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The effect of humor on elder mental and physical health
Geriatric Nursing xx (2014) 1e7
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Geriatric Nursing journal homepage: www.gnjournal.com
Feature Article
The effect of humor on elder mental and physical health Freda DeKeyser Ganz, RN, PhD a, *, Jeremy M. Jacobs, MD b a b
Hadassah Hebrew University School of Nursing, Kiryat Hadassah, P.O. Box 12000, Jerusalem 91120, Israel Department of Geriatrics and Rehabilitation, Hebrew University, Hadassah Medical School, Jerusalem, Israel
a r t i c l e i n f o
a b s t r a c t
Article history: Received 13 October 2013 Received in revised form 21 January 2014 Accepted 27 January 2014 Available online xxx
A convenience sample of community-dwelling older people attending senior centers was asked to participate in a quasi-experimental study to examine the impact of a humor therapy workshop on physical and mental health. Participants were assessed at baseline and at six months for physical (general health and health quality of life) and mental (general well-being, anxiety, depression and psychological distress) health. The sample consisted of 92 subjects, 42 in the control group and 50 in the workshop. Compared to controls, subjects in the workshop had significantly lower follow-up levels of anxiety and depression and improved general well-being. No differences were observed for general health, health quality of life, or psychological distress. This humor therapy workshop was associated with a positive effect upon mental health. It is recommended that attendance at humor workshops be encouraged and that further investigations into the efficacy of such programs on mental and physical health be investigated. Ó 2014 Mosby, Inc. All rights reserved.
Keywords: Humor Community-dwelling elderly Mental health Physical health
Introduction Promoting health and well-being among older people is a growing challenge. The search for effective interventions has led to the therapeutic use of humor as a possible method to promote improved mental and physical health.1 Humor is generally defined as a positive global mental state, unique to each individual, spanning aspects of cognition, emotion, behavior, and communication. The humor workshop in this study can be seen as a type of humor therapy defined by Goodenough and colleagues2 as an intervention that stimulates the discovery, expression or appreciation of the absurdity or incongruity of life’s episodes in order to facilitate physical, mental, emotional, social or spiritual healing and coping, thus leading to improved mental and physical health.
is the effect of positive emotions such as humor on mental health.3 Laughter therapy was found to significantly decrease levels of depression among a sample of community dwelling elderly8 while positive humor was shown to decrease negative and increase positive emotions.9 Thirdly, humor may serve as a coping mechanism that decreases stress, and thusly improves health. Coping humor was found to be significantly associated with social support, self-efficacy, depression and anxiety among a sample of Canadian community dwelling older adults.10 Humor has also been strongly associated with favorable adjustment among recently bereaved spouses.11 Community dwelling elderly Swedish women reported that the use of humor helped them endure pain.12 Others13 found statistically significant relationships between health status and humor coping and life satisfaction among elderly living in assisted living facilities.
Background Humor and physical and mental health
Humor interventions
Several mechanisms have been postulated to explain the association between humor and mental and physical health.3 Evidence supports numerous positive physiological effects on several bodily systems including musculoskeletal, respiratory, cardiovascular, endocrine, immune and nervous systems.4e7 A second mechanism
Five interventional studies were found that investigated the positive effects of humor interventions or laughter therapy on older people (Table 1). While humor therapy is seen as the incorporation of humor into daily life, laughter therapy is defined as a more active process where humor is created.2 The first study examined the effect of one month of once weekly laughter therapy among a sample of community dwelling South Korean older adults.8 The four 1 h sessions consisted of viewing a video about laughter therapy; practicing laughter meditation sessions; laughing aloud while
* Corresponding author. Tel.: þ 972 50 404 8169; fax: þ972 2 643 9020. E-mail address: [email protected] (F.D. Ganz). 0197-4572/$ e see front matter Ó 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2014.01.005
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F.D. Ganz, J.M. Jacobs / Geriatric Nursing xx (2014) 1e7
clapping; dancing and singing; Kegel exercises; and discussion of the effect of positive thinking. This intervention was associated with positive effects on depression, insomnia and sleep quality. In the second interventional study, a sample of South Korean elderly nursing home residents underwent a humor therapy program.14 This humor therapy intervention consisted of 1 h weekly meetings over a period of eight weeks. Therapy included the creation of a collection of humorous materials and seven weekly sessions consisting of sharing jokes and stories; lectures on humor research; laughing exercises and games; and a lecture on how to prioritize humor in one’s life. Those in the experimental group were found to have decreased pain and increased happiness and life satisfaction as compared to a control group. The third interventional study investigated those with COPD. In this study, participants were exposed to a one-time 30 min humorous video. Mood state and physiological measures of dyspnea were found to improve.5 The next study15 determined that a therapeutic program to increase happiness and humor was associated with an increase in life satisfaction among a sample of older adults. This intervention consisted of ten weekly sessions that included lectures, interactive activities, jokes as well as the encouragement of participants to share and discuss humorous aspects of their lives. Kondradt, Hirsh, Jonitz and Junglas16 investigated whether participation in a humor group could decrease depression, and increase cheerfulness and life satisfaction among a sample of older adults diagnosed with major depression. The intervention group met twice a week for 8 sessions. The sessions included remembering funny situations, sharing personal anecdotes, thinking happy thoughts, and emphasizing the place of healthy humor in one’s life; as well as music and dance. The humor group showed a significant improvement in life satisfaction and changes in state seriousness.
In summary, while several interventional studies have been conducted on older adults, few have been conducted on healthy community dwelling elderly who comprise the largest percentage of the elderly population. Each study uses a different definition of what humor therapy consists of and how to measure outcomes associated with the intervention. Most have been short term interventions. The content of these interventions is extremely varied and the potential benefits of these interventions among this age group are poorly defined (Table 1). The purpose of the present study was to examine the effect of a five month intervention using a humor workshop among a sample of Israeli community-dwelling elderly people who attended senior centers. We hypothesized that a humor intervention would be associated with improved mental and physical health among community dwelling older people attending senior centers. Method Subjects The target population for this study was community dwelling older adults. The inclusion criterion was attendance at one of four senior centers used in the study. Exclusion criteria were inability to read or write in either Hebrew or English and cognitive impairment (as assessed by the administrator/social worker in charge of the center). See Fig. 1 for the recruitment and drop-out rates for this sample. Setting The workshop was presented to the senior administrator responsible for social welfare programs in several municipalities. Two municipalities agreed to participate. The workshops were held
Fig. 1. Flow diagram of study methods.
F.D. Ganz, J.M. Jacobs / Geriatric Nursing xx (2014) 1e7
in senior centers that hold social and educational programs for independent community-dwelling older people and are owned and run by their respective municipalities. The municipal social welfare administrator was asked to provide two centers in their jurisdiction with members of similar socio-demographic characteristics, where one center in each municipality was randomized to serve as the control group and one as the intervention group. All members of the senior centers were invited to participate in the workshop. The study was described to all of the members of the center, informed consent was obtained and baseline data were collected for those who met the inclusion criteria. Sample size was determined using a power of .80 and an alpha rate of .05. In order to detect a significant difference between two groups with a moderate effect size, a total of 64 subjects was necessary in each of the groups. Humor therapy workshop intervention The “Humor as a Way of Life” program consisted of one session per week lasting 2e3 h per session. These sessions were based on a successful pilot program that was tested on another population of older people from another city as well as a review of previous techniques described in the literature. The program took approximately five months to complete. The humor therapy workshop used methods similar to other interventions (see Table 2). These sessions were conducted by a humorist who dedicates his time to promoting the use of humor in society and delivering these workshops, and a social worker. The sessions were led by the same moderators in both of the centers in the experimental group and attempts were made to standardize the program as much as possible. Subjects in the control group continued to attend the senior centers without any form of intervention. They were offered the opportunity of participating in a humor workshop at the next opportunity after the completion of the study.
