A preliminary investigation on visual arts in impacting the sleep quality among university students

Abstract

Poor quality sleep has been considerably associated with physiological and psychological health complications. This preliminary study aims to examine the effects of visual art implementation on sleep quality among Malaysian undergraduates. Forty undergraduates (age = 21.15 ± 1.460 years) were recruited. Visual Art Group (VAG; n = 23) engaged in a visual art intervention programme twice weekly whereas Control Group (CG; n = 23) received no treatment over the six-week. Sleep quality was physiologically assessed via sleep tracking device and subjectively via Pittsburgh Sleep Quality Index (PSQI). Negative emotional states were measured through Depression, Anxiety and Stress Scale-21 Items (DASS-21). The attained outcomes suggested improvement of PSQI in VAG, against a declining baseline. Meanwhile, Generalized Estimating Equations analysis revealed significant effects in anxiety and stress among VAG at post-intervention. The present findings manifest that visual art intervention offers a cost-effective method of improving sleep quality and mental health among university students, providing an accessible approach in enhancing sleep behaviors.

Keywords

visual art sleep quality sleep tracking depression anxiety stress university students

Introduction

Being defined as general self-satisfaction with the overall sleep experience, sleep quality simply integrates four aspects, which includes duration, initiation, maintenance and feeling refreshed upon awakening (Kline, 2013). Nurturing adequate and desirable sleep quality among young adults is of utmost importance as it is essentially correlated with individuals’ optimal cognitive, emotional and physical functioning. Nevertheless, the current epidemic of reduced sleep quality has been emerged as a global rising public health concern evidenced through the prevalence of various sleep related problems and disorders among young adults especially those who undertaking tertiary education, across continents including Europe (Foulkes et al., 2019; Norbury and Evans, 2019), Africa (Nsengimana et al., 2023; Seun-Fadipe and Mosaku, 2017), Americas (Becker et al., 2018; Valladares-Garrido et al., 2025) as well as Asian (Zhang et al., 2025; Zhao et al., 2024).

In comparison to the general population, evidence abounds that sleep quality amongst university students is considerably worse and was found to be parallel with local study in Malaysia (Jie et al., 2024). Recent studies revealed that tertiary education students nowadays are more vulnerable to sleep issues whereby unsatisfied sleep quality, chronically sleep-deprived, insomnia or poor sleep quality are commonly reported (Gomez Fonseca and Genzel, 2020; Wang and Bíró, 2021). Existing literature indicates that university students are most likely neglecting in obtaining sufficient sleep within the appropriate range of seven to nine hours per night. Habitually sleeping beyond or below the recommended range may initiate a cascade of symptoms related to serious health problems (Hirshkowitz et al., 2015).

Within the university students’ context, several aspects has been reported as the contributors to endangered sleep quality including hectic academic workload (Chen et al., 2025; Vedaa et al., 2019), physical inactivity (Merellano-Navarro et al., 2022; Rahman et al., 2021), prolonged or night-time use of emitting gadgets (Chen et al., 2017; Liebig et al., 2023), social media or internet-addiction (Al Kazhali et al., 2023), evening chronotype (Glavin et al., 2021) and excessive consumption of stimulant beverage (Ahn et al., 2025; Kaldenbach et al., 2024; Riera-Sampol et al., 2022). Overwhelming with freedom, frequented social activities especially nightlife in addition to unhealthy habits such as smoking and binge-drinking may also contribute to poorer sleep quality (Purani et al., 2019). Considering the residential area, particularly in shared campus residence settings, university students often complain of noise pollution, uncomfortable room temperature and roommates’ habits in affecting their sleep efficiency, resulting in sleep deprivation (Mayne et al., 2021; Meng et al., 2020). Social isolation, emotionally taxing relationships, conflicts or deteriorated interpersonal relationships with family and friends could also elevate psychological distress, hence resulting in sleep disturbances (Zhai et al., 2018). Considering the struggles in balancing both academic responsibilities and work-related commitments, sleep issues were also found to be more prevalent among the employed students (Peltz et al., 2021).

Detrimental impacts associated with sleep difficulties may greatly pose physiological and psychological health complications, which eventually lead to deteriorated life quality and satisfaction. From the psychological perspective, poor sleep quality may alter the emotional well-being and contribute to the development of anxiety and depressive symptoms, increased stress responsiveness, tension, confusion and irritability in addition to cognitive and memory deficits (Mbous et al., 2022). A linear trend of progressively worsened sleep quality has been proposed to be associated with greater mood and anxiety symptomatology (Zou et al., 2020).

