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The effect of online laughter therapy on depression, anxiety, stress, and loneliness among nursing students during the Covid-19 pandemic

Published:September 15, 2022DOI:https://doi.org/10.1016/j.apnu.2022.09.006

      Highlights

      • Laughter therapy is a non-invasive and non-pharmacological complementary medicine technique.
      • This is the first study in which laughter yoga with a pretest-posttest control group was conducted online.
      • Laughter therapy can be applied online for students' mental health.
      • Laughter therapy reduced depression during the Covid-19 pandemic.
      • Laughter therapy can be integrated into nursing education.

      Abstract

      Background

      Nursing students experienced mental symptoms when they switched to distance education due to the pandemic.

      Aims

      This study was conducted to evaluate the effects of online laughter therapy sessions on depression, anxiety, stress, and loneliness levels in first-year nursing students.

      Methods

      In this randomized controlled trial, 61 healthy nursing students were randomly assigned to intervention (n = 32) and control groups (n = 29). The intervention group received online laughter therapy twice weekly for four weeks. The control group received no intervention. The data were collected using a demographic questionnaire, the Depression Anxiety Stress Scale, and the De Jong Gierveld Loneliness Scale at the study initiation and week four in both groups.

      Results

      There was no difference between the mean scores of the groups in the pre-test (p > 0.05). There was a statistically significant difference between groups in terms of depression after online laughter therapy sessions (p < 0.05), but there was no significant difference between anxiety, stress, and loneliness levels (p > 0.05).

      Conclusions

      Online laughter therapy sessions significantly reduced depression but had no effect on anxiety, stress, and loneliness. During the COVID-19 pandemic, online laughter therapy can be organized to reduce depression levels.