3
The General Well Being Scale (GWB)19 measures psychological well-being, a measure of mental health. This 18 item questionnaire assesses both positive and negative feelings and is based on six dimensions (positive well being, self control, vitality, anxiety, depression and general health). A total score of General Well-Being can also be calculated. Each item is based on a time frame of the previous month and is set on a six point scale. The GWB was developed for a national United States health survey and has been shown to have internal reliability ranging from .88 to .95 using different community samples. Test-retest reliability was also evaluated and ranged from .68 to .85 in different samples. Validity was evaluated using factor analysis on the US survey.19 Cronbach alpha reliability for this study was a ¼ .90 for T1 and a ¼ .89 for T2. This questionnaire was translated using the forwardebackward translation approach. The Brief Symptom Inventory (BSI)20 is a 53 item questionnaire, which measures psychological distress, another measure of mental health. The questionnaire is built on a 5 level Likert format from 0 (not at all) to 4 (very much). Responses can be summed to create a total score. The Global Severity Index is another measure of global psychological distress that is determined by dividing the grand total by 53. The scale contains 9 separate dimensions; somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation and psychoticism. The scale has been used on many different populations and has been translated into Hebrew. In a study of 510 Israeli community respondents, the BSI was found to be reliable and valid, with Israelis scoring higher than known international norms for the questionnaire.21 Cronbach alpha reliability for this study was a ¼ .96 for T1 and a ¼ .95 for T2. A demographic data questionnaire recorded subjects’ gender, age, marital status, number of children, place of origin, date of immigration (if relevant), and a self reported appraisal of annual income (below average, average or above average).
Data collection Statistical analysis All of the questionnaires were self-administered however research staff was available to help participants fill out their questionnaires if necessary. Both the control and intervention groups were asked to fill out all questionnaires at baseline, before the project was begun, and to complete the questionnaires six months later, after completion of the workshop. The study was approved by the Institutional Ethical Review Board of the Faculty of Medicine, Hebrew University, and all subjects gave written informed consent. Instruments The following four instruments were used for this study: The first questionnaire was the RAND Health Status Questionnaire17 e shortened version: This questionnaire was designed to measure health related quality of life, a measure of physical and mental health. It contains 12 items that assess eight dimensions of health related quality of life (physical functioning, role limitations due to physical and emotional health, energy/fatigue, emotional well-being, social functioning, pain and general health). Scores for all dimensions are measured on a scale from 0 to 100, a higher score indicating a better quality of life. The questionnaire’s validity and reliability have been validated in previous studies.17,18 Cronbach alpha reliability data for this study were based on the following subscales (only these subscales contained more than 2 items, necessary for a reliability calculation): T1: physical health: a ¼ .86, emotional health: a ¼ .64; T2: physical health: a ¼ .74, emotional health: a ¼ .79. This instrument was translated into Hebrew using a forwardebackward translation approach.
Sample size was determined using a power of .80 and an alpha rate of .05. In order to detect a significant difference between two groups with a moderate effect size, a total of 64 subjects were necessary in each group. Descriptive statistics were used to describe the sample and results of the RAND, GWB and BSI questionnaires. Differences between the two groups were determined using Analysis of Covariance (ANCOVA), where the baseline value at T1 was used as the covariate for each analysis. Data storage and analysis were performed using SPSS version 17. All p-values were 2-tailed and p < .05 was considered significant. Results The sample consisted of 92 subjects, 42 in the control group and 50 in the humor workshop group (see Fig. 1). Most of the participants were females (n ¼ 67, 74.4% among those who responded) either married (n ¼ 45, 48.9%) or widowed (n ¼ 45, 48.9%). The mean age of the sample was 76.9 (SD e 6.8). Similar numbers of respondents either lived alone (n ¼ 41, 44.6%) or with a spouse (n ¼ 45, 48.9%). Most were not born in Israel (n ¼ 75, 81.3% among those that responded) (see Table 3). Subjects in the intervention group reported attending a mean of 11 meetings (out of a possible 16), with only 6 (13% among those that responded) subjects attended less than half of the humor meetings. At baseline the control and humor groups were similar for demographic characteristics, except that those in the workshop immigrated to Israel longer ago (52 years vs. 39 years, t(70.14) ¼ 2.4, p ¼ .018), and there was a higher percentage of Holocaust survivors among the
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Table 1 Humor interventions. Sample
Design
Type of intervention
Length of intervention
Outcome measures
Significant differences between groupsa
Ko and Youn (2011)
N ¼ 109 (48 experimental group þ 61 controls) Community dwelling Korean older adults
Randomized control trial
-
- 1h - Once per week - 4 weeks
-
- Significant difference in depression, insomnia, and sleep - No significant difference in health quality of life
Kondrat, Hirsch, Jonitz and Junglas (2012)
N ¼ 99 (49 experimental groupþ 50 controls) Hospitalized older adults with major depression
Quasi-experimental, pre-test, post-test controlled design
- Twice per week - 8 sessions
-
Geriatric Depression Scale Beck Depression Inventory Short form Health Survey State-Trait Cheerfulness Inventory - Satisfaction with Life Scale - Resilience Scale
- Both groups showed significant improvement in depression, state cheerfulness, state bad mood over time - Only the humor group had changes of state seriousness and life satisfaction
Lebowitz, Suh, Diaz, and Emery (2009)
N ¼ 22 (11 in experimental group þ 11 controls) Older adults with COPD (mean age 66.9)
Randomized control trail
1e30 min video
- Pulmonary function (FRC, FEV1, FVC, RV) - Positive and Negative Affectivity Scales - Dyspnea Numeric Rating Scale
Mathieu (2008)
N ¼ 17 (sample served as own controls) Community dwelling older adults, USA
Pre-test, post-test design
- Once per week - 10 weeks
- Life Satisfaction Scale
- Increased FRC, RV in experimental group compared to controls - No effect on FEV1 - Significant difference in affectivity state in experimental group compared to controls - Significant increase in life satisfaction scores
Tse, Lo, Cheng, Chan, Chan and Chung, (2010)
N ¼ 70 (36 experimental group þ 34 controls) ‘cognitively intact’ Korean Nursing Home Residents
Quasi-experimental, pre-test, post-test controlled design
- One hour - Weekly - 8 weeks
- Cantonese Verbal Pain Rating Scale - Subjective Happiness Scale - UCLA Loneliness Scale - Revised Life Satisfaction Index-A Scale
a
Significant difference between the experimental and control group (p < .05).
Laughter video Laughter meditation Laugh out loud sessions Dancing and singing Kegel exercises Discussions on the effect of positive thinking - Educational session on effects of laughing - Sharing of personal anecdotes and jokes - Sharing of happiness thoughts - Giving of compliments - Discussion of humor when under stress - Use of playful props Humorous video
- Presentation about factors contributing to happiness and life satisfaction - Sharing of personal funny anecdotes and jokes - Use of playful props - Lecture on importance of exercise, nutrition, recreation and attitude to living a happy life - Humorous videos - Dance - Collection of humorous materials - Sharing jokes and stories - Lectures on humor research - Laughing exercises and games - Lecture on how to prioritize humor in one’s life
Geriatric Depression Scale SF-36 (health quality of life) Insomnia Severity Index Pittsburgh Sleep Quality Index
- Significant improvement in pain scores and all psychological measures for the experimental group - No significant differences in all measures for the control group
F.D. Ganz, J.M. Jacobs / Geriatric Nursing xx (2014) 1e7
Source
F.D. Ganz, J.M. Jacobs / Geriatric Nursing xx (2014) 1e7 Table 2 The humor therapy workshop intervention. Week
Content
Prior studies using similar methods Source
Intervention
1e4
Incorporation of humor into daily life Development of supportive and mirthful environment Create and review video recordings of humorous life stories or personal funny anecdotes
[14]
Prioritize humor in daily life Emphasize place of humor in life View humorous videos
5e12
[16] [5,8]
[14]
Share jokes and personal stories Share humorous aspects of life Remember funny situations, share personal anecdotes
[15] [16]
intervention vs. the control group (68% vs. 32%, c2(1) ¼ 10.47, p ¼ .001). Holocaust survivors were found to differ from other seniors on only two variables, age and time since immigration to Israel, where survivors were older (survivors: mean ¼ 78.9 years, others: 74.8 years) and survivors immigrated longer ago (survivors: 60.0 years, others: 33.0 years). These variables were not found to significantly correlate with the outcome variables. Table 4 compares the outcome measures between the intervention and control groups at baseline (T1) and 6 months later (one month following completion of the humor workshop) (T2). At
Table 3 Demographic characteristics of the humor workshop and control group samples.