By referring to physiological health variables, activation and intensify activity of the sympathetic nervous system, sympathoadrenal system and hypothalamic–pituitary–adrenal axis are often induced by sleep disruption. The associated changes in circadian rhythms and proinflammatory responses could endanger the stress responsivity and somatic pain (Medic et al., 2017). It could also lead to deterioration of immune and neuroendocrine functions including increment of adrenocorticotropic hormone and cortisol levels, which may gradually develop into severe health issues or chronic co-morbidities. Meanwhile, studies reported the significant linear and positive correlation between academic performance and sleep quality (Okano et al., 2019; Toscano-Hermoso et al., 2020), indicated that lower grade point average or academic failure might induced by a poorer sleep quality, daytime somnolence, longer sleep latency and high frequency of sleep disturbances (Maheshwari and Shaukat, 2019).

Visual art intervention

While traditional approaches for sleep disturbances management often involve pharmacological treatments, which are associated with a range of side effects, development of dependency or chronic health risks as well as limited accessibility or financial support, growing interest in non-pharmacological alternatives was observed. Over recent decades, there has been a surge of interest in investigating the effect of mindfulness-based intervention. These interventions are increasingly applied as therapeutic strategies in enhancing both physiological and psychological health.

In alignment with the philosophy and mindfulness perspective, blooming interest in creative art therapy has been recognized. Creative art therapy simply integrates the core components of mindfulness, body awareness, imagery and attention to breathing within an art therapy framework, constructing a new perspective of therapeutic treatment. A diverse type of creative art activities, which incorporate multiple sensory modalities including visual, auditory and kinesthetics has been widely introduced to the community.

Studies documented the efficiency of art-based therapy in treating various negative mental symptoms across age groups, ranging from young children to elders within diverse settings like hospitals, outpatient and residential care, in addition to non-clinical settings (Carsley et al., 2018; Phan et al., 2022). Among various non-pharmacological creative art strategies, visual art intervention emerged as a promising approach due to its cost-effective nature and high accessibility in supporting emotional regulation, whilst posing minimal side effects.

Purpose of study

Considering that major behavioral and lifestyle changes are eventually associated with the beginning of university life, within the unique social developmental period of transition from adolescence into young adulthood (Cheng et al., 2026), well establishment of healthy sleep behaviors is deemed to be crucial. Nurturing good sleep hygiene during this formative stage may reduce the incidence of serious physiological or psychological health complications over the stage of life, thereby promoting better public health and overall economic growth.

Existing non-pharmacological sleep interventions predominantly focus on kinesthetics and auditory approaches in impacting the psychological well-being, with the majority focusing on community-dwelling elderly and clinical population diagnosed with sleep disorders and chronic illness (Abbing et al., 2018; Bosman et al., 2021). Nonetheless, the potential role of visual art activities in improving sleep quality remains comparatively underexplored, particularly among university students, who often suffer sleep difficulties, reflecting the widespread sleep problems among younger generations nowadays. Meanwhile, existing literature predominantly focuses on one specific activity, instead of multi-activity approaches within the same discipline, which could greatly reduce the occurrence of boredom or lack of interest over long term implementation. To our knowledge, there is limited interventional studies evidence on the effectiveness of visual art intervention toward sleep quality among university students, especially among Malaysians. Hence, this study aims to execute a preliminary study in examining the efficiency of visual art intervention on sleep quality, considering both physiological and psychological approaches. It is hopeful that the outcomes shall contribute to a more comprehensive understanding of how visual sensory engagement may promote efficient sleep.

Methods

Research design

The present study employed a quasi-experimental design incorporating a pre-test–intervention–post-test approach to examine the relationship between the engagement in visual art intervention and sleep quality. An overview of the experimental protocol is provided (Supplemental Material 1). Ethical approval was obtained from Universiti Malaya Research Ethics Committee (UMREC; reference number: UM.TNC2/UMREC_2846).

Participants recruitment

Sample size estimation was determined from a priori power analysis, using G*Power for Windows (v3.1.9.7) with an alpha (α) and statistical power equivalent to 0.05 and 0.95, respectively. The analysis revealed that 46 participants was sufficient, accounting for a 15% attrition rate. Participants were recruited through the implementation of proactive recruitment strategies via university email lists, social media platforms (e.g. Facebook, Instagram, WhatsApp and Telegram) and distribution of printed material (e.g. posters and leaflets). Eligibility screening involved in-person assessments using the self-reported PSQI and DASS-21. A purposive non-probability sampling method was adopted where students who met the cut-off scores were enrolled. The scores were then served as baseline assessment.

A non-equivalent comparison group design was employed, whereby 23 eligible students recruited during the first semester were assigned to the Visual Art Group (VAG), while another 23 students were recruited during the second semester to serve as the Control Group (CG). Prior to the interventional phase, participants were briefly educated with the study’s essential details and protocols via Participate Information Sheet (PIS). Written informed consent was obtained and basic demographic information was collected. Familiarization sessions were conducted to educate the participants on the usage of sleep tracking devices and questionnaires. All participants were instructed to adhere to their usual daily routines behaviors, particularly of sleep behaviors, habitual diets and exercise regime throughout the entire study period.