      Keywords

      Introduction

      The frequency of mental health problems in the university population is higher than in the society in the pre-pandemic period, and depression, anxiety, and stress are the most common mental symptoms (
      • Auerbach R.P.
      • Mortier P.
      • Bruffaerts R.
      • Alonso J.
      • Benjet C.
      • Cuijpers P.
      • Murray E.
      WHO world mental health surveys international college student project: Prevalence and distribution of mental disorders.
      ;
      • Özel Y.
      • Türkleş S.
      • Erdoğan S.
      Investigation of mental state in university students.
      ;
      • Zeng Y.
      • Wang G.
      • Xie C.
      • Hu X.
      • Reinhardt J.D.
      Prevalence and correlates of depression, anxiety and symptoms of stress in vocational college nursing students from Sichuan, China: A cross-sectional study.
      ). The reason for this is that the university-age is a critical and new turning point in terms of both developmental and environmental changes (
      • Fruehwirth J.C.
      • Biswas S.
      • Perreira K.M.
      The Covid-19 pandemic and mental health of first-year college students: Examining the effect of Covid-19 stressors using longitudinal data.
      ). University students experience the transition period from adolescence to adulthood, such as finding their own identity, adapting to the values and rules of society, and reaching physical and social maturity (
      • Taghizadeh Moghaddam H.
      • Bahreini A.
      • Ajilian Abbasi M.
      • Fazli F.
      • Saeidi M.
      Adolescence health: The needs, problems and attention.
      ). It has been reported that university students have higher depression, anxiety, and stress scores in the first year (
      • Xinqiao L.
      • Siqing P.
      • Wenjuan G.
      Changes in undergraduate students’ psychological well-being as they experience University life.
      ). In the first year of university, new experiences such as adapting to the new social environment, living away from family, getting used to a dormitory, getting used to another city, and demanding economic independence can be a factor that creates stress for students.
      The World Health Organization predicts that mental illnesses such as depression, anxiety, stress, and loneliness will increase in society due to the impact of the Covid-19 pandemic (). It has been reported that nursing students have experienced psychological problems such as depression, anxiety, and stress due to quarantine and social isolation measures during the pandemic process (
      • Akdeniz G.
      • Kavakci M.
      • Gozugok M.
      • Yalcinkaya S.
      • Kucukay A.
      • Sahutogullari B.
      A survey of attitudes, anxiety status, and protective behaviors of the university students during the COVID-19 outbreak in Turkey.
      ;
      • Kalkan Uğurlu Y.
      • Mataracı Değirmenci D.
      • Durgun H.
      • Gök Uğur H.
      The examination of the relationship between nursing students' depression, anxiety and stress levels and restrictive, emotional, and external eating behaviors in COVID-19 social isolation process.
      ;
      • Yanik D.
      • Yeşilçinar I.
      COVID-19 pandemi sürecinde yaşanan sosyal izolasyonun hemşirelik öğrencileri üzerindeki etkileri: Niteliksel araştırma.
      ). Starting to the nursing profession, which carries many health risks, especially the risk of contracting infectious diseases, may have negatively affected the depression, anxiety, and stress levels of students (
      • Arabacı L.B.
      • Korhan E.A.
      • Tokem Y.
      • Torun R.
      Nursing students’ anxiety and stress levels and contributed factors before-during and after first clinical placement.
      ). In addition, it is stated that problems such as lifestyle changes, social isolation, the anxiety of disease transmission, and adaptation to distance education during the pandemic process negatively affect the mental health of students (
      • Akdeniz G.
      • Kavakci M.
      • Gozugok M.
      • Yalcinkaya S.
      • Kucukay A.
      • Sahutogullari B.
      A survey of attitudes, anxiety status, and protective behaviors of the university students during the COVID-19 outbreak in Turkey.
      ;
      • Fruehwirth J.C.
      • Biswas S.
      • Perreira K.M.
      The Covid-19 pandemic and mental health of first-year college students: Examining the effect of Covid-19 stressors using longitudinal data.
      ;
      • Wang X.
      • Hegde S.
      • Son C.
      • Keller B.
      • Smith A.
      • Sasangohar F.
      Investigating mental health of US college students during the COVID-19 pandemic: Cross-sectional survey study.
      ).2
      Loneliness is a negative subjective experience and an important public health problem due to the inadequacy of social relations and interactions (
      • Bu F.
      • Steptoe A.
      • Fancourt D.
      Who is lonely in lockdown? Cross-cohort analyses of predictors of loneliness before and during the COVID-19 pandemic.
      ). It is claimed that measures such as the “Stay at Home” call, curfews, temporary closure of schools, and social distance implemented in the COVID-19 pandemic restrictions adversely affect the mental health of the society and cause a feeling of loneliness (
      • Usher K.
      • Bhullar N.
      • Jackson D.
      Life in the pandemic: Social isolation and mental health.
      ). It is emphasized that with these measures taken to prevent the spread of the contagious disease, the feeling of loneliness intensifies as a result of the inability of people to communicate face to face with their friends, neighbors, and relatives (
      • Rossi A.
      • Panzeri A.
      • Pietrabissa G.
      • Manzoni G.M.
      • Castelnuovo G.
      • Mannarini S.
      The anxiety-buffer hypothesis in the time of COVID-19: When self-esteem protects from the impact of loneliness and fear on anxiety and depression.
      ).
      Laughter therapy is a complementary medicine technique using breathing techniques and laughter (
      • Kataria M.
      Laugh for no reason.
      ). It is stated that laughter therapy reduces levels of stress, depression, anxiety, and loneliness (
      • Alici N.K.
      • Bahceli P.Z.
      Effects of laughter therapy on life satisfaction and loneliness in older adults living in nursing homes in Turkey: A parallel-group randomized controlled trial.
      ;
      • Kataria M.
      Laugh for no reason.
      ;
      • Kaur L.
      • Walia I.
      Effect of laughter therapy on level of stress: A study among nursing students.
      ;
      • Kim S.H.
      • Kim Y.H.
      • Kim H.J.
      Laughter and stress relief in cancer patients: a pilot study.
      ;
      • Shahidi M.
      • Mojtahed A.
      • Modabbernıa A.
      • Mojtahed M.
      • Shafıabad A.
      • Delavar A.
      • Honari H.
      Laughter yoga versus group exercise program in elderly depressed women: A randomized controlled trial.
      ;
      • Yazdani M.
      • Esmaeilzadeh M.
      • Pahlavanzadeh S.
      • Khaledi F.
      The effect of laughter yoga on general health among nursing students.
      ). In a study of nursing freshmen before the COVID-19 pandemic, it was reported that face-to-face laughter therapy significantly reduced salivary cortisol, a biomarker of stress, as well as depression and anxiety (
      • Ozturk F.O.
      • Tezel A.
      Effect of laughter yoga on mental symptoms and salivary cortisol levels in first-year nursing students: A randomized controlled trial.
      ). It is recommended to conduct online activities to improve the mental state of students and provide support during the pandemic process (
      • Wang X.
      • Hegde S.
      • Son C.
      • Keller B.
      • Smith A.
      • Sasangohar F.
      Investigating mental health of US college students during the COVID-19 pandemic: Cross-sectional survey study.
      ). Although laughter therapy is usually done face-to-face, it has been observed that it can also be done remotely with online sessions on social media during the pandemic process. This is the first study to use online laughter therapy to reduce students' mental problems. This study was conducted to evaluate the effects of online laughter therapy sessions on depression, anxiety, stress, and loneliness levels in first-year nursing students.
      The hypotheses are as follows:

      H.1: Online laughter therapy has an effect on reducing the level of depression.

      H.2: Online laughter therapy has an effect on reducing the level of anxiety.

      H.3: Online laughter therapy has an effect on reducing the level of stress.

      H.4: Online laughter therapy has an effect on reducing loneliness.

      Materials and methods

      Design

      The present study was designed as a parallel, two-armed, randomized controlled trial. This study was conducted on first-year nursing students at a state university nursing faculty in Ankara, Turkey between May 01 and 31, 2021. Participants were randomized to intervention (online laughter therapy) and control group.

      Participants

      Participants eligible for inclusion criteria in this study were: (a) being a first-year nursing student, (b) being aged above 18 years old, (c) feeling in good health to go about their daily lives, performing normal school lives.
      Exclusion criteria in this study included having any condition where laughter therapy should be avoided (having had abdominal surgery in the last three months, taking regular medications, epilepsy, uncontrollable hypertension, glaucoma, hernia) (
      • Kataria M.
      Laugh for no reason.
      ).
      The reason of choosing those exclusion criteria was to avoid unintended side effects of laughing. People might over-strain themselves while laughing and that can cause a rise in intra-abdominal pressure (
      • Kataria M.
      Laugh for no reason.
      ).

      Sample size and sampling

      The study population comprised 213 first-year nursing students at the Ankara University Nursing Faculty. The sample size was calculated with the use of software (G-Power) considering the study design, and the main statistical test of the study. In the power analysis, the required sample size was calculated as 26, with an effect size of 0.80, a power of 0.80, and a margin of error of 0.05. Thus, the sample of the research was composed of 70 students, considering the dropout rate (Fig. 1).
      For sampling, a screening tool was applied online to 213 first-year students for the inclusion criteria, and 194 students who met the inclusion criteria were included in the study. To form the intervention group and control group, a random selection was made from a real random number selector website, www.random.org, among 194 students who met the inclusion criteria. There were 35 students in the intervention group and 35 students in the control group. However, three students from the intervention group did not attend the sessions and six students from the control group did not complete the post-test. As a result, this study was completed with a total of 61 students, 32 from the intervention group and 29 from the control group (Fig. 1). In this study, only the second author was blinded to the group allocation.

      Procedure

      The e-mail addresses and phone numbers of the students were obtained from the student affairs unit of the University, and the intervention and control groups were reached. An online information meeting was held with the intervention and control group students one week before the start of the laughter therapy sessions.
      • Pre-test: Before the online laughter therapy sessions started, the link to the online questionnaire was shared with the intervention and control group students. Students were asked to fill out the questionnaire.
      • Intervention (online laughter therapy sessions): A person who has been trained in laughter therapy and applies this intervention to a group is called a laughter therapy leader. The corresponding author is the leader of laughter therapy, and she had students do the online laughter therapy sessions herself. The intervention group took eight online sessions of laughter therapy, that is two sessions per week for four weeks. The number of laughter therapy sessions in this study was determined in line with the studies in the literature (
        • Ozturk F.O.
        • Tezel A.
        Effect of laughter yoga on mental symptoms and salivary cortisol levels in first-year nursing students: A randomized controlled trial.
        ;
        • Yazdani M.
        • Esmaeilzadeh M.
        • Pahlavanzadeh S.
        • Khaledi F.
        The effect of laughter yoga on general health among nursing students.
        ). Each laughter therapy session lasted about 40–45 min. A laughter therapy session consists of clapping and warming-up exercises, deep breathing exercises, childlike playfulness, and laughter exercises (Fig. 2).
        Fig. 2
        Fig. 2Parts of an online laughter therapy session (
        • Kataria M.
        Laugh for no reason.
        ).
      • Post-test: After all the online laughter therapy sessions were completed, the online questionnaire link was shared with the students in the intervention and control groups and the students were asked to fill in the questionnaire.