Age (missing: 5) 60e74 75e84 85 Sex Males Females Family status Married Divorced Widowed Living status Alone With spouse With other Place of birth (missing: 1) Israel Eastern Europe Western Europe Asia Africa Other Income Below average Average Above average Education (missing: 2) Up to high school Post HS Time since immigration (years) Holocaust survivors
Control group
Humor workshop
Total sample
N ¼ 42
n ¼ 50
n ¼ 92
14 (35.9%) 15 (38.5%) 10 (25.6%)
18 (37.5%) 26 (54.2%) 4 (8.3%)
32 (36.8%) 41 (41.7%) 14 (11.5%)
8 (18.5%) 34 (81.5%)
15 (30.0%) 35 (70.0%)
23 (25.6%) 67 (74.4%)
25 (50.0%) 25 (50.0%)
45 (48.9%) 2 (2.2%) 45 (48.9%)
21 (50.0%) 20 (47.6%) 1 (2.4%)
20 (40.0%) 25 (50.0%) 5 (10.0%)
41 (44.6%) 45 (48.9%) 6 (6.5%)
10 11 3 4 3 10
7 27 3 4 5 4
17 38 6 8 8 14
20 (47.6%) 2 (4.8%) 20 (47.6%)
(24.4%) (26.8%) (7.3%) (9.8%) (7.3%) (24.4%)
14 (37.8%) 21 (56.8%) 2 (5.4%) 31 9 38.9 13
0
(77.5%) (22.5%) (26.6) (31.0%)
(14.0%) (54.0%) (6.0%) (8.0%) (10.0%) (8.0%)
16 (32.0%) 34 (68.0%) 0 39 11 52.1 34
(78.0%) (22.0%) (22.4) (68.0%)
(18.7%) (41.8%) (6.6%) (8.8%) (8.8%) (15.2%)
30 (34.5%) 55 (63.2%) 2 (2.3%) 70 20 46.4 47
(77.8%) (22.2%) (25.1)y (51.6%)**
y p ¼ .018, **p ¼ .001. No statistically significant differences between the groups for all other findings.
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baseline the only differences found between the intervention vs. control group were related to mental health [a higher positive wellbeing sub-scale score from the GWB scale (12.2 3.2 vs. 10.7 3.3, p ¼ .035), and lower depression sub-scale score from the BSI (.4 .48 vs. .7 .66, p ¼ .014)]. No other differences at baseline were observed for any of the parameters. At baseline, the mean level of reported general health (RAND scale) (a measure of physical health) was reported as fair (39 out of 100, SD ¼ 23.2), with subjects reporting their pain level to be minor to moderate (mean ¼ 64.9 out 100, SD ¼ 30.8). The baseline total General Well Being Score (a measure of mental health) was 75.3 (SD ¼ 18.5) and the mean total BSI score (a measure of mental health) was 27.9 (SD ¼ 25.0). At follow-up, a number of significant differences were found between the groups, while controlling for baseline scores. Humor workshop participants showed an improved mental health, as measured by improved positive well-being (F(1,64) ¼ 8.6, p ¼ .005), decreased anxiety [as measured by the GWB (F(1,64) ¼ 11.3, p ¼ .001) and by the BSI (F(1,65) ¼ 5.7, p ¼ .02)], decreased depression [as measured by the GWB (F(1,67) ¼ 38.0, p ¼ .0001) and increased total general well-being (F(1,61) ¼ 31.1, p ¼ .0001)]. There were no statistically significant differences for any of the other psychological distress domains or of the physical health domains. Discussion This study demonstrates the positive influence of a humor intervention workshop among a community dwelling sample of older people. Improvements in mental health (well being, anxiety and depression) were shown at 6 months, in comparison to a control group. No changes were observed in self-assessed measures of physical health or function. Humor and mental health Several studies have shown a significant relationship between humor and depression and anxiety, similar to the results of this study. Humor was found to be associated with decreased depression and increased well-being in a correlational study of college students22 and with depression and anxiety in a sample of community dwelling elders in Canada.10 An experimental study of chronic obstructive pulmonary disease patients living in the community (mean age 67 years old), also found that those who completed a laughter induction study and viewed a humorous video had lower levels of anxiety and depression compared to a control group.5 Similarly a recent intervention study using laughter therapy among South Korean community dwelling older people found positive effects upon depression, cognition and sleep.8 In our study, none of the indicators of psychological distress other than depression and anxiety were found to be statistically significantly different between the groups after the humor intervention. Here too, the literature is mixed related to the impact of humor on psychological distress. For example, Jovanovic23 found that humor was a mediator between extroversion, neuroticism and life satisfaction and between neuroticism and subjective well-being among a sample of young adults. The current study did not show a difference in levels of neuroticism between the groups. Another possible explanation for lack of significant findings is that neuroticism, a potential personality trait, might not be altered by a relatively short humor intervention. On the other hand, in a review of studies that examined the stress moderating effects of humor, Martin3 concluded that while several small studies did find some evidence to support this idea, the majority of the evidence does not show such a relationship. This conclusion is similar to that obtained
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Table 4 Mean, standard deviation and Analysis of Co-variance (ANCOVA) scores on the General Well Being Schedule, Brief Symptom Inventory and Rand Health Status Questionnaire at baseline (T1) and 6 month follow-up (T2) for the control and humor workshop groups. Variable
Control group T1
General well being Positive well-being Anxiety Depression General health Total score Brief symptom inventory Anxiety Depression Total BSI Global severity Rand Health Status Questionnaire Physical function Role limitation Physical Emotional Fatigue Emotional Well-being Social function Pain General health
Humor group T2
T1
ANCOVA T2
F(df)
10.7 21.4 15.8 10.6 73.5
(3.3) (5.7) (4.6) (4.7) (21.3)
10.7 20.3 14.8 10.3 67.1
(3.2) (4.2) (3.9) (4.4) (16.7)
12.2 22.5 17.2 11.2 76.8
(3.2) (4.2) (3.1) (3.1) (16.2)
13.4 22.5 18.4 11.8 81.1
(3.4) (4.5) (3.0) (2.6) (15.9)
1 e see below 11.3 (1,61)** 38.0 (1,64)** 2 e see below 31.1 (1, 58)**
.60 .68 30.0 .57
(.73) (.66) (25.5) (.48)
.57 .60 29.1 .54
(.57) (.52) (21.9) (.41)
.57 .42 26.5 .50
(.57) (.51) (23.6) (.45)
.50 .42 24.3 .46
(.58) (.46) (21.3) (.40)
5.7 (1,62)* 3 e see below .45 (1,65) .45 (1,65)
57.0 (45.3)
59.0 (36.0)
61.9 (34.1)
63.1 (31.4)
.05 (1,64)
52.0 (51.0) 42.0 (47.0) 45.0 (36.1)
48.0 (41.0) 42.0 (45.0) 53.0 (32.6)
54.9 (45.8) 61.0 (37.9) 50.8 (25.5)
51.2 (45.4) 63.4 (40.3) 66.2 (21.6)
.04 (1,64) 2.97 (1,63) 2.86 (1,56)
64.8 63.2 75.0 45.0
66.5 75.0 69.7 42.0
67.7 77.4 62.8 37.5
74.0 74.4 65.2 41.9
4 e see below 1.01 (1,57) .46 (1,57) .67 (1,62)
(28.4) (39.4) (33.3) (28.0)
(27.2) (27.6) (30.7) (24.7)
(21.4) (28.9) (29.0) (17.9)
(17.3) (23.4) (22.3) (21.5)
**p < .001, *p < .05. 1e4: Data did not comply with ANCOVA assumptions. Paired t tests for each group listed as follows: 1: Humor group: t(39) ¼ 2.9, p ¼ .005; Control group: t(23) ¼ .79, p ¼ .44. 2: Humor group: t(41) ¼ 2.3, p ¼ .025; Control group: t(23) ¼ 2.1, p ¼ .051. 3: Humor group: t(40) ¼ .05, p ¼ .96; Control group: t(23) ¼ .66, p ¼ .52. 4: Humor group: t(42) ¼ 2.5, p ¼ .017; Control group: t(22) ¼ .22, p ¼ .82.
