = 0.008, eta 2 = 0.159) scores across the pre-treatment, during-treatment, and post-treatment measurements. The HTP-T analysis revealed that children had difficulty regulating anxiety and fear, expressed concerns about family and environmental events, reported feelings of loneliness, and exhibited strong emotional attachment to their families. Conclusion: The study demonstrated that incorporating puppet-assisted HTP-T during chemotherapy contributed to reducing children's fear and anxiety and offered a useful approach for identifying influencing factors. Implications for nursing practice: HTP-T, a therapeutic play technique incorporating puppetry and projective methods, may be effective in reducing fear and anxiety among children undergoing chemotherapy. (c) 2026 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.