      Instruments

      An online questionnaire was prepared via Google Forms, using the questionnaire, DASS-42, and De Jong Gierveld Loneliness Scale to collect data.
      The questionnaire included closed-ended questions related to demographic features (age, gender, residence, marital status, whether there are any health problems, taking regular medications, surgery in the last three months).
      The Depression, Anxiety, and Stress Scale (DASS-42) was developed by
      • Lovibond P.F.
      • Lovibond S.H.
      Depression Anxiety Stress Scales.
      and adapted into Turkish by
      • Bilgel N.
      • Bayram N.
      Turkish version of the depression anxiety stress scale (DASS-42): Psychometric properties.
      . The scale consists of 42 items, 14 of which are depression, 14 are anxiety and 14 are stress. Depression items measure dissatisfaction, helplessness, worthlessness, loss of interest, and low energy level. Anxiety items assess the individual's level of autonomic arousal, situational anxiety, subjective anxiety, and muscle response. Stress items measure persistent tension, irritability, and a tendency to overreact to stressful events. The scale is a four-point Likert-type scale, and the items are evaluated between 0 and 3 (0 = not at all suitable for me, 1 = somewhat appropriate for me, 2 = usually suitable for me, 3 = completely suitable for me). The total scores of the scale range from 0 to 42 for each sub-dimension. Scores considered in the normal range are 0–9 for depression, 0–7 for anxiety, and 0–14 for stress. Scores above these ranges indicate the degree of the problem from mild to extreme (
      • Bilgel N.
      • Bayram N.
      Turkish version of the depression anxiety stress scale (DASS-42): Psychometric properties.
      ). The Cronbach's alpha reliability coefficients for the depression, anxiety, and stress sub-dimensions of the scale are 0.92, 0.86, and 0.88, respectively. In this study, the Cronbach's alpha reliability coefficient for the depression, anxiety, and stress sub-dimensions of the scale were 0.95, 0.88, and 0.92, respectively.
      The De Jong Gierveld Loneliness Scale (DJGLS) was originally developed by
      • De Jong-Gierveld J.
      • Kamphuis F.H.
      The development of a Rasch-type loneliness scale.
      and adapted into Turkish by
      • Çavdar D.
      • Bağcı V.
      • Çorbacı E.C.
      • Sarıtaş S.
      • Taşdelen M.K.
      Adaptation of De Jong Gierveld loneliness scale into Turkish.
      . De Jong Gierveld Loneliness Scale consists of 11 items and two subscales. On the scale, six negatively worded items measure emotional loneliness and five positively phrased items measure social loneliness. The sum of these two subscales constitutes the overall loneliness score. Since the items in the social loneliness dimension contain positive statements, the items are reverse coded. After reverse coding, “not applicable = 0” and “not applicable = 0”; A total of 11 points can be obtained by recoding as “appropriate = 1” and “very suitable = 1”. According to these scores, people can be divided into four groups: not alone (0, 1, 2 points), moderately lonely (range 3 to 8), severely lonely (9, 10 points), and very severely lonely (11 points). In the study of
      • Çavdar D.
      • Bağcı V.
      • Çorbacı E.C.
      • Sarıtaş S.
      • Taşdelen M.K.
      Adaptation of De Jong Gierveld loneliness scale into Turkish.
      , the Cronbach Alpha reliability coefficient of the scale was found to be 0.87. In this study, Cronbach's alpha reliability coefficient for the DJGLS was 0.80.