in the current study. Another potential explanation is the low levels of psychological distress found in this sample as well as low levels of variance, thereby decreasing the likelihood of finding statistical significance. In a review of the literature, Ruch, Proyer and Weber24 conclude that interventions for the elderly that focus on personality strengths, such as humor, can strengthen general well-being. This conclusion was supported by this study. In a similar study, a sample of elderly nursing home residents underwent a humor therapy program. Those in the experimental group were found to have decreased pain and increases in happiness and life satisfaction as compared to a control group.14 While increased well-being and life satisfaction were found in both studies, the current study did not find a significant change in the level of pain or any other health quality of life indicators.
chronic illness. This conclusion might also apply to the current research sample as well. A primary methodological consideration, which has implications for subsequent research and practical implementation of humor therapy, concerns the definition per se of humor therapy. The lack of standardization and clear guidelines concerning what exactly constitutes humor therapy is problematic, and presents a barrier to the replication of research findings. Our study is the first such study conducted over a six month period among this subject population and is thus an important contribution to the research that does exist from other cultures. Whilst numerous aspects of humor are culturally defined, nonetheless research is needed aimed at isolating the key, culturally independent elements of the humor process, in order to encourage widespread implementation of humor therapy.
Humor and physical health
Methodological aspects
The literature is mixed with regard to the relationship between humor and measures of health quality of life. As opposed to results of this study, Boyle and Joss-Reid18 found a significant relationship between humor and health quality of life among a community sample of adults 18e65 years old in Australia. However it should be noted that the authors did not include the elderly in their sample. In a study of elderly people living in assisted living facilities,13 a significant association was described between humor and health status. A correlational study of community dwelling elders also found a significant correlation between humor and physical and mental health status.10 Others6 found that in a sample of patients with chronic systemic sclerosis, humor was negatively associated with disease severity, pain, disability and distress. However, after controlling for confounding factors, these disease-related variables were not found to be significant. The authors concluded that humor may not have a direct impact on quality of life among those with
Other methodological aspects worthy of discussion include the attrition rate and membership in the control and experimental groups. The attrition rate was low-moderate and differed between the intervention and control groups however there were no demographic differences found between those who completed the questionnaires and those who didn’t in both the workshop and control groups. Attendance at the workshop was not 100% however no significant correlation was found between the number of meetings attended and scores on the outcome variables. The intervention group included significantly more Holocaust survivors and those who immigrated to Israel significantly earlier than the control group. However, neither of these variables was found to be associated with significant differences in any of the outcome variables. Furthermore, the known increased psychological pathology among older Holocaust survivors might be expected to attenuate the positive effects of humor, thus emphasizing the
F.D. Ganz, J.M. Jacobs / Geriatric Nursing xx (2014) 1e7
validity of our findings. An additional bias may have existed in that more “positive” subjects may have agreed to enroll in the intervention humor workshop. Several limitations of our study deserve mention. This study was conducted on a small convenience sample in only two cities. Individual randomization to groups did not take place therefore causal relationships should be made with great caution. Our study lacked detailed information concerning medical comorbidity, general physical health status, or medications being taken. Concomitant antianxiety or antidepressant therapy, or recent improved medical status cannot be ruled out as contributing to the improved outcomes observed among the intervention group. It should also be noted that there was only one control group that received usual care. There was no additional control group that received increased attention without humor therapy. Therefore it is unknown if the results were due to the humor intervention or to increased attention. Thus interpretations deserve caution. Finally, our sample size was relatively small, and due to limited resources we did not have adequate power for our study. The lack of association with improved self-rated physical well-being may well be a result of the lack of sufficient power. Given the significant positive results of this study, further efforts should be made to incorporate humor workshops into the schedules of other senior citizen centers. Improved anxiety, depression and psychological well being among older people are clearly desirable outcomes, and the magnitude of increase observed on the various scales of measured was clinically significant. The use of humor can be easily implemented and has been found to be cost effective in relation to other less conventional types of therapy.25 Therefore, it seems possible to design humor programs among community dwelling non-patient groups, without known psychological or affective problems, in order to promote and maintain well being and psychological health. Further studies should be conducted in larger samples using more varied populations from other cultures and settings, particularly as other studies, found significant relationships between health and humor. Conclusion We found that the implementation of a five month humor workshop, aimed at encouraging the use of humor strategies, among community dwelling older people was associated with positive effects upon subsequent depression, anxiety and general well-being. We encourage similar workshops be added to the programs of community centers and recommend that further research be aimed at investigating the use of humor with other older populations. Acknowledgments This study was partially funded by the Israel Ministry of Social Welfare and was supported by the Netanya and Rishon Le Zion municipalities. Thanks go to Mr. Enzo Agada Goren and Mr. Modechai Greenberg for their active participation in the design and data
7
collection of the study. Thanks also go to the “Happy Nation Society” whose members supported the study and dedicated their time and effort to its completion.
