Investigating the effect of laughter yoga on happiness and life expectancy in an elderly population

Abstract

BACKGROUND:

During the elderly period, individuals experience physical and psychological crises. One of the factors that positively influence critical life situations is happiness and hope. Given the significant physical and psychological effects of laughter yoga on the body, this study aimed to determine the impact of laughter yoga on the happiness and hope (life expectancy) of elderly individuals.

MATERIALS AND METHOD:

This field study employed a pretest, posttest design. The sampling method utilized was non-random, specifically convenience sampling. A total of 220 elderly retirees, who were frequent visitors to the Social Security Retirees’ Center in Gorgan, Iran, were selected for the study. These participants were then randomly assigned to either the intervention or control groups through a blocked randomization process, resulting in 110 individuals in the intervention group and 110 in the control group. The intervention group participated in eight sessions of 45-minute laughter yoga, led by certified instructors and researchers. Data collection was conducted using the Oxford Happiness Questionnaire and Snyder’s Hope Scale. The data were analyzed using the Mann–Whitney U test and Wilcoxon signed-rank test. The significance level for all statistical tests was set at P ≤ 0.05.

RESULTS:

The two groups were similar in terms of gender, age, marital status, education level, and occupation. The mean and standard deviation (SD) of the life expectancy of the elderly participants before the intervention began was 65.86 ± 7.64 in the intervention group and 65.70 ± 7.58 in the control group (P = 0.96). The mean and SD of the happiness of the elderly participants before the intervention was 63.18 ± 8.88 in the intervention group and 63.29 ± 7.56 in the control group (P = 0.37). The mean and SD of the life expectancy of the elderly participants after the intervention was 69.4 ± 42.32 in the intervention group and 65.77 ± 8.99 in the control group (P < 0.001). The mean and SD of the happiness of the elderly participants after the intervention was 69.86 ± 10.91 in the intervention group and 64.55 ± 9.28 in the control group (P < 0.001).

CONCLUSION:

The findings of this study demonstrate that laughter yoga can significantly increase happiness and improve life expectancy among elderly individuals. Consequently, laughter yoga can serve as a noninvasive method to enhance the mental well-being of older adults and as a preventive measure. It is advised that community service providers and caregivers for the elderly consider integrating laughter yoga into their eldercare programs.