Inclusion criteria encompassed: (a) undergraduate registered under Universiti Malaya (UM); (b) age between 18 and 25 years old; (c) resident in on-campus or off-campus hostel; (d) absence of pre-existing chronic co-morbidities, diagnosed sleep disorders, psychiatric problems and severe health issues; (e) free from usage of prescription drugs or medications and addictions including tobacco, alcohol or any stimulant substances; (f) exempted from ongoing night shift work.

Intervention

During the execution of the study, participants in VAG were exposed to a six-week visual art intervention programme, with a suggested frequency of two sessions per week and each session ranged from 30 to 45 minutes before bedtime. Sessions were delivered in distraction-free and private setting of participants’ preferences (e.g. bedroom and study room). Participants engaged in various creation of directed and spontaneous art productions, which consists of mandala coloring, collage making and clay sculpting (Supplemental Material 2). The use of electronic devices (e.g. mobile phones, tablets and laptops) was prohibited throughout the intervention sessions to minimize the potential confounding effects due to digital stimulation and blue-light exposure. For the first three weeks, participants were introduced to each activity in a structured manner. They were given flexibility to select their preferred activities from the fourth week onward in order to avoid excessive stress and burden whilst maximizing the relaxation effect.

All intervention sessions were delivered by trained researchers who had completed a certified course on the intervention protocol. In maintaining the fidelity of intervention, weekly supervision was provided by a consultant psychiatrist with extensive clinical experiences as well as guidance by a psychology officer with professional credentials as a registered counselor and certified practitioner endorsed by the Board of Counselors Malaysia. All necessary art materials were supplied to participants. All intervention sessions were conducted under the guidance of therapists and counselor, with all necessary art material provided. Participants were expected to complete all the pre-determined intervention sessions, with replacement sessions allowed within the same week to ensure the adherence and data reliability. Meanwhile, participants in CG engaged in their usual routines without any intervention programme being offered.

Assessments

Assessments of sleep quality and mental health symptoms were conducted at four pre-determined time points throughout the six-week longitudinal study period: (1) T₁ = week 0 as baseline assessment; (2) T₂ = end of week 1 during intervention phase; (3) T₃ = end of week 3 during intervention phase; (4) T₄ = end of week 6 as post-test. The intervention effects were evaluated by comparing the outcomes between baseline assessment and post-test, as well as across each time point.

Assessments of sleep quality

In terms of the sleep quality assessment, integrating both quantitative and qualitative approaches offers higher reliability of sleep evaluation (Kreutz et al., 2021). Hence, a combination of both physiological and psychological sleep parameters measures was implemented in this study.

Physiological sleep quality assessment

In order to reflect the naturalistic sleep conditions, sleep quality assessment was conducted in the participants’ home environments, within their comfort zones. A wrist-worn consumer-grade wearable, namely Xiaomi Smart Band 7 Pro (Xiaomi Inc.) was utilized as it enables non-invasive physiological measurement of sleep parameters under natural free-living conditions. Xiaomi Smart Band series has been utilized in previous research studies whereby acceptable reliability and validity were reported for earlier models of the Xiaomi Smart Band in assessing sleep-related parameters, specifically within the non-clinical population (Concheiro-Moscoso et al., 2023; Degroote et al., 2020; Topalidis et al., 2021). The consistency of the device’s core algorithms and sensor technology applied across the series further support the use of Smart Band 7 Pro in this study, for sleep assessment within the population of healthy university students.

Participants were instructed to wear the device on their dominant wrist on each data collection night prior to sleep onset. Taking into account that prevalence of sleeping-in late and irregular sleep schedule during weekends may lead to high variability in sleep data, data collections were conducted on weekday nights. Data of three consecutive nights were then averaged to obtain the estimated overall sleep patterns across the week.

Psychological sleep quality assessment

Pittsburgh Sleep Quality Index (PSQI) was administered to assess participants’ perceived sleep quality. It is a validated self-reported questionnaire, which is widely implemented in the assessment of individuals’ sleep quality over a 1-month time interval in both psychiatric clinical practice and research settings (Buysse et al., 1989). It comprises 7 domains together with 19 items: (1) subjective sleep quality (one item), (2) sleep latency (two items), (3) sleep duration (one item), (4) habitual sleep efficiency (three items), (5) sleep disturbances (nine items), (6) use of sleeping medication (one item) and (7) daytime dysfunction due to sleepiness (two items). Each subscale ranges 0–3, yielding a global score from 0 to 21 whereby higher scores indicate worsen sleep quality. A cut-off score of equal to or greater than five is considered as poor sleep quality while a score of greater than eight is indicative as clinically accepted criterion for sleep impairment.

