The Effect of Laughter Therapy on Self-Esteem and Quality of Life in Patients With Stoma
Condition: Stoma Colostomy; Stoma Ileostomy
Study type: Interventional

Summary: 
      Stoma is a surgical intervention to ensure that body wastes are removed differently from the
      normal physiological opening. The stoma patient has to cope with complex emotional, social
      and physical problems associated with this change. Physical health problems (such as stoma),
      change in body image and negative emotions affect self-esteem and quality of life. Laughing
      provides mental and physical relaxation with the release of endorphins. Therefore, laughter
      therapy has an important contribution to increase the well-being of patients.This study was
      planned as a randomized controlled experimental study to evaluate the effect of laughter
      therapy on self-esteem and quality of life in patients with stoma.
    

Detailed description: 
      The total number of individuals with a stoma is thought to be between 725,000 and 1 million
      (Faqs, 2020). Stoma can cause many physical, social, cognitive and emotional problems in an
      individual's life. These problems can negatively affect the quality of life of patients with
      stoma (Karadag et al. 2011).

      Self-esteem is an individual's positive or negative evaluation of himself/herself (Ayaz,
      2008). This evaluation stems not from the individual's need to feel perfect, but from the
      need to accept himself and be accepted by others. Physical health problems, changes in body
      image and negative emotions affect self-esteem.

      Laughter is generally considered to be a visual expression of happiness or a feeling of joy,
      and it occurs with stimuli such as hearing a joke or being tickled. Neurophysiology has shown
      that laughter is associated with the activation of the lower middle frontal lobe cortex,
      which produces endorphins (Satish 2012). Laughing provides mental and physical relaxation
      with the release of endorphins (Farifteh et al. 2014).

      Psychological benefits of laughing;

        -  Decreases symptoms of depression, anxiety and stress level.

        -  Increases self-confidence, hope, energy and strength.

        -  Increases memory, creative thinking and problem solving ability.

        -  Increases interpersonal relationship and social interaction.

        -  Collaboration enhances group identity and solidarity.

        -  Strengthens the relationship between the health personnel and the patient.

        -  Provides psychological well-being.

        -  Increases joy and it's mostly contagious (Ripoll and Casado 2010).

      It was found to increase optimism and self-esteem in a study of menopausal women (Cha et al.
      2013). As a result of Cho and Oh's (2011) study, it was stated that laughter therapy can be
      an effective nursing intervention applied to increase the quality of life and recovery in
      individuals with breast cancer. Although laughing therapy was applied in different patient
      groups and its positive effects were proven, a study on patients who had undergone surgical
      intervention could not be reached. This study was planned as a randomized controlled
      experimental study to evaluate the effect of laughter therapy on self-esteem and quality of
      life in patients with stoma.

      Study Population and Sampling: In the study, in calculating the sample size to be used to
      measure the effect of laughter therapy on self-esteem and quality of life in patients with
      stoma, the d value was determined as d = 0.66, α = 0.05 (margin of error), 1-β = 0.95 (power)
      in the light of academic studies. With the help of the G-power (version 3.1) package program,
      the number of samples to be included in the study was calculated as 68 people (Yoshikawa et
      al. 2019). Considering a possible 10% loss in the study, it was decided to include a total of
      74 participants, 37 participants in each group.

      Randomization: The research was conducted as an open-label, blinded, randomized and
      controlled experimental study. A simple computer-assisted randomization method was used to
      distribute the groups homogeneously.

      For this purpose, 74 sets were created using the functions available on the
      "https://www.random.org/integer-sets" website. In each of these sets, there were a total of 8
      participants: 4 participants from the experimental group and 4 participants from the control
      group. The 74 sets created as the next process were shown with 1 number each. "RANDBETWEEN"
      function was used in Excel. Thus, 10 numbers between 1 and 74 were generated and 10 sets to
      be used in randomization were randomly determined. 72 patients were randomized in the first 9
      sets and 2 patients in the 10th set.

      Data Collection Method: Data will be collected by the researcher by calling the participants
      by phone. WhatsApp video chat method will be applied for the individuals in the experimental
      group.