Introduction

According to the forecast of the World Health Organization, between 2015 and 2050, the proportion of the world’s population over 60 years will nearly double from 12% to 22%. By 2030, one in six people in the world will be 60 years or older, since the number of elderly people is increasing. Paying attention to the physical and mental problems of the elderly should be one of the priorities of the society.[1] The World Health Organization defines mental health as follows: Mental health is more than the absence of mental disorders. Mental health is a state of mental well-being that enables people to cope with the stresses of life, realize their abilities, learn well and work well, and contribute to their community.[2] Due to the nature of old age, loneliness, and physical discomfort, the elderly suffer from many problems, especially mental problems, which can place a great burden on the person, family and society; therefore, there is a need for support, social attention, and positive interventions. Interventions reduce depression and anxiety and improve mental health by creating life expectancy, happiness, and laughter. One of the components of mental health is life expectancy.[3] Hope fosters a sense of optimism and adaptability to challenges. Possessing a sense of hope can facilitate building self-confidence for interpersonal connections, making it easier to establish loving relationships with others.[4] Hopefulness may be a learned developed behavior through the use of positive psychology.[5] Hope involves empowering individuals to set goals, along with identifying tools to achieve those goals and motivating progress toward them.[6,7] Hope is essential for life and a key factor in sustaining a high quality of life. It encompasses potential future prospects and individual aspirations.[8] A hopeful individual can find alternative solutions and employ them even in challenging life situations, ultimately acting as a protective factor for mental well-being amidst adversity. Another indicator of mental health is happiness. Mental happiness is the balance between positive and negative emotions and satisfaction in life.[9] Happiness is a pleasure, an inner state, and a cognitive and global evaluation of life satisfaction.[10,11] The happier they feel when experiencing more positive emotions than negative ones.[9] Laughter is a behavioral response to stimuli such as humor, positive emotions, or cognitive perceptions of incongruity, and it is a unique emotional reaction to happiness. Laughter triggers the release of serotonin in the digestive system and reduces cortisol production, positively altering negative mental states such as anxiety and stress and contributing to improved mental well-being, poor quality of life, and depression.[12] Laughter is a global, effective, low-cost, and side-effect-free remedy.[13] Laughter, a powerful tool in preventing depression and anxiety while alleviating tension,[14] has witnessed global popularity through the rise of laughter yoga. Presently, there are over 8000 laughter clubs in 100 countries. This group-based practice fosters enthusiasm, joy, and heightened positive emotions, thereby strengthening interpersonal connections.[15] According to Sis Çelik and colleagues, laughter therapy, particularly in the form of laughter yoga, emerged as effective in bolstering resilience.[16] Furthermore, a study by Lee et al.[17] highlighted the multifaceted benefits of laughter yoga, including the reduction of depression, occupational stress, and sleep disorders, along with the promotion of mental happiness. There is various evidence regarding the use of laughter yoga to reduce stress and anxiety in depressed people, improve quality of life,[18] reduce salivary cortisol and increase the sex hormone DHEA among healthy students,[19] increase self-esteem and happiness in patients treated for addiction,[20] and improve physical function (blood pressure, cortisol level, sleep quality) and psychosocial health (satisfaction with life, quality of life, loneliness, death anxiety, depression, mood, happiness) in the elderly.[21] There is a reduction in pain and an increase in sleep quality in hemodialysis patients,[22] which supports the effects of laughter yoga. Based on the role of hope and happiness in the lives of the elderly and the effectiveness of an easy and affordable intervention such as laughter yoga, and considering that there are fewer studies on the effect of laughter yoga on the elderly in Iran, conducting research that can determine the effectiveness of the intervention of laughter yoga on happiness and hope in the elderly is essential. Therefore, the present study was conducted with the aim of determining the impact of laughter yoga on the level of happiness and hope in the elderly. The results of the present study can affect the planning process of a wide range of care workers to senior managers.

Materials and Methods

Study design and setting

Study participants and sampling

This field experiment was conducted in 2022 using a pretest/posttest design without blinding. The research population consisted of elderly individuals who were members of the Social Security Pensioners Center in Gorgan (Iran). The sample size was determined based on information obtained from the study “The Effect of Laughter Therapy and Physical Activities on Hope and Meaning in Life in the Elderly in Tehran” by Madadi and Koolaee (2016).[23] At the confidence level of 0.95 and the power of the test 0.90, and using the sample size formula to compare the averages of two groups, the sample size in each group was determined to be 88. Considering 20% attrition, the sample size at the beginning of the study was 110 people in each group.

The study included elderly individuals aged 60 and above who met the inclusion criteria. A random sampling method was used. In the first stage, available samples were selected. All eligible participants were invited. Those meeting the criteria were ranked based on their pretest scores (from lowest to highest). They were then randomly assigned to two intervention and control groups using the four-letter block method (two letters “A” and two letters “B”). The study did not use a matched design because the participants were randomly assigned to either the intervention or control group.

Inclusion and exclusion criteria

The inclusion criteria were being an elderly individual aged 60 and above, not suffering from prominent cognitive and mental problems such as Alzheimer’s disease, having speech ability, not having significant bone fracture problems (i.e. a condition that would prevent performing laughter yoga techniques), having the ability to communicate and respond to study questions, and not participating in laughter yoga programs in the past and present. The exclusion criteria included missing more than two sessions from the second to the seventh sessions (as determined by the team and based on other studies) and experiencing a significant adverse event or acute illness during the yoga sessions.

Data gathering tools

The data collection tools were the Oxford Happiness Questionnaire and Snyder’s Hope Scale.

