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Effectiveness of Laughter Yoga on Stress in Patients with Cancer in a Selected Hospital
*Corresponding author: Jubee Joseph, Department of Medical Surgical Nursing, Father Muller College of Nursing, Mangaluru, Karnataka, India. jubeejoseph@fathermuller.in
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Received: ,
Accepted: ,
How to cite this article: Abraham A, Joseph J, Varughese S. Effectiveness of Laughter Yoga on Stress in Patients with Cancer in a Selected Hospital. Indian J Palliat Care. 2026;32:318-27. doi: 10.25259/IJPC_403_2025
Abstract
Objectives:
Cancer is a life-changing diagnosis that can cause a lot of emotional pain for both patients and their families. Alongside medical treatments, it is really important to have supportive methods in place that can help ease stress and improve overall well-being. This study aimed to assess the effectiveness of Laughter Yoga in reducing perceived stress among patients with cancer.
Materials and Methods:
This study employed a time-series, non-randomised control group design with pre-test and post-test measures, conducted within the oncology department of a tertiary care hospital. A total of 60 cancer patients were assessed for stress levels using the perceived stress scale (PSS-10). Participants in the intervention group received Laughter Yoga sessions 3 times per week, each lasting 30 min, over a period of 30 days. Post-intervention assessments were conducted on the 10th, 20th and 30th days for both the intervention and control groups through face-to-face interviews.
Results:
The findings revealed that the mean pre-test stress score in the intervention group was 33.6 ± 5.74, which significantly declined to 18.9 ± 7.45 following the intervention. In contrast, the control group maintained a relatively stable stress score of 32.53 ± 5.72. Statistical analysis indicated a significant difference in mean stress levels across various time intervals before and after the intervention (F = 383.4, p = 0.001). Post hoc Bonferroni tests further confirmed significant reductions in stress levels at each follow-up point, day 10, day 20 and day 30 when compared to baseline measurements (p = 0.001).
Conclusion:
The study demonstrated that Laughter Yoga was associated with a significant reduction in perceived stress among individuals with cancer, highlighting the importance of integrating such adjunctive therapies into oncology centres to better support patients experiencing varying levels of psychological distress.
Keywords
Laughter therapy
Laughter yoga
Patients with cancer
Stress
INTRODUCTION
Cancer is a major global health issue, ranking as the second leading cause of death worldwide.[1] Globally, cancer resulted in approximately 20 million new cases and 10 million deaths in 2022. Projections suggest a rise to 29.9 million new cases and 15.3 million cancer deaths per year by 2040.[2] According to the World Health Organization, India is ranked third in the world in terms of the number of cancer cases, following China and the United States in 2022. Breast, lung, colon, rectal and prostate cancers are the most prevalent types. Kerala, Mizoram, Tamil Nadu, Karnataka, Punjab and Assam have the highest overall crude cancer incidence rates.[3]
The diagnosis of cancer is an immensely stressful experience for any individual. Despite advancements in treatment, it remains a serious and potentially life-threatening disease. Patients with cancer face multifaceted challenges, including physical, social, psychological and financial burdens, which can significantly impact their daily lives.[4] Hans Selye, who initially used the term ‘stress’ in a biological context, defined stress as a wide range of strong external stimuli, both physiological and psychological, which can cause a physiological response called the general adaptation syndrome.[5] After being diagnosed with cancer, a lot of people undergo a surge in stress, which can easily develop into a chronic state. As per recent studies, chronic stress could potentially contribute to the growth of cancer. Stress, especially in cases of ovarian, breast and colorectal cancer, may hasten the spread of the illness to the entire body.[6] When the body is experiencing stress, it releases neurotransmitters such as norepinephrine that can stimulate cancer cells. As a result, cancer cells can spread throughout the body. Furthermore, long-term stress can impair the immune system, which is already weakened by cancer treatment. When the immune system is compromised, it becomes more susceptible to illness and infection.[7]
In addition to traditional counselling, stress reduction can be achieved through various activities, including exercise, yoga, acupuncture, massage, mindfulness meditation, art or music therapy, aromatherapy, biofeedback, Tai Chi and social support.[8] Laughter-based interventions have been explored as inexpensive, non-pharmacological approaches to psychological well-being. It is a universal medicine that healthcare professionals and doctors have observed numerous physical advantages over time.[9] Laughter was pioneered by Dr. Madan Kataria, an Indian physician, in India in 1999. It is a unique technique that encourages genuine laughter without relying on humour by combining deep breathing exercises from yoga (pranayama) with simulated laughter. This method enhances energy flow, improves mood and reduces stress. This approach sidesteps the need for humour, making laughter accessible to everyone regardless of their sense of humour.[10] Laughter reduces stress by balancing the sympathetic and parasympathetic systems and releasing endorphins, which bring joy and relief from pain, resulting in mental and physical relaxation.[11]
The literature reveals that stress and cancer are interrelated. An umbrella review examined the relationship between psychological stress, depression or anxiety and cancer outcomes.[12] Findings from systematic reviews suggest a potential association between these factors and increased cancer incidence and mortality in the general population and among cancer patients. These findings emphasise the significance of addressing psychological well-being in cancer care and prevention. The study investigated the link between psychosocial stress and the development of various cancers, including breast, colorectal, lung, prostate and pancreatic cancer.[13] The review analysed 65 studies, highlighting the potential impact of different stress types on cancer development. While the exact mechanisms remain unclear, possible pathways include endocrine and immune system dysregulation. The study emphasises the need for interventions targeting both stress itself and stress-induced lifestyle factors for effective cancer prevention and treatment. Laughter yoga can potentially reduce perceived stress levels and improve positive psychological capital. In 84 lung cancer patients, the intervention group experienced a significant stress reduction and improved psychological well-being compared to the control group. Laughter yoga significantly reduced perceived stress (p < 0.01, d = 1.087) and increased positive psychological capital (p < 0.01, d = 0.692) in 84 lung cancer patients undergoing chemotherapy compared to a control group.[14] Laughter can effectively reduce stress in cancer patients before chemotherapy. This occurs through endorphin release, which promotes relaxation and counteracts the negative impact of chronic stress on immune function. As a natural and side-effect-free approach, laughter enhances patient well-being and can positively impact the treatment process.[11] In the Indian context, there has been a scarcity of studies examining the impact of Laughter Yoga on stress levels among cancer patients. Consequently, the researcher has been motivated to conduct this study to address this gap in the literature and contribute to the enhancement of well-being among individuals diagnosed with cancer.
