The Effects of Hospital Clowning on Physical and Emotional States of Pediatric Patients During Chemotherapy Treatment

  • Patrícia ArriagaEmail author
  • Ana Sofia Melo
  • Susana Caires
Original Paper



Pediatric cancer treatments interfere with the patient’s life on physical, psychological, and social levels. Hospital Clowns (HCs) use nonpharmacological techniques to reduce the distress that hospital treatments can cause and increase children’s wellbeing, but few studies have analyzed their effects.


This study examined the HC effects on the physical and emotional responses of pediatric patients during ambulatory chemotherapy. Given the variability in patients’ adjustments to cancer treatment, the role of a child’s age and temperament, and caregiver anxiety was considered in explaining the responses over and beyond the HC effects on patient outcomes.


Following a quasi-experimental design, 82 pediatric patients were assigned to one of two conditions: HC intervention versus control group (CG) in two separate trials. Pediatric patients self-reported of physical symptoms (pain, nausea, and fatigue) and emotional states (distress, happiness, and calm) were measured at baseline and post-chemotherapy in both trials. Caregivers provided information on children’s temperament and reported their own anxiety. Marginal Multilevel Modeling was used to examine the effects of the HC interventions on the outcomes by controlling caregiver anxiety, and child age and emotionality.


Compared to the CG, patients receiving the HC visit during chemotherapy reported higher levels of calm and happiness, and less fatigue, pain, and distress. HCs did not affect nausea.


This study showed the importance of HCs as agents of supportive pediatric care, whose short-term effects during ambulatory chemotherapy seem to contribute to increasing the well-being of pediatric patients.


Pediatric Chemotherapy Distress Hospital Clowns 



The authors would like to express their gratitude to all participants, Nurses, to the Hospital Clowns and to Operação Nariz Vermelho who made this research possible.

Author Contributions

All the authors take responsibility for the integrity of the data. The first author drafted the manuscript, performed the data analysis and takes responsibility for the accuracy of the data analysis; the second author collected the data; all authors contributed to the design of the study and to the interpretation of data.


The Portuguese National Foundation for Science and Technology (FCT) funded this study through the Grants SFRH/BD/80378/2011, UID/PSI/03125/2019, and UID/CED/01661/2019.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures were in accordance with the ethical standards of the institutional and national research committee of the three Hospitals in which the study was conducted (Lisbon IPO Francisco Gentil, UIC/781, No.164/13; Oporto IPO, CES-IPO:203/013, and Oporto S. João Hospital Center, CES-HSJ:26/09/2012) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study. Caregivers provided written informed consent and pediatric patients gave verbal assent.


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Authors and Affiliations

  1. 1.ISCTE-Instituto Universitário de Lisboa, CIS-IULLisbonPortugal
  2. 2.Institute of EducationUniversity of MinhoBragaPortugal
  3. 3.Agrupamento Escolas de Briteiros, GuimarãesBragaPortugal

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