Snyder’s Hope Scale, developed by Snyder et al. (1991),[24] consists of 12 questions in two areas: factorial and strategic thinking, rated on an 8-point Likert scale ranging from “completely disagree” (score of 1) to “completely agree” (score of 8) and self-administered. For this scale, the reliability coefficient was obtained through Cronbach’s alpha 0.76 and factor analysis of two factors, agent thinking and paths. Four questions measure operative thinking (questions 2, 9, 10, and 12), four questions measure strategic thinking (questions 4, 1, 7, and 8), and four questions measure deviations. The range of scores is between 12 and 96. Here, 12 is the lowest score, and 96 is the highest score. Saffarinia and her colleagues obtained a Cronbach’s alpha of 0.82 for this questionnaire in 2017.[25]

The Oxford Happiness Questionnaire is a suitable instrument for measuring happiness in different groups. This questionnaire was developed by Argyle in 1990 and consists of a 29-item factor with four options. Each response to the questions is scored 0, 1, 2, or 3, corresponding to options A, B, C, or D, respectively. The total happiness score ranges from 0 to 87,[26] where a higher score indicates a higher level of happiness. This questionnaire was translated and standardized in Iran by AliPoor and Noorbala in 1999. Cronbach’s alpha was 0.93, and the reliability of the test was 0.92. The retest reliability of the questionnaire after 3 weeks was 0.79. The face validity of the questionnaire was confirmed by 10 experts.[27] Fassih-Ramandi et al.[28] calculated the Face Validity Assessment and Content Validity Assessment and Construct Validity Assessment and reliability of the prosperity scale in a sample of elderly people in Iran with the Oxford Happiness Questionnaire and concluded that this questionnaire is valid and reliable. The Cronbach’s alpha coefficient was 0.819, and the test–retest reliability of the questionnaire was 0.821.

Intervention description

Laughter yoga, pioneered by Dr. Kataria, is a combination of unconditional laughter with yoga stretching exercises and yogic breathing [Table 1]. In laughter yoga, each laughter session lasts between 30 and 40 seconds, followed by “ho-ho, ha-ha” chants combined with taking two deep breaths and clapping.

Table 1.

Laughter Yoga Techniques

Laughter Yoga Technique		Description
One-meter laugh		Placing one hand on the other hand that is extended to the side and pulling the shoulders as if measuring something, pulling the shoulders together with the sound of ee.ee.eeee in three movements to laugh.
Talkative laughter		Laughter accompanied by pointing the index finger at the members.
Laughing on the phone		Laughing and pretending at the same time as talking on the phone and nodding to the members.
Shy laugh		We laugh with our hand in front of our face while covering half of our face with our hand.
Laughter and greeting		The palms are together in front of the face (the Indian greeting method) and shake hands with the members.
Laughter from the bottom of the heart		After saying the words, the first laugh from the bottom of the heart along with opening and throwing the hands to the sky from both sides.
Laughing coffee milk		Holding two imaginary glasses full of milk and coffee with open hands in front of you and making a sound. and then emptying the first glass into the second glass and vice versa and at the end of the glass laughing.
Silent laughter		Opening the mouth as much as possible and making others laugh without making any sound along with moving and looking into the eyes of others.
Laughing of a lion		Completely sticking out the tongue along with opening the eyes too much and clawing the hands in front of you like a lion and laughing from the bottom of your heart.
Apologizing and forgiving laughter		Grasping the soft ear and shaking the head, laughing and apologizing and raising the hand as a sign of surrender.
Gradual laughter		Starting with the appearance of a smile on the face and gradually enlarging it until it turns into a hearty laugh.
Laughter for no reason		When they ask us why are you laughing, we raise our shoulders and put our hands in front of our face in a position that I don’t know and laugh.
Mobile bill laugh		We put our hand in front of the other hand to show the bill to the other and laugh.
Examination laughter		To show the center of laughter in our body, we put our hands in the position that we are examining ourselves with a stethoscope, we examine several places in the chest, and when we reach the brain, we point to our head and laugh.
Dishwasher laugh		Like when we are washing the dishes, we draw our hands twice on an imaginary dish and each time we say, and then, we put the imaginary dish up in the dish holder and laugh at the same time.
Laughing balloon		We put our hand in front of our mouth and stand in a position as if we are inflating a balloon. We laughed.