References 1. Cernerud L, Olsson H. Humor as seen from a public health perspective. Scand J Public Health. 2004;3:396e398. 2. Goodenough B, Low LF, Casey AN, et al. Study protocol for a randomized controlled trial of humor therapy in residential care: the Sydney Multisite Intervention of LaughterBosses and ElderClowns (SMILE). Int Psychogeriatr. 2012;24:2037e2044. 3. Martin RA. Humor, laughter and physical health: methodological issues and research findings. Psychol Bull. 2001;127:504e519. 4. Lai JCL, Chonga AML, Siub OT, Evansc P, Chand CLW, Ho RTH. Humor attenuates the cortisol awakening response in healthy older men. Biol Psychol. 2010;84:375e380. 5. Leibowitz KR, Suh S, Diaz PT, Emery CF. Effects of humor and laughter on psychological functioning, quality of life, health status, and pulmonary functioning among patients with chronic obstructive pulmonary disease: a preliminary investigation. Heart Lung. 2011;40:310e319. 6. Merz EL, Malcarne VL, Hansdottir I, Furst DE, Clements PJ, Weisman MH. A longitudinal analysis of humor coping and quality of life in systemic sclerosis. Psychol Health Med. 2009;14:553e566. 7. Wilkins J, Eisenbraun AJ. Humor theories and the physiological benefits of laughter. Holist Nurs Pract. 2009;23:349e354. 8. Ko HJ, Youn HCH. Effects of laughter therapy on depression, cognition and sleep among the community-dwelling elderly. Geriatr Gerontol Int. 2011;11:267e274. 9. Samson AC, Gross JJ. Humour as emotion regulation: the differential consequences of negative versus positive humour. Cogn Emot. 2012;26:375e384. 10. Marziali E, McDonald L, Donahue P. The role of coping humor in the physical and mental health of older adults. Aging Ment Health. 2008;12(6):713e718. 11. Lund DA, Utz R, Caserta MS, deVries B. Humor, laughter and happiness in the daily lives of recently bereaved spouses. Omega. 2009;58(2):87e105. 12. Forssen ASK. Humour, beauty and culture as personal health resources: experiences of elderly Swedish women. Scand J Public Health. 2007;35:228e234. 13. Celso BG, Ebener DJ, Burkhead EJ. Humor coping, health status and life satisfaction among older adults residing in assisted living facilities. Aging Ment Health. 2003;7(6):438e445. 14. Tse MMY, Lo APK, Cheng TLY, Chan EKK, Chan AHY, Chung HSW. Humor therapy: relieving chronic pain and enhancing happiness for older adults. J Aging Res; 2010;343574. 15. Mathieu SI. Happiness and humor group promotes life satisfaction for senior center participants. Activ Adapt Aging. 2008;32(2):134e148. 16. Kondradt B, Hirsh RD, Jonitz MF, Junglas K. Evaluation of a standardized humor group in a clinical setting: a feasibility study for older patients with depression. Int J Geriatr Psychiatry. 2012;28:850e857. 17. Hays RD, Sherbourne CD, Mazel RM. The RAND 36-Item Health Survey 1.0. Health Econ. 1993;2:217e227. 18. Boyle GJ, Joss-Reid JM. Relationship of humour to health: a psychometric investigation. Br J Health Psychol. 2004;9(1):51e66. 19. Dupuy HJ. The general well being schedule. In: McDowell I, Newell C, eds. Measuring Health: A Guide to Rating Scales and Questionnaires. New York: Oxford University Press; 1987:125e133. 20. Derogatis LR, Spencer PM. BSI Administration and Procedures Manual. Baltimore, MD: Clinical Psychometric Research; 1982. 21. Gilbar O, Ben-Zur H. Adult Israeli community norms for the Brief Symptom Inventory. Int J Stress Manage. 2002;9(1):1e10. 22. Kuiper NA, McHale N. Humor styles as mediators between self-evaluative standards and psychological wellbeing. J Psychol. 2009;143(4):359e376. 23. Jovanovic V. Do humor styles matter in the relationship between personality and subjective well being? Scand J Psychol. 2011;52(5):502e507. 24. Ruch W, Proyer RT, Weber M. Humor as a character strength among the elderly. Empirical findings on age related changes and its contribution to satisfaction with life. Z Gerontol Geriatr. 2010;43:13e18. 25. Bennett MP, Lengacher CA. Humor and laughter may influence health. I. History and background. Evid Based Complement Alternat Med. 2006;3(1): 61e63.
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Feature Article
The effect of humor on elder mental and physical health Freda DeKeyser Ganz, RN, PhD a, *, Jeremy M. Jacobs, MD b a b
Hadassah Hebrew University School of Nursing, Kiryat Hadassah, P.O. Box 12000, Jerusalem 91120, Israel Department of Geriatrics and Rehabilitation, Hebrew University, Hadassah Medical School, Jerusalem, Israel
a r t i c l e i n f o
a b s t r a c t
Article history: Received 13 October 2013 Received in revised form 21 January 2014 Accepted 27 January 2014 Available online xxx
A convenience sample of community-dwelling older people attending senior centers was asked to participate in a quasi-experimental study to examine the impact of a humor therapy workshop on physical and mental health. Participants were assessed at baseline and at six months for physical (general health and health quality of life) and mental (general well-being, anxiety, depression and psychological distress) health. The sample consisted of 92 subjects, 42 in the control group and 50 in the workshop. Compared to controls, subjects in the workshop had significantly lower follow-up levels of anxiety and depression and improved general well-being. No differences were observed for general health, health quality of life, or psychological distress. This humor therapy workshop was associated with a positive effect upon mental health. It is recommended that attendance at humor workshops be encouraged and that further investigations into the efficacy of such programs on mental and physical health be investigated. Ó 2014 Mosby, Inc. All rights reserved.
Keywords: Humor Community-dwelling elderly Mental health Physical health
Introduction Promoting health and well-being among older people is a growing challenge. The search for effective interventions has led to the therapeutic use of humor as a possible method to promote improved mental and physical health.1 Humor is generally defined as a positive global mental state, unique to each individual, spanning aspects of cognition, emotion, behavior, and communication. The humor workshop in this study can be seen as a type of humor therapy defined by Goodenough and colleagues2 as an intervention that stimulates the discovery, expression or appreciation of the absurdity or incongruity of life’s episodes in order to facilitate physical, mental, emotional, social or spiritual healing and coping, thus leading to improved mental and physical health.
is the effect of positive emotions such as humor on mental health.3 Laughter therapy was found to significantly decrease levels of depression among a sample of community dwelling elderly8 while positive humor was shown to decrease negative and increase positive emotions.9 Thirdly, humor may serve as a coping mechanism that decreases stress, and thusly improves health. Coping humor was found to be significantly associated with social support, self-efficacy, depression and anxiety among a sample of Canadian community dwelling older adults.10 Humor has also been strongly associated with favorable adjustment among recently bereaved spouses.11 Community dwelling elderly Swedish women reported that the use of humor helped them endure pain.12 Others13 found statistically significant relationships between health status and humor coping and life satisfaction among elderly living in assisted living facilities.
Background Humor and physical and mental health
Humor interventions
Several mechanisms have been postulated to explain the association between humor and mental and physical health.3 Evidence supports numerous positive physiological effects on several bodily systems including musculoskeletal, respiratory, cardiovascular, endocrine, immune and nervous systems.4e7 A second mechanism
Five interventional studies were found that investigated the positive effects of humor interventions or laughter therapy on older people (Table 1). While humor therapy is seen as the incorporation of humor into daily life, laughter therapy is defined as a more active process where humor is created.2 The first study examined the effect of one month of once weekly laughter therapy among a sample of community dwelling South Korean older adults.8 The four 1 h sessions consisted of viewing a video about laughter therapy; practicing laughter meditation sessions; laughing aloud while
* Corresponding author. Tel.: þ 972 50 404 8169; fax: þ972 2 643 9020. E-mail address: [email protected] (F.D. Ganz). 0197-4572/$ e see front matter Ó 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2014.01.005
2
F.D. Ganz, J.M. Jacobs / Geriatric Nursing xx (2014) 1e7
clapping; dancing and singing; Kegel exercises; and discussion of the effect of positive thinking. This intervention was associated with positive effects on depression, insomnia and sleep quality. In the second interventional study, a sample of South Korean elderly nursing home residents underwent a humor therapy program.14 This humor therapy intervention consisted of 1 h weekly meetings over a period of eight weeks. Therapy included the creation of a collection of humorous materials and seven weekly sessions consisting of sharing jokes and stories; lectures on humor research; laughing exercises and games; and a lecture on how to prioritize humor in one’s life. Those in the experimental group were found to have decreased pain and increased happiness and life satisfaction as compared to a control group. The third interventional study investigated those with COPD. In this study, participants were exposed to a one-time 30 min humorous video. Mood state and physiological measures of dyspnea were found to improve.5 The next study15 determined that a therapeutic program to increase happiness and humor was associated with an increase in life satisfaction among a sample of older adults. This intervention consisted of ten weekly sessions that included lectures, interactive activities, jokes as well as the encouragement of participants to share and discuss humorous aspects of their lives. Kondradt, Hirsh, Jonitz and Junglas16 investigated whether participation in a humor group could decrease depression, and increase cheerfulness and life satisfaction among a sample of older adults diagnosed with major depression. The intervention group met twice a week for 8 sessions. The sessions included remembering funny situations, sharing personal anecdotes, thinking happy thoughts, and emphasizing the place of healthy humor in one’s life; as well as music and dance. The humor group showed a significant improvement in life satisfaction and changes in state seriousness.