Assessment of mental health symptoms

The Depression, Anxiety and Stress Scale-21 Items (DASS-21) is a set of standardized self-reported mental health screening instruments, which has been widely validated and applied across various settings including clinical or non-clinical population (Lovibond and Lovibond, 1995). It consists of a separate assessment of three related negative emotional states including depression (DASS-21-D), anxiety (DASS-21-A) and stress (DASS-21-S) over the past week. Each subscale comprises seven items rated on a four-point Likert scale, yields a maximum raw score of 21, with higher scores indicating greater symptom severity. To maintain the comparability with original DASS-42, subscale scores are then multiplied by two, with a suggested pathological ranges of 8–20 for both depression and anxiety while 15–34 for stress. Within the Malaysian context, excellent internal consistency was reported (Cronbach’s alpha = 0.959; Thiyagarajan et al., 2022), supporting its use in present study.

Statistical analyses

Descriptive statistics were computed to summarize the demographic characteristics and baseline measures of both groups. A generalized estimating equations (GEE) analysis was conducted to examine the effect of time, group and their interaction on sleep-related outcomes. This analytic approach was selected as it extends standard regression analysis and accounts for within-subject correlations due to repeated measurements across four time points. Population-averaged effects estimation is allowed while intra-subject correlation could be accommodated without requiring stringent distributional assumptions.

The GEE model was specified using an identity link function, assuming a normal distribution for continuous outcomes (interval-scaled variables) and an autoregressive (AR-1) working correlation structure to account for within-subject correlations across the time points.

The primary model specified time (T₁, T₂, T₃ and T₄), group (VAG vs CG) and the interaction term (group × time) as predictors. A significant interaction effect was interpreted as evidence of differential changes over time between groups. Statistical significance was determined by a test result of p < 0.050. The statistical analysis was conducted using IBM SPSS Statistics for Macintosh, Version 26.0 (IBM Corp., 2019).

Results

Demographic data

Out of the initially recruited participants, six participants withdrew or were excluded due to incomplete data across the assessment time points. Hence, only 40 complete data sets (VAG: n = 20; CG: n = 20) were retained for statistical analyses.

Both groups demonstrated a comparable mean age (VAG = 20.16 ± 1.17; CG = 22.16 ± 0.83) and a nearly balanced distribution of gender (Supplemental Material 3). Reflecting the multiracial society in Malaysia, participants comprised of diverse racial groups (Malay: n = 12; Chinese: n = 25; Indian: n = 2; Bumiputera: n = 1). In addition, both groups reported comparable socioeconomic backgrounds, predominantly from middle-income households and declared no significant financial constraints throughout the entire intervention period. No significant difference was reported in terms of the demographic characteristics between both groups.

Sleep quality and mental health assessments

Comparing the physiological sleep parameters of both groups at pre- and post-intervention, GEE analysis indicated significant difference of physiological sleep score in CG (p < 0.050) while no significant change was observed in VAG (p > 0.050; Supplemental Material 4). This suggested that deteriorated sleep quality was detected in CG after the six-week study phase while the sleep quality of VAG remained relatively consistent over the six-week intervention.

Relative to the results of CG, which did not reach statistical significance, significant change in perceived sleep quality was reported in VAG at Week 3 (MD = 2.700, SE = 0.559, p = 0.003, 95% CI (0.376, 5.024)) and Week 6 (PSQI: MD = 3.700, SE = 0.579, p < 0.001, 95% CI (1.358, 6.042)), suggesting that visual art intervention positively influenced the participants’ perceived sleep quality.

In terms of the self-reported mental health screening results, significant effect in DASS-21-A was noted for baseline to week 3 (MD = 2.800, SE = 0.658, p = 0.020, 95% CI (0.154, 5.460)) as well as baseline to week 6 (MD = 2.800, SE = 0.654, p = 0.018, 95% CI (0.155, 5.445)) in VAG. As for the DASS-21-S, a significant time-by-group interaction was detected, MD = 3.800, SE = 0.896, p = 0.021, 95% CI (0.177, 7.432), indicating differential changes in perceived stress over time between the visual art intervention and VAG. Meanwhile, the analysis revealed no significant main effect of time within the control group for perceived anxiety and stress across the time points (p > 0.050), indicating consistent level across the assessment time points. However, no statistical interaction in DASS-21-D was found for VAG.