Eight sessions of laughter yoga were conducted over four weeks (each session lasting 45 minutes) in the intervention group. All individuals in the intervention group were invited to attend each session, and the elderly participants completed the Snyder Hope Scale and Oxford Happiness Questionnaire before and after the intervention. This technique was facilitated by the project coordinator and three laughter yoga instructors over eight sessions of 45 minutes each, involving 110 elderly individuals. All three laughter yoga instructors were present during each session.

The laughter yoga program began by discussing happy issues such as national and religious celebrations and having a positive sense of daily tasks. Then, hand-clapping with the rhythm of 1-2-3 started, where participants clapped their hands together with their fingers and palms in contact. Subsequently, hand movements were performed up and down in a pendulum-like motion, accompanied by movement in other body parts. Short and simple vocalizations such as “ha ha” and “ho ho” were performed. Coordinated and rhythmic movements were added to increase enthusiasm and joy. Then, broken speech, similar to what children say during play, was used. These speech patterns aimed to reduce inhibitory barriers and shyness. Laughter exercises followed, contributing to achieving mental and physical relaxation. They clapped along with laughter. Then, laughter yoga exercises were introduced, with each exercise lasting approximately 30 to 45 seconds, involving hand-clapping, vocalizations of ha ha, ho ho, and taking two deep breaths. The exercises included techniques such as laughing from the heart, laughing with a closed mouth, and gradual laughter. Exercises for joyful laughter (one-meter laugh, argument laugh, phone conversation laugh, shy laugh) and value-based laughter (greetings laugh, laughter of respect and appreciation, laughter of handshakes, laughter of hugs, etc.) were included. At the end of the session, participants loudly repeated positive affirmations such as “I am the happiest person on Earth” and looked at each other while laughing.

In the intervention group, eight sessions of laughter yoga were conducted over a period of four weeks, with each session lasting 45 minutes. This technique was administered by three laughter yoga instructors and was carried out in eight 45-minute sessions for a total of 110 elderly participants in the intervention group.

The selected laughter yoga techniques can all be applied while sitting. At the beginning of the laughter yoga sessions, the general health status of the participants was assessed, and they were informed that they could perform all laughter yoga exercises while seated. If any participants felt unable to stand during the exercises, they were encouraged to remain seated. The researcher, under the supervision of an international laughter yoga instructor, completed this course in (April–May 2022) and obtained a valid certification. These certificates have been given directly by Dr. Kataria to laughter yoga teachers to present to laughter yoga leader after completing the course and obtaining the necessary qualifications to learn laughter yoga.

Statistical analysis

The data were analyzed using frequency distribution tables, calculation of means and standard deviations, and assessment of normality distribution using the Shapiro-Wilk test in SPSS software.

The data did not follow a normal distribution (P < 0.001). The comparison of the means of happiness and life expectancy scores in the two groups before the intervention was performed using the Mann-Whitney U test. Within each group, the comparison of means before and after the intervention was carried out using the Wilcoxon test. The significance level of all statistical tests was equal to 0.05.

Ethical considerations

This study was approved by the Ethics Committee of Golestan University of Medical Sciences with the ethics code IR.GOUMS.REC.1401.300. All the ethical considerations such as informed consent, participant anonymity, data confidentiality, participants’ freedom to leave at any stage of the research, and their verbal consent were observed and maintained during the research. This trial was registered in Iranian Registry of Clinical Trials with code: IRCT20211231053577N1.

Results

In this study, 220 retired elderly individuals from the Retirees’ Center of the Social Security in Gorgan participated. Of these, 110 participants were assigned to the intervention group, and 113 were assigned to the control group [Chart 1]. The youngest participant was 60 years old, and the oldest participant was 90 years old. The average age of the participants in the intervention group was 68.72 years with a standard deviation of 6.35, and the average age of the participants in the control group was 67.92 years with a standard deviation of 6.33. The Spearman correlation test indicated that the distribution of age between the intervention and control groups was not significantly different (P = 0.116). Among the participants, 60.4% of the intervention group and 56.6% of the control group were female, and 39.6% of the intervention group and 43.4% of the control group were male. The Mann-Whitney U test showed that gender distribution did not significantly differ between the two groups (P = 0.572).

Chart 1.