In summary, while several interventional studies have been conducted on older adults, few have been conducted on healthy community dwelling elderly who comprise the largest percentage of the elderly population. Each study uses a different definition of what humor therapy consists of and how to measure outcomes associated with the intervention. Most have been short term interventions. The content of these interventions is extremely varied and the potential benefits of these interventions among this age group are poorly defined (Table 1). The purpose of the present study was to examine the effect of a five month intervention using a humor workshop among a sample of Israeli community-dwelling elderly people who attended senior centers. We hypothesized that a humor intervention would be associated with improved mental and physical health among community dwelling older people attending senior centers. Method Subjects The target population for this study was community dwelling older adults. The inclusion criterion was attendance at one of four senior centers used in the study. Exclusion criteria were inability to read or write in either Hebrew or English and cognitive impairment (as assessed by the administrator/social worker in charge of the center). See Fig. 1 for the recruitment and drop-out rates for this sample. Setting The workshop was presented to the senior administrator responsible for social welfare programs in several municipalities. Two municipalities agreed to participate. The workshops were held
Fig. 1. Flow diagram of study methods.
F.D. Ganz, J.M. Jacobs / Geriatric Nursing xx (2014) 1e7
in senior centers that hold social and educational programs for independent community-dwelling older people and are owned and run by their respective municipalities. The municipal social welfare administrator was asked to provide two centers in their jurisdiction with members of similar socio-demographic characteristics, where one center in each municipality was randomized to serve as the control group and one as the intervention group. All members of the senior centers were invited to participate in the workshop. The study was described to all of the members of the center, informed consent was obtained and baseline data were collected for those who met the inclusion criteria. Sample size was determined using a power of .80 and an alpha rate of .05. In order to detect a significant difference between two groups with a moderate effect size, a total of 64 subjects was necessary in each of the groups. Humor therapy workshop intervention The “Humor as a Way of Life” program consisted of one session per week lasting 2e3 h per session. These sessions were based on a successful pilot program that was tested on another population of older people from another city as well as a review of previous techniques described in the literature. The program took approximately five months to complete. The humor therapy workshop used methods similar to other interventions (see Table 2). These sessions were conducted by a humorist who dedicates his time to promoting the use of humor in society and delivering these workshops, and a social worker. The sessions were led by the same moderators in both of the centers in the experimental group and attempts were made to standardize the program as much as possible. Subjects in the control group continued to attend the senior centers without any form of intervention. They were offered the opportunity of participating in a humor workshop at the next opportunity after the completion of the study.
3
The General Well Being Scale (GWB)19 measures psychological well-being, a measure of mental health. This 18 item questionnaire assesses both positive and negative feelings and is based on six dimensions (positive well being, self control, vitality, anxiety, depression and general health). A total score of General Well-Being can also be calculated. Each item is based on a time frame of the previous month and is set on a six point scale. The GWB was developed for a national United States health survey and has been shown to have internal reliability ranging from .88 to .95 using different community samples. Test-retest reliability was also evaluated and ranged from .68 to .85 in different samples. Validity was evaluated using factor analysis on the US survey.19 Cronbach alpha reliability for this study was a ¼ .90 for T1 and a ¼ .89 for T2. This questionnaire was translated using the forwardebackward translation approach. The Brief Symptom Inventory (BSI)20 is a 53 item questionnaire, which measures psychological distress, another measure of mental health. The questionnaire is built on a 5 level Likert format from 0 (not at all) to 4 (very much). Responses can be summed to create a total score. The Global Severity Index is another measure of global psychological distress that is determined by dividing the grand total by 53. The scale contains 9 separate dimensions; somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation and psychoticism. The scale has been used on many different populations and has been translated into Hebrew. In a study of 510 Israeli community respondents, the BSI was found to be reliable and valid, with Israelis scoring higher than known international norms for the questionnaire.21 Cronbach alpha reliability for this study was a ¼ .96 for T1 and a ¼ .95 for T2. A demographic data questionnaire recorded subjects’ gender, age, marital status, number of children, place of origin, date of immigration (if relevant), and a self reported appraisal of annual income (below average, average or above average).
Data collection Statistical analysis All of the questionnaires were self-administered however research staff was available to help participants fill out their questionnaires if necessary. Both the control and intervention groups were asked to fill out all questionnaires at baseline, before the project was begun, and to complete the questionnaires six months later, after completion of the workshop. The study was approved by the Institutional Ethical Review Board of the Faculty of Medicine, Hebrew University, and all subjects gave written informed consent. Instruments The following four instruments were used for this study: The first questionnaire was the RAND Health Status Questionnaire17 e shortened version: This questionnaire was designed to measure health related quality of life, a measure of physical and mental health. It contains 12 items that assess eight dimensions of health related quality of life (physical functioning, role limitations due to physical and emotional health, energy/fatigue, emotional well-being, social functioning, pain and general health). Scores for all dimensions are measured on a scale from 0 to 100, a higher score indicating a better quality of life. The questionnaire’s validity and reliability have been validated in previous studies.17,18 Cronbach alpha reliability data for this study were based on the following subscales (only these subscales contained more than 2 items, necessary for a reliability calculation): T1: physical health: a ¼ .86, emotional health: a ¼ .64; T2: physical health: a ¼ .74, emotional health: a ¼ .79. This instrument was translated into Hebrew using a forwardebackward translation approach.
Sample size was determined using a power of .80 and an alpha rate of .05. In order to detect a significant difference between two groups with a moderate effect size, a total of 64 subjects were necessary in each group. Descriptive statistics were used to describe the sample and results of the RAND, GWB and BSI questionnaires. Differences between the two groups were determined using Analysis of Covariance (ANCOVA), where the baseline value at T1 was used as the covariate for each analysis. Data storage and analysis were performed using SPSS version 17. All p-values were 2-tailed and p < .05 was considered significant. Results The sample consisted of 92 subjects, 42 in the control group and 50 in the humor workshop group (see Fig. 1). Most of the participants were females (n ¼ 67, 74.4% among those who responded) either married (n ¼ 45, 48.9%) or widowed (n ¼ 45, 48.9%). The mean age of the sample was 76.9 (SD e 6.8). Similar numbers of respondents either lived alone (n ¼ 41, 44.6%) or with a spouse (n ¼ 45, 48.9%). Most were not born in Israel (n ¼ 75, 81.3% among those that responded) (see Table 3). Subjects in the intervention group reported attending a mean of 11 meetings (out of a possible 16), with only 6 (13% among those that responded) subjects attended less than half of the humor meetings. At baseline the control and humor groups were similar for demographic characteristics, except that those in the workshop immigrated to Israel longer ago (52 years vs. 39 years, t(70.14) ¼ 2.4, p ¼ .018), and there was a higher percentage of Holocaust survivors among the
4
Table 1 Humor interventions. Sample
Design
Type of intervention
Length of intervention
Outcome measures
Significant differences between groupsa
Ko and Youn (2011)
N ¼ 109 (48 experimental group þ 61 controls) Community dwelling Korean older adults
Randomized control trial
-
- 1h - Once per week - 4 weeks
-
- Significant difference in depression, insomnia, and sleep - No significant difference in health quality of life
Kondrat, Hirsch, Jonitz and Junglas (2012)
N ¼ 99 (49 experimental groupþ 50 controls) Hospitalized older adults with major depression
Quasi-experimental, pre-test, post-test controlled design
- Twice per week - 8 sessions
-
Geriatric Depression Scale Beck Depression Inventory Short form Health Survey State-Trait Cheerfulness Inventory - Satisfaction with Life Scale - Resilience Scale
- Both groups showed significant improvement in depression, state cheerfulness, state bad mood over time - Only the humor group had changes of state seriousness and life satisfaction
Lebowitz, Suh, Diaz, and Emery (2009)
N ¼ 22 (11 in experimental group þ 11 controls) Older adults with COPD (mean age 66.9)
Randomized control trail
1e30 min video
- Pulmonary function (FRC, FEV1, FVC, RV) - Positive and Negative Affectivity Scales - Dyspnea Numeric Rating Scale
Mathieu (2008)
N ¼ 17 (sample served as own controls) Community dwelling older adults, USA
Pre-test, post-test design
- Once per week - 10 weeks
- Life Satisfaction Scale
- Increased FRC, RV in experimental group compared to controls - No effect on FEV1 - Significant difference in affectivity state in experimental group compared to controls - Significant increase in life satisfaction scores
Tse, Lo, Cheng, Chan, Chan and Chung, (2010)
N ¼ 70 (36 experimental group þ 34 controls) ‘cognitively intact’ Korean Nursing Home Residents
Quasi-experimental, pre-test, post-test controlled design
- One hour - Weekly - 8 weeks
- Cantonese Verbal Pain Rating Scale - Subjective Happiness Scale - UCLA Loneliness Scale - Revised Life Satisfaction Index-A Scale
a
Significant difference between the experimental and control group (p < .05).