Discussion

Improved mental health symptoms

Concerning the university student, contemporary lifestyle is typically characterized by a rapid life pace, overwhelming with constant distraction and fragmented focus, which contribute to the disruption of sleep hygiene. Under the high-demand and constant stimuli-rich environment, noises exist in the form of distracting sounds, images and individuals’ own fleeting thoughts, leading to diminished sense of self-identity, feeling lost and easily stray from the intended path along the way. Identifying the source of distraction is the initial step to regain the state of mental tranquility and attention control. In this study, visual art intervention was introduced prior to retiring for the night, suggesting as a strategy in preparing the body to wind down when approaching bedtime. Interestingly, the results revealed a reduction of perceived stress and anxiousness after receiving the six-week visual art intervention.

Extensively documented in previous studies, structured and regulated visual art interventions offer predictability that support cognitive stability, potentially evoke the feelings of calmness and mindfulness. Achieving the sensory integration demands, visual art activities utilize the aspects of colors, forms, textures and imagery in engaging the visual sense. For instance, high symmetrical and repetitive patterns within the pre-determined artistic geometric structure of mandala coloring promote a sense of control while the coloring movements resemble the calming rhythm fostered during meditative practices (Rankanen et al., 2022). The combination of coordinated fine motor movements with visual input promotes the mind-body connection, thus facilitating the mind to enter a state of sustained and focused attention, which is associated with a distorted sense of time. Through the stimulation of a flow-like state of mind (Buchanan and Csikszentmihalyi, 1991), it emphasizes the interaction and conceptualizing of body, mind and perception as a unity by providing a medium for individuals to be intensely and purposefully conscious of their feelings and bodily sensation. Thus, this enhances the moment-to-moment awareness and promotes the immersion experience, whereby external distractions and stressors fade.

Visual art intervention emphasizes the hands-on experience that fosters deeper sensory connection, which in turns enhance the sensory-perceptual and cognitive development. Due to its nature of moldable and remoldable, clay modeling techniques that comprise stretch, pummel and flatten could act as a medium for emotional expression (Vaartio-Rajalin et al., 2021). Aligning with our current findings, past research suggested the improved ability in handling stress proactively as participants responded that the tactile engagement tends to promote a greater sense of attachment, which enables them to overcome the inner stressors with focus and clarity (Cheshure and Van Lith, 2024). By promoting intense focus and reduced self-consciousness, individuals have found to be conducive to relaxation and inner pleasure, hence ameliorate the distressed and anxious feelings that subsequently interrupt sleep quality.

Considering that external environmental stimuli and internal psychological disturbances elevate physiological alertness and neurophysiologic arousal levels, this could eventually contribute to difficulties in falling asleep or delayed sleep onset. Visual art engagement has shown promising effect in inducing a meditative-like state, which fosters the state of mindfulness and immersive experiences, supports the redirection of attention away from external stressors while promoting confronting of internal distraction including owns’ instructive thoughts and negative emotions, hence better equipping individuals in managing the earlier anxious and stressful experiences. Simultaneously, these low-stimulation activities demand a certain level of attention that cultivates a deeper sense of awareness, enabling individuals to transform their cognitive and physical abilities into a deeper and resilient focus toward the present moment (Daudén Roquet et al., 2023).

Extending beyond the limits of verbal communication, visual art intervention serves as a non-verbal medium for expression of internal experiences and emotions, which are difficult or impossible to articulate verbally. In certain scenarios, verbal expression tends to dilute or censor the emotional content, while non-verbal art expression allows bypassing of cognitive filtering, often facilitating a more direct access in engagement with emotional processes. Particularly for those who are reluctant in expressing their own feelings, the visual art intervention empowers them with freedom to select their own comfortable communication medium, without the constraints of vocabulary or speech abilities.

Given that our intervention was delivered within the participants’ own familiar and comfortable environment, this enhances the sense of psychological safety. By facilitating gentle introspection under a safe and calm environment, it offers individuals an opportunity in exploring inner feelings and experiences, which subsequently contribute to the reconfiguration and reorganization of ruminative thoughts. The process of self-reflection could diminish the confusion or fogginess while cultivating a greater awareness regarding owns’ values, motivations and aspirations, leading to an improved mental clarity that plays a major role in combating the overwhelming distressed experiences.

Physiological insights into emotional regulation

Emphasizing various interrelated senses in promoting a multi-sensory engagement, past studies highlighted the therapeutic benefits of low-effort but sensory-rich visual art activities in inducing intense haptic, proprioceptive and visual sensations (Nan and Ho, 2017). Chronic anxiety and stress tend to stimulate the sympathetic nervous system. Heightened physiological arousal triggers a series of maladaptive “fight or flight” responses including increased heart rate, blood pressure and muscle tension, which disrupt mental health and sleep quality (Medic et al., 2017).