Consort flowchart of the study

The marital status distribution indicated that 74.58% of the intervention group and 76.1% of the control group were married. The Chi-square test demonstrated no significant difference in marital status distribution between the intervention and control groups (P = 0.468). Educational status revealed that 86.5% of the intervention group and 77.9% of the control group had education levels below a diploma. The Chi-square test showed no significant difference in educational status distribution between the two groups (P = 0.242).

Regarding occupation, 44.1% of the intervention group and 32.7% of the control group were homemakers. The Chi-square test showed that there was no significant difference in the distribution of employment status in the intervention and control groups (P = 0.170). Ethnicity distribution showed that 59.5% of the intervention group and 48.7% of the control group were of Persian ethnicity. The Chi-square test revealed a significant difference in ethnicity distribution between the two groups (P = 0.005).

A total of 42.3% of the elderly participants in the intervention group had an underlying disease of hypertension, and 23.9% of the elderly participants in the control group had an underlying disease of diabetes. Other underlying diseases that were reported were kidney problems, eyesight, epilepsy, asthma, and lung problems. The Chi-square test showed that there was no significant difference between the underlying diseases in the two groups (P = 0.117).

The mean and standard deviation of the life expectancy of the elderly participants in the study before the intervention in the intervention group was 65.86 ± 7.64. The mean and standard deviation of the life expectancy of the elderly participants in the study before the intervention in the control group was 65.70 ± 8.58.

The average and standard deviation of the life expectancy of the elderly participants in the study after the intervention was 69.42 ± 8.32 in the intervention group and 65.77 ± 8.99 in the control group.

According to the Mann-Whitney U test, there was no significant difference in life expectancy between the assigned elderly participants in the intervention and control groups, and they were homogenous (P = 0.966). Based on the Mann-Whitney U test, after the laughter yoga intervention, life expectancy in the intervention group was significantly higher than that in the control group (P < 0.001).

The mean and standard deviation of the happiness of the elderly participating in the research before the intervention was 63.18 ± 8.88 in the intervention group and 63.29 ± 7.56 in the control group.

The mean and standard deviation of the happiness of the elderly participants in the study after the intervention was 69.86 ± 10.91 in the intervention group and 64.55 ± 9.28 in the control group.

Moreover, based on the Mann-Whitney U test, the assigned elderly participants in the intervention and control groups did not significantly differ in terms of happiness and were homogenous (P = 0.379).

Table 2 shows that the average age of the elderly in the intervention group was 68.72 years and in the control group was 67.92 years. According to Mann-Whitney U test, there was no significant between the intervention and control groups in terms of age status. (P = 0.116).

Table 2.

The Average Age of the Elderly Participants in the Research

Group		Age				Minimum Age		Maximum Age		P
		Average		Standard deviation
Intervention		68.72		6.35		60		90		0.116*
Control		67.92		6.33		60		80
Total		68.32		6.34		60		90		-

*Mann-Whitney U test

According to Table 3, the Wilcoxon rank sum test, the life expectancy of the elderly increased significantly after the laughter yoga program compared to before the intervention (P < 0.001). However, the life expectancy of the elderly in the control group did not change (P = 0.794).

Table 3.

Comparison of Mean and Standard Deviation (SD) of Happiness and Life Expectancy Before and After Intervention Among Elderly Individuals in the Intervention and Control Groups

Group				Happiness				P		Life Expectancy				P
				Mean		SD				Mean		SD
Intervention		Before		63.18		8.88		<0.001*,a,b		65.86		7.64		<0.001*,a,b
		After		69.86		10.91				69.42		8.32
Control		Before		63.29		7.56		0.155*,c,d		65.70		8.58		0.794*,c,d
		After		65.77		8.99				65.77		8.99
Wilcoxon rank sum test*     a: Eta squared (η2)=12.041     b: Effect size-based paired t test=0.67     c: Eta squared (η2)=12.05     d: Effect size-based paired t test=0.148										Wilcoxon rank sum test*     a: Eta squared (η2)=12.041     b: Effect size-based paired t test=0.67     c: Eta squared (η2) =12.05     d: Effect size-based paired t test=0.148

According to the Wilcoxon rank sum test, the happiness of the elderly increased significantly after the laughter yoga program compared to before the intervention (P < 0.001), but the happiness of the elderly did not change in the control group (P = 0.155).