      Statistical analysis

      The data were analyzed via the Statistical Package for the Social Sciences (SPSS) version 26.0. Demographic characteristics such as gender, marital status, and residence were determined by percentage and frequency. The age of the participants was calculated by analyzing the mean, minimum, and maximum values. The values of skewness and kurtosis were all within the recommended limit of ±2, which indicates the normal distribution of all the constructs of the study (
      • George D.
      • Mallery M.
      SPSS for windows step by step: A simple guide and reference.
      ). Independent sample t-test was used to compare the pretest and posttest scores between the intervention and control groups. Statistical significance level was accepted as p < 0.05.

      Ethical principles

      Permission was obtained from the Koc University nursing school and ethics committee (Date: 25/02/2021, No:2021.072.IRB3.033) for this research. Participants who are willing to participate in the study signed an online consent form to enter the online questionnaire.
      In order to carry out the research, students were asked for their e-mail addresses and mobile phone number. This information was collected only for the purpose of sending information about the online survey and online laughter therapy sessions. Contact information of students was not shared with third parties.

      Results

      The demographic characteristics of the students in the intervention and control groups were similar. The students were all girls, all single, and all stayed in their own homes. The mean age of the students was 19.59 ± 2.31 (min = 18, max = 36).
      The outcome variables of depression, anxiety, and stress were measured using data from the DASS-42, with means for each of the measures at pre-test and post-test by group shown in Table 1. At baseline (i.e., before the intervention group had undergone the online laughter therapy intervention), no significant difference was found between the intervention and control groups in terms of mean DASS-42 total score (t = 0.875, p = 0.385). After online laughter therapy intervention, there was a statistically significant difference between mean DASS-42 total scores of the intervention and control groups (t = −2.268, p = 0.027). While there were no statistical difference between the groups in terms of depression (t = 0.854, p = 0.960), anxiety (t = 1.563, p = 0.123), and stress (t = 1.128, p = 0.264) subscale scores before laughter therapy, it was found that the mean scores of depression subscale in the intervention group after online laughter therapy were lower than those before the intervention and also the results of the independent t-test showed a significantly difference between intervention and control groups (t = −2.997, p = 0.003). However, there was no significant difference in anxiety and stress subscale scores between intervention and control groups (p > 0.05) (Table 1).
      Table 1Comparison of Depression Anxiety Stress Scale mean scores before and after the intervention according to groups.
      DASS-42Intervention (n = 32)Control (n = 29)tp
      Mean (SD)Mean (SD)
      DASS-42 (pre-test)44.65 (22.70)39.44 (23.78)0.8750.385
      DASS-42 (post-test)27.78 (17.95)39.65 (22.84)−2.2680.027
      SubscalesDepression subscale (pre-test)13.93 (9.67)14.06 (10.74)0.8540.960
      Depression subscale (post-test)7.03 (6.11)13.44 (9.94)−2.9970.003
      Anxiety subscale (pre-test)11.90 (7.31)9.13 (6.42)1.5630.123
      Anxiety subscale (post-test)7.90 (6.70)9.51 (6.58)−0.9450.348
      Stress subscale (pre-test)18.81 (8.63)16.24 (9.16)1.1280.264
      Stress subscale (post-test)12.84 (7.31)16.68 (9.13)−1.8240.073
      Independent samples t-test. Bold values indicate a statistically significant difference.
      The outcome variable of loneliness was measured using data from The De Jong Gierveld Loneliness Scale, with means for each of the measures at pre-test and post-test by group shown in Table 2. The results show that there was no statistical difference between the groups in terms of loneliness before and after online laughter therapy sessions (p > 0.05) (Table 2).
      Table 2Comparison of De Jong Gierveld Loneliness Scale mean scores before and after the intervention according to groups.
      DJGLSIntervention (n = 32)Control (n = 29)t
      Independent samples t-test.
      p
      Mean (SD)Mean (SD)
      DJGLS (pre-test)3.75 (3.25)3.93 (2.71)0.1770.815
      DJGLS (post-test)2.84 (2.42)3.72 (3.08)−1.2460.218
      SubscalesSocial Loneliness (pre-test)6.65 (2.90)5.31 (3.32)1.6870.097
      Social Loneliness (post-test)1.15 (1.34)1.58 (1.65)−1.1160.269
      Emotional Loneliness (pre-test)2.37 (1.77)2.34 (1.71)0.0670.947
      Emotional Loneliness (post-test)1.68 (1.49)2.13 (1.82)−1.0590.294
      a Independent samples t-test.