      Data Collection Tools:

        1. Personal information form (sociodemographic characteristics): With this form, which was
           prepared by the researcher in line with the literature, it is planned to obtain
           information about the sociodemographic characteristics (gender, age, occupation, etc.)
           and stoma (diagnosis, stoma type, etc.) of the participants.

        2. Rosenberg Self-Esteem Scale: Rosenberg Self-Esteem Scale was developed by Morris
           Rosenberg in 1965. In 1985, The validity and reliability study of the scale, which was
           translated into Turkish by Dr. Füsun Çetin Çuhadaroğlu, was also conducted by
           Çuhadaroğlu (Çuhadaroğlu, 1986). This scale consists of 10 questions that measure
           self-esteem. IThe highest score that can be obtained from the scale is 6.

        3. City of Hope Quality of Life Ostomy: The scale was developed by the Hope Center Pain and
           Palliative Care Research Center in 1995 to evaluate the quality of life of cancer
           patients. It is a 43-item Likert-type scale revised for individuals with ostomy. The
           Turkish adaptation and validity-reliability study of the scale was carried out by Erol
           and Vural (2012).

      Intervention:

      The first component of intervention is the laughter therapy that is a combination of warm up
      exercise, deep breathing exercises, childlike playfulness and laughter exercises.

      Hand clapping and warm-up exercises: Hands are kept parallel to each other and clapped so
      that the fingertips touch each other. In order to synchronize the group and increase the
      energy level of the group, rhythms such as ho-ho, ha-ha-ha are usually added to the clapping.

      Deep breathing exercises: Deep breathing exercises are exercises for filling and emptying the
      lungs, providing physical and mental relaxation. It is applied by breathing through the nose
      and exhaling slowly through the mouth.

      Childlike acting: One of the purposes of the laughing exercises is that childlike acting
      comes to life in the mind and helps to laugh. During this exercise, songs can be sung, games
      can be played, and laughing can be helped with music.

      Laughter exercises: yogic laugh exercises (Lion laugh), cheerful laugh exercises (milkshake,
      hot soup laugh) and physical laughter exercises.

      Participants will do laughter therapy with whatsapp group call. It is important for
      participants to share their images and voices in order to make eye contact and hear the
      sounds of laughter. Each group will consist of at least 5 people. Each session of laughter
      therapy will be offered one a weekly and 30-40 minutes each time.

      Experimental Group

        -  After obtaining permission from the participants, patients will be called by phone and
           questions will be asked about Rosenberg Self-Esteem Scale, sociodemographic
           characteristics, City of Hope Quality of Life Ostomy.

        -  Participants in this group will receive a 4 week of laughter therapy. Laughter therapy
           will be conducted on whatsapp.

        -  After laughter therapy (after 1 month): Patients will be called again by phone to ask
           questions about the Rosenberg Self-Esteem Scale and City of Hope Quality of Life Ostomy.

        -  After 3 month: Patients will be called again by phone to ask questions about the
           Rosenberg Self-Esteem Scale and City of Hope Quality of Life Ostomy.

      Control Group

        -  After obtaining permission from the participants, patients will be called by phone and
           questions will be asked about Rosenberg Self-Esteem Scale, sociodemographic
           characteristics, City of Hope Quality of Life Ostomy.

        -  After 2 weeks: Patients will be called by phone and asked if they have any complaints
           about their disease.

        -  After 1 month: Patients will be called again by phone to ask questions about the
           Rosenberg Self-Esteem Scale and City of Hope Quality of Life Ostomy.

        -  After 3 month: Patients will be called again by phone to ask questions about the
           Rosenberg Self-Esteem Scale and City of Hope Quality of Life Ostomy.
    

Intervention name(s): Laughter Therapy
Intervention type(s): Behavioral
Intervention description(s): The first component of intervention is the laughter therapy that is a combination of warm up exercise, deep breathing exercises, childlike playfulness and laughter exercises. Participants will do laughter therapy with whatsapp group call. Each group will consist of at least 5 people. Each session of laughter therapy will be offered one a weekly and 30-40 minutes each time.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Randomized controlled experimental design
Masking: None (Open Label)
Primary purpose: Health Services Research
Keywords: Laughter Therapy; Quality of Life; Self Esteem; Stoma