Laughter video Laughter meditation Laugh out loud sessions Dancing and singing Kegel exercises Discussions on the effect of positive thinking - Educational session on effects of laughing - Sharing of personal anecdotes and jokes - Sharing of happiness thoughts - Giving of compliments - Discussion of humor when under stress - Use of playful props Humorous video
- Presentation about factors contributing to happiness and life satisfaction - Sharing of personal funny anecdotes and jokes - Use of playful props - Lecture on importance of exercise, nutrition, recreation and attitude to living a happy life - Humorous videos - Dance - Collection of humorous materials - Sharing jokes and stories - Lectures on humor research - Laughing exercises and games - Lecture on how to prioritize humor in one’s life
Geriatric Depression Scale SF-36 (health quality of life) Insomnia Severity Index Pittsburgh Sleep Quality Index
- Significant improvement in pain scores and all psychological measures for the experimental group - No significant differences in all measures for the control group
F.D. Ganz, J.M. Jacobs / Geriatric Nursing xx (2014) 1e7
Source
F.D. Ganz, J.M. Jacobs / Geriatric Nursing xx (2014) 1e7 Table 2 The humor therapy workshop intervention. Week
Content
Prior studies using similar methods Source
Intervention
1e4
Incorporation of humor into daily life Development of supportive and mirthful environment Create and review video recordings of humorous life stories or personal funny anecdotes
[14]
Prioritize humor in daily life Emphasize place of humor in life View humorous videos
5e12
[16] [5,8]
[14]
Share jokes and personal stories Share humorous aspects of life Remember funny situations, share personal anecdotes
[15] [16]
intervention vs. the control group (68% vs. 32%, c2(1) ¼ 10.47, p ¼ .001). Holocaust survivors were found to differ from other seniors on only two variables, age and time since immigration to Israel, where survivors were older (survivors: mean ¼ 78.9 years, others: 74.8 years) and survivors immigrated longer ago (survivors: 60.0 years, others: 33.0 years). These variables were not found to significantly correlate with the outcome variables. Table 4 compares the outcome measures between the intervention and control groups at baseline (T1) and 6 months later (one month following completion of the humor workshop) (T2). At
Table 3 Demographic characteristics of the humor workshop and control group samples.
Age (missing: 5) 60e74 75e84 85 Sex Males Females Family status Married Divorced Widowed Living status Alone With spouse With other Place of birth (missing: 1) Israel Eastern Europe Western Europe Asia Africa Other Income Below average Average Above average Education (missing: 2) Up to high school Post HS Time since immigration (years) Holocaust survivors
Control group
Humor workshop
Total sample
N ¼ 42
n ¼ 50
n ¼ 92
14 (35.9%) 15 (38.5%) 10 (25.6%)
18 (37.5%) 26 (54.2%) 4 (8.3%)
32 (36.8%) 41 (41.7%) 14 (11.5%)
8 (18.5%) 34 (81.5%)
15 (30.0%) 35 (70.0%)
23 (25.6%) 67 (74.4%)
25 (50.0%) 25 (50.0%)
45 (48.9%) 2 (2.2%) 45 (48.9%)
21 (50.0%) 20 (47.6%) 1 (2.4%)
20 (40.0%) 25 (50.0%) 5 (10.0%)
41 (44.6%) 45 (48.9%) 6 (6.5%)
10 11 3 4 3 10
7 27 3 4 5 4
17 38 6 8 8 14
20 (47.6%) 2 (4.8%) 20 (47.6%)
(24.4%) (26.8%) (7.3%) (9.8%) (7.3%) (24.4%)
14 (37.8%) 21 (56.8%) 2 (5.4%) 31 9 38.9 13
0
(77.5%) (22.5%) (26.6) (31.0%)
(14.0%) (54.0%) (6.0%) (8.0%) (10.0%) (8.0%)
16 (32.0%) 34 (68.0%) 0 39 11 52.1 34
(78.0%) (22.0%) (22.4) (68.0%)
(18.7%) (41.8%) (6.6%) (8.8%) (8.8%) (15.2%)
30 (34.5%) 55 (63.2%) 2 (2.3%) 70 20 46.4 47
(77.8%) (22.2%) (25.1)y (51.6%)**
y p ¼ .018, **p ¼ .001. No statistically significant differences between the groups for all other findings.
5
baseline the only differences found between the intervention vs. control group were related to mental health [a higher positive wellbeing sub-scale score from the GWB scale (12.2 3.2 vs. 10.7 3.3, p ¼ .035), and lower depression sub-scale score from the BSI (.4 .48 vs. .7 .66, p ¼ .014)]. No other differences at baseline were observed for any of the parameters. At baseline, the mean level of reported general health (RAND scale) (a measure of physical health) was reported as fair (39 out of 100, SD ¼ 23.2), with subjects reporting their pain level to be minor to moderate (mean ¼ 64.9 out 100, SD ¼ 30.8). The baseline total General Well Being Score (a measure of mental health) was 75.3 (SD ¼ 18.5) and the mean total BSI score (a measure of mental health) was 27.9 (SD ¼ 25.0). At follow-up, a number of significant differences were found between the groups, while controlling for baseline scores. Humor workshop participants showed an improved mental health, as measured by improved positive well-being (F(1,64) ¼ 8.6, p ¼ .005), decreased anxiety [as measured by the GWB (F(1,64) ¼ 11.3, p ¼ .001) and by the BSI (F(1,65) ¼ 5.7, p ¼ .02)], decreased depression [as measured by the GWB (F(1,67) ¼ 38.0, p ¼ .0001) and increased total general well-being (F(1,61) ¼ 31.1, p ¼ .0001)]. There were no statistically significant differences for any of the other psychological distress domains or of the physical health domains. Discussion This study demonstrates the positive influence of a humor intervention workshop among a community dwelling sample of older people. Improvements in mental health (well being, anxiety and depression) were shown at 6 months, in comparison to a control group. No changes were observed in self-assessed measures of physical health or function. Humor and mental health Several studies have shown a significant relationship between humor and depression and anxiety, similar to the results of this study. Humor was found to be associated with decreased depression and increased well-being in a correlational study of college students22 and with depression and anxiety in a sample of community dwelling elders in Canada.10 An experimental study of chronic obstructive pulmonary disease patients living in the community (mean age 67 years old), also found that those who completed a laughter induction study and viewed a humorous video had lower levels of anxiety and depression compared to a control group.5 Similarly a recent intervention study using laughter therapy among South Korean community dwelling older people found positive effects upon depression, cognition and sleep.8 In our study, none of the indicators of psychological distress other than depression and anxiety were found to be statistically significantly different between the groups after the humor intervention. Here too, the literature is mixed related to the impact of humor on psychological distress. For example, Jovanovic23 found that humor was a mediator between extroversion, neuroticism and life satisfaction and between neuroticism and subjective well-being among a sample of young adults. The current study did not show a difference in levels of neuroticism between the groups. Another possible explanation for lack of significant findings is that neuroticism, a potential personality trait, might not be altered by a relatively short humor intervention. On the other hand, in a review of studies that examined the stress moderating effects of humor, Martin3 concluded that while several small studies did find some evidence to support this idea, the majority of the evidence does not show such a relationship. This conclusion is similar to that obtained
6
F.D. Ganz, J.M. Jacobs / Geriatric Nursing xx (2014) 1e7
Table 4 Mean, standard deviation and Analysis of Co-variance (ANCOVA) scores on the General Well Being Schedule, Brief Symptom Inventory and Rand Health Status Questionnaire at baseline (T1) and 6 month follow-up (T2) for the control and humor workshop groups. Variable
Control group T1
General well being Positive well-being Anxiety Depression General health Total score Brief symptom inventory Anxiety Depression Total BSI Global severity Rand Health Status Questionnaire Physical function Role limitation Physical Emotional Fatigue Emotional Well-being Social function Pain General health
Humor group T2
T1
ANCOVA T2
F(df)
10.7 21.4 15.8 10.6 73.5
(3.3) (5.7) (4.6) (4.7) (21.3)
10.7 20.3 14.8 10.3 67.1
(3.2) (4.2) (3.9) (4.4) (16.7)
12.2 22.5 17.2 11.2 76.8
(3.2) (4.2) (3.1) (3.1) (16.2)
13.4 22.5 18.4 11.8 81.1
(3.4) (4.5) (3.0) (2.6) (15.9)