      Discussion

      This study was conducted to examine the effects of online laughter therapy sessions on depression, anxiety, stress, and loneliness levels in first-year nursing students. This study is the first in the literature to show that laughter therapy can be done online during the COVID-19 pandemic and is effective in reducing depression. In addition, this study was carried out in May, when full closure measures were taken, and the curfew and distance education continued in Turkey. It is thought that this study will be an important basis for future online laughter therapy studies. The findings of the study were discussed with previous studies since there was no study examining the effects of laughter therapy on students' depression, anxiety, stress, and loneliness levels during the pandemic process.
      Depression affects >264 million people worldwide, and it is predicted that its prevalence and degree may increase with the effect of the pandemic. It is estimated that 76–85 % of people in low- and middle-income countries do not have access to treatment for depression (; ). In the studies, it is stated that nursing students experience depression at various frequencies and degrees during the pandemic (
      • Kalkan Uğurlu Y.
      • Mataracı Değirmenci D.
      • Durgun H.
      • Gök Uğur H.
      The examination of the relationship between nursing students' depression, anxiety and stress levels and restrictive, emotional, and external eating behaviors in COVID-19 social isolation process.
      ;
      • Wang X.
      • Hegde S.
      • Son C.
      • Keller B.
      • Smith A.
      • Sasangohar F.
      Investigating mental health of US college students during the COVID-19 pandemic: Cross-sectional survey study.
      ;
      • Islam M.A.
      • Barna S.D.
      • Raihan H.
      • Khan M.N.A.
      • Hossain M.T.
      Depression and anxiety among university students during the COVID-19 pandemic in Bangladesh: A web-based cross-sectional survey.
      ). Laughter therapy is an effective complementary medicine technique for reducing depression (
      • Kataria M.
      Laugh for no reason.
      ;
      • Shahidi M.
      • Mojtahed A.
      • Modabbernıa A.
      • Mojtahed M.
      • Shafıabad A.
      • Delavar A.
      • Honari H.
      Laughter yoga versus group exercise program in elderly depressed women: A randomized controlled trial.
      ). In this study, it was found that online laughter therapy sessions significantly reduced students' depression. According to this result, H.1 hypothesis was accepted. The findings of our study are similar to the studies in which face-to-face laughter therapy was performed on nursing students before the pandemic (
      • Ozturk F.O.
      • Tezel A.
      Effect of laughter yoga on mental symptoms and salivary cortisol levels in first-year nursing students: A randomized controlled trial.
      ;
      • Yazdani M.
      • Esmaeilzadeh M.
      • Pahlavanzadeh S.
      • Khaledi F.
      The effect of laughter yoga on general health among nursing students.
      ). In a study of elderly women with depression in Iran, laughter therapy was found to be effective in the improvement of depression (
      • Shahidi M.
      • Mojtahed A.
      • Modabbernıa A.
      • Mojtahed M.
      • Shafıabad A.
      • Delavar A.
      • Honari H.
      Laughter yoga versus group exercise program in elderly depressed women: A randomized controlled trial.
      ). In this study, the significant decrease in the level of depression may be related to the introduction of more oxygen into the body with deep breathing exercises, increased energy level with warm-up exercises, various physiological changes (increase in beta-endorphin level and decrease in cortisol) in the body with childlike playfulness and laughter exercises. More, it is thought that during the COVID-19 pandemic restrictions, by participating in an online activity that provides group interaction such as laughter therapy in a socially isolated environment at home, they interact with their friends so that there could be an improvement in depression.
      It is stated that anxiety and stress are commonly seen in nursing students during the COVID-19 pandemic (
      • Islam M.A.
      • Barna S.D.
      • Raihan H.
      • Khan M.N.A.
      • Hossain M.T.
      Depression and anxiety among university students during the COVID-19 pandemic in Bangladesh: A web-based cross-sectional survey.
      ;
      • Kalkan Uğurlu Y.
      • Mataracı Değirmenci D.
      • Durgun H.
      • Gök Uğur H.
      The examination of the relationship between nursing students' depression, anxiety and stress levels and restrictive, emotional, and external eating behaviors in COVID-19 social isolation process.
      ;
      • Naser A.Y.
      • Dahmash E.Z.
      • Al-Rousan R.
      • Alwafi H.
      • Alrawashdeh H.M.
      • Ghoul I.
      • Alyami H.S.