In terms of neurobiological modulation, elevated perceived stress and anxiety is linked to increased activation of bilateral amygdala, which is highly sensitive to negative emotions, particularly fear, stress, anxiety and anger. Engagement in visual art activities, which requires relaxed yet focused attention induces unique activation within the amygdala and prefrontal cortex, which act as the neuroanatomical stress vulnerabilities (Zhang et al., 2020). The activation enhances conscious awareness of feelings and bodily sensations while modulating amygdala connectivity to stress-related brain regions, promoting a positive and rewarding experience associated with self-expressing process. It strengthens self-regulation toward negative emotional stimuli, leading to a more resilient mind with improved concentration (Zhao et al., 2019).

Engagement in focused attention visual art activities elevated neuronal metabolic demand of oxygen and glucose, resulting in localized increase of cerebral blood flow (CBF) in task-relevant brain regions and enhanced functional connectivity in prefrontal cortex and default mode network (DMN), which facilitate emotional self-control and self-regulation (Mora Álvarez et al., 2023). These neural adaptations mitigate the ruminative and wandering thoughts, thus ameliorate perceived anxiety and stress, which were in agreement with our current findings. Additionally, natural stimulation of exteroceptors and interceptors through fine motor movement and tactile engagement during the art creation supports real-time continuous sensorimotor feedback loop within the peripheral and central nervous systems.

Reflected by the electroencephalogram findings, decline of high-frequency brain wave patterns, especially the gamma and high beta (beta-2) power in frontal and parietal brain regions indicates the shift from a hyper-aroused state a more relaxed and emotionally balanced mental state while lowering the physiological arousal (Pagni et al., 2023). Concurrently, increased theta power promoted by tranquil experiences during artworks production enables relaxation and negative emotional recovery, contributing to alleviation of stress and anxiety symptoms, thereby enhancing readiness for sleep.

Aligning with downregulated amygdala reactivity, immersing in repetitive structured tactile activities, which are low in cognitive demand could transmit a neurophysiological signal of psychological safety. This attenuates the sympathetic nervous activities and promotes a shift toward parasympathetic dominance that governs the “rest-and-digest” mode (Haiblum-Itskovitch et al., 2018), effectively calms the overstimulated nervous systems, resulting in relaxed emotional states. In terms of neuroendocrine balance, this autonomic rebalancing mitigates the hyperactivation of the HPA axis during the counteraction with stress-induced arousal. Along with HPA axis downregulation and stabilized circadian cortisol rhythms, the relaxation effects promote an earlier sleep onset and reduce nighttime awakenings (Nicolaides et al., 2020).

Non-significant effect in depression

Interestingly, while significant improvements of perceived stress and anxiety were observed following the six-week intervention, lack of significant change was detected in terms of the depression among VAG. In contrast, results indicated significant differences in depressive symptoms among CG, which possibly reflected the consistent elevation of psychological distress and depressive symptoms experienced by the students over the academic semester. Hence, it suggests the potential stabilizing and protective effect of visual art intervention against the worsening depressive symptoms. However, our current findings stand in partial contrast to previous research studies that have reported beneficial effects of art-based interventions on depression. Nevertheless, upon further investigation and subsequent analysis, this discrepancy could be explained from several perspectives.

In fact, the artistic expression process offers temporary distraction in relieving pent-up feelings, thereby demonstrating immediate effect for the acute distress and anxious symptoms, nevertheless, its impact on depression is limited. As proposed by the Accumulation Model, worsening depressive symptoms could be the result from an accumulation or extended exposure to a stressor (Pindek et al., 2019). A high degree of depression often provokes persistent negative thoughts with a pervasive sense of sadness, hopelessness and helplessness, which further exacerbate into loss of interest and motivation toward most of the activities or even daily functioning, making it challenging to active engagement while gaining emotional pleasure and satisfaction during the creative process, suggesting the possibility of overshadow the potential benefits of art expressive activities.

Considering the fundamental nature of depression, which is deemed to be more chronic and complex, visual art intervention alone may not be sufficient in tackling the underlying cognitive and affective features of depressed feelings. Hence, a more comprehensive approach might be required for the multi-faceted sleep management in possibly elicit sustained relief to the deeper cognitive distortions, for instance, lifestyle changes, prolonged or specifically targeted pharmacological treatment.

In terms of the intervention mode, current sessions were delivered individually, with primarily emphasis on self-reflection and emotional self-regulation, enabling self-communication with absence of interpersonal exchange. In contrast, group-based art intervention facilitated social interaction and communication while feedback received from diverse perspectives foster a better self-reflection. Study suggested the possibility of group dynamics in enhancing motivation and mutual support, thus contributing to a greater cognitive involvement and sustained creative engagement (Quinn et al., 2025). Validation of shared emotional experiences promotes the sense of connectedness and support in regulation of overwhelming feeling, leading to positive emotional responses.