1 e see below 11.3 (1,61)** 38.0 (1,64)** 2 e see below 31.1 (1, 58)**
.60 .68 30.0 .57
(.73) (.66) (25.5) (.48)
.57 .60 29.1 .54
(.57) (.52) (21.9) (.41)
.57 .42 26.5 .50
(.57) (.51) (23.6) (.45)
.50 .42 24.3 .46
(.58) (.46) (21.3) (.40)
5.7 (1,62)* 3 e see below .45 (1,65) .45 (1,65)
57.0 (45.3)
59.0 (36.0)
61.9 (34.1)
63.1 (31.4)
.05 (1,64)
52.0 (51.0) 42.0 (47.0) 45.0 (36.1)
48.0 (41.0) 42.0 (45.0) 53.0 (32.6)
54.9 (45.8) 61.0 (37.9) 50.8 (25.5)
51.2 (45.4) 63.4 (40.3) 66.2 (21.6)
.04 (1,64) 2.97 (1,63) 2.86 (1,56)
64.8 63.2 75.0 45.0
66.5 75.0 69.7 42.0
67.7 77.4 62.8 37.5
74.0 74.4 65.2 41.9
4 e see below 1.01 (1,57) .46 (1,57) .67 (1,62)
(28.4) (39.4) (33.3) (28.0)
(27.2) (27.6) (30.7) (24.7)
(21.4) (28.9) (29.0) (17.9)
(17.3) (23.4) (22.3) (21.5)
**p < .001, *p < .05. 1e4: Data did not comply with ANCOVA assumptions. Paired t tests for each group listed as follows: 1: Humor group: t(39) ¼ 2.9, p ¼ .005; Control group: t(23) ¼ .79, p ¼ .44. 2: Humor group: t(41) ¼ 2.3, p ¼ .025; Control group: t(23) ¼ 2.1, p ¼ .051. 3: Humor group: t(40) ¼ .05, p ¼ .96; Control group: t(23) ¼ .66, p ¼ .52. 4: Humor group: t(42) ¼ 2.5, p ¼ .017; Control group: t(22) ¼ .22, p ¼ .82.
in the current study. Another potential explanation is the low levels of psychological distress found in this sample as well as low levels of variance, thereby decreasing the likelihood of finding statistical significance. In a review of the literature, Ruch, Proyer and Weber24 conclude that interventions for the elderly that focus on personality strengths, such as humor, can strengthen general well-being. This conclusion was supported by this study. In a similar study, a sample of elderly nursing home residents underwent a humor therapy program. Those in the experimental group were found to have decreased pain and increases in happiness and life satisfaction as compared to a control group.14 While increased well-being and life satisfaction were found in both studies, the current study did not find a significant change in the level of pain or any other health quality of life indicators.
chronic illness. This conclusion might also apply to the current research sample as well. A primary methodological consideration, which has implications for subsequent research and practical implementation of humor therapy, concerns the definition per se of humor therapy. The lack of standardization and clear guidelines concerning what exactly constitutes humor therapy is problematic, and presents a barrier to the replication of research findings. Our study is the first such study conducted over a six month period among this subject population and is thus an important contribution to the research that does exist from other cultures. Whilst numerous aspects of humor are culturally defined, nonetheless research is needed aimed at isolating the key, culturally independent elements of the humor process, in order to encourage widespread implementation of humor therapy.
Humor and physical health
Methodological aspects
The literature is mixed with regard to the relationship between humor and measures of health quality of life. As opposed to results of this study, Boyle and Joss-Reid18 found a significant relationship between humor and health quality of life among a community sample of adults 18e65 years old in Australia. However it should be noted that the authors did not include the elderly in their sample. In a study of elderly people living in assisted living facilities,13 a significant association was described between humor and health status. A correlational study of community dwelling elders also found a significant correlation between humor and physical and mental health status.10 Others6 found that in a sample of patients with chronic systemic sclerosis, humor was negatively associated with disease severity, pain, disability and distress. However, after controlling for confounding factors, these disease-related variables were not found to be significant. The authors concluded that humor may not have a direct impact on quality of life among those with
Other methodological aspects worthy of discussion include the attrition rate and membership in the control and experimental groups. The attrition rate was low-moderate and differed between the intervention and control groups however there were no demographic differences found between those who completed the questionnaires and those who didn’t in both the workshop and control groups. Attendance at the workshop was not 100% however no significant correlation was found between the number of meetings attended and scores on the outcome variables. The intervention group included significantly more Holocaust survivors and those who immigrated to Israel significantly earlier than the control group. However, neither of these variables was found to be associated with significant differences in any of the outcome variables. Furthermore, the known increased psychological pathology among older Holocaust survivors might be expected to attenuate the positive effects of humor, thus emphasizing the
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validity of our findings. An additional bias may have existed in that more “positive” subjects may have agreed to enroll in the intervention humor workshop. Several limitations of our study deserve mention. This study was conducted on a small convenience sample in only two cities. Individual randomization to groups did not take place therefore causal relationships should be made with great caution. Our study lacked detailed information concerning medical comorbidity, general physical health status, or medications being taken. Concomitant antianxiety or antidepressant therapy, or recent improved medical status cannot be ruled out as contributing to the improved outcomes observed among the intervention group. It should also be noted that there was only one control group that received usual care. There was no additional control group that received increased attention without humor therapy. Therefore it is unknown if the results were due to the humor intervention or to increased attention. Thus interpretations deserve caution. Finally, our sample size was relatively small, and due to limited resources we did not have adequate power for our study. The lack of association with improved self-rated physical well-being may well be a result of the lack of sufficient power. Given the significant positive results of this study, further efforts should be made to incorporate humor workshops into the schedules of other senior citizen centers. Improved anxiety, depression and psychological well being among older people are clearly desirable outcomes, and the magnitude of increase observed on the various scales of measured was clinically significant. The use of humor can be easily implemented and has been found to be cost effective in relation to other less conventional types of therapy.25 Therefore, it seems possible to design humor programs among community dwelling non-patient groups, without known psychological or affective problems, in order to promote and maintain well being and psychological health. Further studies should be conducted in larger samples using more varied populations from other cultures and settings, particularly as other studies, found significant relationships between health and humor. Conclusion We found that the implementation of a five month humor workshop, aimed at encouraging the use of humor strategies, among community dwelling older people was associated with positive effects upon subsequent depression, anxiety and general well-being. We encourage similar workshops be added to the programs of community centers and recommend that further research be aimed at investigating the use of humor with other older populations. Acknowledgments This study was partially funded by the Israel Ministry of Social Welfare and was supported by the Netanya and Rishon Le Zion municipalities. Thanks go to Mr. Enzo Agada Goren and Mr. Modechai Greenberg for their active participation in the design and data
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collection of the study. Thanks also go to the “Happy Nation Society” whose members supported the study and dedicated their time and effort to its completion.
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