      Mental health status of the general population, healthcare professionals, and university students during 2019 coronavirus disease outbreak in Jordan: A cross-sectional study.
      ). Laughter therapy is an intervention that has positive effects on anxiety and stress levels. In this study, although there was a significant decrease in the anxiety and stress levels of the students in the intervention group with the online laughter therapy, this decrease did not reach the level of significance in the intergroup analysis. According to this result, hypotheses H.2 and H.3 were rejected. The lack of a significant decrease in anxiety and stress levels might be associated with the students having a concern about disease transmission due to the ongoing pandemic process for more than a year, the distance education process, and the inability to practice face-to-face even though they are receiving training in a profession that requires practice/skill. All these concerns might be settled and chronic (
      • Yanik D.
      • Yeşilçinar I.
      COVID-19 pandemi sürecinde yaşanan sosyal izolasyonun hemşirelik öğrencileri üzerindeki etkileri: Niteliksel araştırma.
      ). In addition, students might still feel intense and constant sources of anxiety and stress such as the ongoing pandemic process, the change in daily lifestyle with the restrictions made during the pandemic process, the desire to return to the normal lifestyle before the pandemic, economic difficulties, false information circulating about the disease, and lack of social activity.
      In studies conducted with nursing students during the pandemic, it has been reported that most of the students socially isolate themselves to protect themselves from infectious disease and experience a severe sense of loneliness (
      • Akdeniz G.
      • Kavakci M.
      • Gozugok M.
      • Yalcinkaya S.
      • Kucukay A.
      • Sahutogullari B.
      A survey of attitudes, anxiety status, and protective behaviors of the university students during the COVID-19 outbreak in Turkey.
      ;
      • Yanik D.
      • Yeşilçinar I.
      COVID-19 pandemi sürecinde yaşanan sosyal izolasyonun hemşirelik öğrencileri üzerindeki etkileri: Niteliksel araştırma.
      ). Laughter therapy is reported to reduce loneliness (
      • Alici N.K.
      • Bahceli P.Z.
      Effects of laughter therapy on life satisfaction and loneliness in older adults living in nursing homes in Turkey: A parallel-group randomized controlled trial.
      ;
      • Sabori Z.
      • Khayatan F.
      • Ghanavat M.
      The effect of Kataria Laughter Training (Laughter Yoga) on hopelessness and loneliness in children with leukemia.
      ). In this study, a decrease was observed in the loneliness level of the intervention and control groups, but this decrease did not reach the level of significance between the groups. Thus, H.4 hypothesis was rejected. The decrease in the level of loneliness in both groups may be related to the gradual reduction of restrictions and the gradual transition to normalization in Turkey after May 17th, 2021. It is thought that with the reduction of restrictions, the students may have met their friends and relatives and reduced their loneliness levels.

      Strengths and limitations

      In this study, delivering an online intervention can be considered both a strength and a limitation. This study shows that online intervention attempts can be made to improve mental health even in an environment where face-to-face interventions are not possible, curfews are applied, measures to combat pandemics are taken, which can be considered the strength of this study. On the contrary, implementing laughter therapy online is also a limitation, because there is more face-to-face interaction in nature of laughter therapy, so laughter therapy sessions are held more enthusiastically. Also, a small number of attendees rarely experienced technical connectivity issues and joined a few sessions late, so technical issues may be a limitation. The results of this study can only be generalized to the study sample.

      Conclusions

      Online laughter therapy was found to be effective in reducing depression among first-year nursing students but was not found to be effective for anxiety, stress, and loneliness. It is recommended to apply for a laughter therapy program online and integrate it into the nursing education process to reduce the depression level of university students during the quarantine process in the restrictions during the COVID-19 pandemic process and potential pandemic restrictions that may occur in the following years.

      Declaration of competing interest

      The authors state that there is no conflict of interest.

      Acknowledgments

      The authors would like to thank all the participants of this research.

      Funding

      None.

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