Aligning with the floor effect, relatively low baseline depression levels in the sample might also be one of the possible factors in limiting the potential for statistically significant improvement. Another aspect that requires attention is the psychometric properties of questionnaires. DASS-21 targets on state negative emotions and reflects emotional changes in the recent past, often within the past week, instead of long term or chronic conditions. Since the assessments were conducted in the morning following the second intervention night in each respective intervention week, the impact of visual art intervention toward trait depression might not be adequately captured.

Improved psychological sleep quality

Prior studies highlighted the impact of growing academic demands on sleep quality, with findings indicating worsening sleep across the academic semester, predominantly due to converging assignments deadlines and assessment preparations (Liu et al., 2023). Absence of structured intervention in CG left the participants vulnerable to stress-induced sleep disturbances, which further explain the natural deterioration of perceived sleep quality throughout the study weeks.

In contrast, significant increase in PSQI score was observed among the VAG, suggesting improved perceived sleep quality against the expected declining baseline, which further reinforces the beneficial impacts provided by the visual art intervention. Taking into account that low adherence to physical exercise among university students due to time constraint, intense academic commitments, inadequate access to sport facilities and lack of interest or motivation (Alkhawaldeh et al., 2024), visual art intervention serve as a more accessible and appealing alternative in support mental and emotional well-being. Despite differences in physical intensity and exertion, constant engagement in visual art intervention share the common underlying mechanisms. Minimal physical exertion combined with coordinated and repetitive motor-sensory interaction, visual art intervention eventually lead to elevated cognitive demand, particularly due to the stimulation of various brain regions that are involved in motor control, attention, memory and emotional processing. Independent of intense information processing, the continuous cognitive engagement occupies the mind in a calming but focused state, inducing a healthy and gentle cognitive exertion which promotes structured relaxation effect without overstimulation. Meanwhile, it leads to mental fatigue which is appropriate for homeostatic sleep pressure regulation, thereby benefiting the sleep initiation and maintenance (Tononi and Cirelli, 2014).

During the course of the artistic expression, sustained focus and attentiveness tend to reduce physiological arousal while eliciting positive emotional responses associated with pleasant feelings, which in turns stimulate a greater degree of creative ideation. Proficient creative expression was evidenced among our participants’ artistic performance across the visual art intervention, as reflected by their art works which showcased imaginative expression and distinct sense of personal identity.

Non-significant effect in physiological sleep quality

In current study, both psychological and physiological sleep assessments were employed to capture complementary aspects of sleep quality. The psychological assessment via PSQI reflects the participants’ perceived sleep quality and restfulness, which may be influenced by cognitive or emotional factors such as stress and mood or recollection bias. In contrast, physiological assessment via sleep tracking device provides quantifiable physiological indices such as sleep duration, efficiency and latency. However, the potential divergence between these two approaches underscores the complex and multi-dimensional nature of sleep experience whereby this dual approach may introduce challenges in interpretation, as variations between the two assessments could reflect differences in measurement constructs rather than actual differences in sleep quality. Acknowledging this distinction strengthens the interpretation of findings and highlights the value of integrating both assessment approaches for a more holistic evaluation of sleep outcomes in achieving a higher research construct validity.

Reflecting the cognitive and emotional evaluations of sleep, PSQI is sensitive to individuals’ own perception of sleeping experiences, both satisfactory and difficult. However, it may not directly reflect on the physiological sleep metrics as tracked by sleep tracking devices. Past studies highlighted the common findings of differences between self-reported and objective sleep measures within a healthy population (Trimmel et al., 2021).This clarified the outcome observed in current research whereby improved PSQI score while no significant differences in physiological sleep score within VAG during post-intervention. Due to the complex and multifactorial nature of sleep perception, sleep score might be attributed by various underlying behavioral and physiological mechanisms factors, beyond the physiological sleep architecture. Consistent findings indicate that improved sleep consistency or reduced sleep latency and nighttime awakenings might not fully reflect on the overall sleep score (Kaplan et al., 2017; Lenneis et al., 2024). This further confirms the psychological impacts of visual art intervention in reducing perceived sleep issues while enhancing sleep satisfaction, while not necessarily resulting in actual alterations of sleep architecture. Similarly, this explained insignificant changes in physiological sleep architecture within both groups over the six-week intervention, particularly the duration of each sleep stages including deep, light and REM.

Limitations and future directions

Reflecting the dynamic interaction incorporating multiple physiological systems, sleep architecture is a complex process, which is regulated by a highly complex interplay of brain structures, hormonal systems and neurotransmitters. Hence, the change in physiological sleep parameters such as stage-specific sleep duration, number of complete sleep cycles or its architecture appears to be relatively stable and resistant to modification following short-term intervention or treatment, particularly among the healthy population. Further research is warranted to explore the underlying mechanisms, which drive these differences and to determine whether intervention with greater duration or combined modalities may elicit perceptual and physiological improvements.