Discussion

The results of the current study demonstrated that laughter yoga, as one of the recognized methods of laughter therapy, leads to a significant increase in life expectancy and happiness among retired elderly individuals. Retirees who participated in 8 sessions of 45 minutes each of laughter yoga showed a meaningful improvement in their happiness and hope compared to those who continued with their daily routines.

In a cross-sectional study, Sadat Hoseini and colleagues (2018) concluded that happiness and hope increase the quality of care and the quality of care also affects mental health. This study was different from the present study in terms of the type of study, the type and number of samples, and the implementation method, but it was similar to the present study in terms of variables (happiness and hope).[29]

In a semiexperimental study conducted by Ji-Soo Lee and colleagues (2020), it was concluded that laughter therapy effectively reduces job-related stress and enhances mental well-being and happiness. However, the methods of implementation, measurement tools, and samples in their study differed from those in the present study.[17]

In a systematic review by Kuru Alici and colleagues (2020), after analyzing 7 experimental studies and randomized controlled trials, it was stated that laughter yoga has positive effects on the physical performance of elderly individuals, including blood pressure, cortisol levels, sleep quality, and psychosocial well-being, such as life satisfaction, quality of life, loneliness, death anxiety, depression, mood, and happiness. They recommended laughter yoga as a cost-effective method without any undesirable effects for enhancing the health of elderly individuals.[21]

In a quasi-experimental study, Papeli Meibodi et al. (2021)[30] concluded that positive psychotherapy has an effect on increasing happiness. This study was different from the present study in terms of the type of study, the type and number of samples, the inclusion criteria, and the implementation method, but it was similar to the present study in terms of its methodology.

The current study introduced laughter yoga as a method to improve happiness. Happiness is recognized as a significant factor in the well-being of elderly individuals, particularly in terms of psychological well-being. Researchers have explored various strategies to enhance this aspect, including art and painting,[31] piano art,[32] physical activities,[33] and reminiscence therapy.[34] Considering the results of the current study, laughter yoga can be added to these approaches.

Another significant finding of this study was the improvement in life expectancy among retired elderly individuals after participating in laughter yoga sessions. Given that laughter has many effects on the physical and mental mechanisms of a person, the release of emotions causes a person to feel much stress reduction and relaxation after laughing for a while. In this way, creating positive thoughts and emotions in a person increases hope.[35]

Although an exhaustive search did not yield a specific study on the impact of laughter yoga on the hope of elderly individuals, Öztürk and colleagues (2023) reported that laughter yoga reduces feelings of loneliness, increases flexibility, and enhances the quality of life in older adults. They suggested incorporating laughter yoga programs into activities in elderly care homes.[36] The novelty of this study lies in its investigation into the effects of laughter yoga on happiness and life expectancy within the elderly population. This research explores how the practice of laughter yoga, known for its significant physical and psychological impacts, can influence the well-being and longevity of elderly individuals. By focusing on the correlation between laughter yoga and both happiness and life expectancy in this specific demographic, the study sheds light on potential holistic approaches to improving the quality of life for older adults.

Limitations and recommendation

The participants in this study were exclusively drawn from the retiree community, and the short duration of the intervention was due to time constraints inherent in student research, including limitations in this study.

It is worth noting that this research focused on mentally healthy elderly individuals; therefore, generalization of the results should be approached with caution.

Conclusion

The study’s results highlight the substantial increase in happiness and hope among retired elderly individuals who participated in laughter yoga sessions. This contrasted starkly with the minimal changes observed in the control group. These outcomes underscore the potential for integrating laughter yoga interventions into health policies targeting elderly well-being. The study suggests that by emphasizing factors that impact happiness and hope, nursing managers and nurses can enhance interventions for elderly care. Future research should explore laughter yoga’s role in diminishing psychological and physiological risks in retired individuals, along with its effects on happiness and hope among the working elderly. These findings offer insights for shaping health policies that prioritize comprehensive elderly care strategies.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.