Logically explaining that the sleep score generated by Xiaomi wearables represents a comprehensive composite index, the sleep evaluation was resulted from a complex interplay involving physiological and behavioral metrics including sleep duration, sleep stage percentages, frequency and duration of awakenings, resting heart rate and breathing quality, which have been specified in available technical information. Nonetheless, the underlying proprietary algorithm or exact sleep score computation is not publicly disclosed. The lack of transparency potentially limits the interpretability and sensitivity in detecting subtle variations of sleep parameters, thereby reducing the capability in capturing nuanced improvements resulting from short-term interventions. Meanwhile, unsupported raw data extraction in current sleep tracking devices possibly hindered a comprehensive evaluation for better understanding of sleep patterns as manual transcription of data constrains in-depth sleep stage segments and architecture analysis, whereby this infeasibility should be acknowledged as a methodological limitation.

Additionally, the sleep tracking device employed in current study is not regarded as the gold standard for sleep measurement compared to other validated research-grade actigraphy devices or polysomnography. The focus of current research study, however, was to explore convenient and non-invasive methods in initial sleep care strategy, covering both intervention and assessment, instead for clinical diagnosis. Hence, the use of such consumer-grade wearable remains appropriate for general wellness monitoring to promote early awareness of potential sleep issues.

Moreover, the relatively small sample size may have limited the statistical power and generalizability of the findings. Due to the voluntary nature of the participation, individuals who chose to participate may have been more motivated or had a higher interest in sleep or health-related topics, potentially leading to self-selection bias. Future studies with larger and more diverse samples recruited through randomized sampling or broader outreach strategies are warranted to increase generalizability of the result. As current study employed a non-equivalent comparison group design without random assignment, it may also limit the causal inference whereby there may be unmeasured confounders that affect the observed associations. Thus, the findings should be interpreted with caution.

Conclusion

In this study, enhanced sleep quality in physiological and psychological after the six-week visual art intervention has been found to be parallel with existing art-based intervention studies. Our findings highlight a bidirectional relationship between bodily awareness and emotional regulation, suggesting the effectiveness of visual art intervention in ameliorating cognitive arousal while promoting emotional regulation in maintaining mental calmness. This ultimately contributes to enhanced overall sleep efficiency. Through regular engagement in repetitive, low-intensity and sensory-integrative tasks as part of pre-sleep routine, visual art intervention tends to establish a behavioral cue for mental winding down, which cultivates structured sleep routines aligned with healthy sleep hygiene principles. It thereby supports its efficacy to be a cost-effective strategy for initial sleep regulation by reducing the occurrence of gradual development into serious physiological or psychological health complications contributed by endangered sleep quality. Hence, the results underscore the value of incorporating creative and non-pharmacological modalities into mental health and wellness interventions, advocating visual art intervention to serve as an alternative approach in sleep quality management, particularly among the university students.

Supplemental Material

sj-docx-1-hpq-10.1177_13591053261425377 – Supplemental material for A preliminary investigation on visual arts in impacting the sleep quality among university students

Supplemental material, sj-docx-1-hpq-10.1177_13591053261425377 for A preliminary investigation on visual arts in impacting the sleep quality among university students by Beatrice Qin Thon See, Chow-Khuen Chan, Hua Nong Ting, Mahmoud Danaee, Sharmilla Kanagasundram, Budi Utomo, Hanie Nadia Shasmin and Shifa Fauziyah in Journal of Health Psychology

Footnotes

Acknowledgements

The authors would like to address their deepest gratitude toward the participants and relevant parties for their willingness to cooperate for the success of the study.

ORCID iDs

Beatrice Qin Thon See

Chow-Khuen Chan

Hua Nong Ting

Mahmoud Danaee

Sharmilla Kanagasundram

Budi Utomo

Hanie Nadia Shasmin

Shifa Fauziyah

Ethical considerations

Ethical approval was obtained from the Universiti Malaya Research Ethics Committee (UMREC; Reference No: UM.TNC2/UMREC_2846).

Consent to participate

Participate Information Sheet (PIS) was handed to participants prior to the participation and informed consent was obtained as an agreement for voluntary participation.

Consent for publication

The Participant Information Sheet (PIS) informed participants of the potential for publication. Written informed consent for publication was provided by all participants. All data were anonymised prior to analysis and publication.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research is supported by the Universiti Malaya Impact Oriented Interdisciplinary Research Grant (IIRG004C-2022SAH).

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

The datasets generated and/ or analyzed during current study are available from the corresponding author, upon reasonable request.*

Supplemental material

Supplemental material for this article is available online.

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