Hypotheses
The hypotheses framed for this study were tested at the 0.05 level of significance:
H1: There is a significant difference between the mean pre-intervention and mean post-intervention stress in the intervention group.
H2: There is a significant difference in post-intervention stress levels between the intervention and control groups.
H3: There is a significant association between the pre-intervention Stress in patients with cancer and the selected Baseline variable.
MATERIALS AND METHODS
Study design and setting
The study aimed to assess the effectiveness of laughter yoga on stress in patients with cancer in a selected Hospital in Mangaluru. It is a nonrandomised controlled trial (Clinical CTRI/2024/01/061152).
Research population and sample
The research was conducted between 15 October 2023, and 30 June 2024. It was performed in the oncology inpatient department of a tertiary Hospital in Mangaluru. Before data collection, ethical approval was obtained from the Institutional Ethics Committee (FMIEC/CCM/083/2023; Date: February 23, 2023) and the Institutional Review Board. Thereafter, the formal written permission was obtained from the concerned authority. The sample size for the present study was determined using a formula based on the previous study; the mean post-test stress scores were 79.94 ± 12.03 for the intervention group and 66.19 ± 11.17 for the control group.[15] Based on these findings, a sample size of 30 per group was deemed necessary at 90% power and a 5% level of significance. The sample size for this study was determined using the formula [Equation 1].[16]
Equation 1:
σ1 = SD of the outcome variable in group 1
σ2 = SD of the outcome variable in group 2 M1 = Mean of the outcome variable in group 1 M2=Mean of the outcome variable in group 2
Ƶ1-α = level of significance at 0.05
Ƶ1-β = 90% Power = 1.28 (The Z0.90=1.28 from Gaussian table.
The study participants with cancer were informed about the study’s objectives and assured of confidentiality. Informed consent was obtained from each participant before the data collection started. Data were collected through face-to-face interviews with 60 cancer patients who fit specific criteria. The participants, aged between 40 and 80, included both men and women who were undergoing various cancer treatments, such as chemotherapy, radiation, immunotherapy or surgery. They were able to understand Kannada, English or Malayalam and had all given their informed consent to participate in the study. Patients were not included if they were critically ill, unable to take part in Laughter Yoga due to recent oral or surgical procedures, or had been diagnosed with psychiatric disorders or mental challenges. To ensure a proper study setup and minimise contamination between groups, purposive sampling was employed. The control group (n=30) was assessed first, followed by the intervention group (n=30). While this approach helped maintain the integrity of the intervention, the non-randomised design may affect the generalizability of the findings, which is highlighted in the limitations section.
The investigator completed training in Laughter Yoga before the study and utilised the PSS to measure stress levels both before and after the intervention. The Laughter Yoga sessions kicked off with a warm-up that included clapping and chanting (‘Ho, ho, ha, ha, ha’), followed by laughter exercises that integrated deep breathing techniques and laughter meditation. The intervention sessions were conducted three times per week, each lasting 30 minutes, scheduled three hours after the patients’ regular cancer treatments, and continued for one month for participants in the intervention group. Meanwhile, the control group received the usual care provided by the hospital.
Stress levels were measured again on the 10th, 20th and 30th days for both groups. After data collection was completed, the control group was also given the chance to learn Laughter Yoga, allowing them to benefit from the intervention as well.
Data collection tools
Tool 1: Baseline proforma
The researcher developed a baseline proforma, guided by relevant literature. This proforma included the following variables: Age, gender, educational status, occupational status, marital status, number of children, duration of illness, type of cancer, surgical history, co-morbidities, mode of treatment, number of hospitalisations, stage of cancer, family history and availability of insurance.
Tool 2: Perceived stress scale (PSS-10)
The PSS-10, a 10-item instrument with a 5-point Likert scale, was utilised to measure perceived stress. It assesses two domains: Perceived helplessness and lack of self-efficacy. Scores range from 0 to 40, with higher scores indicating high perceived stress. Stress levels were categorised as low (0–13), moderate (14–26) and high (27–40).
Content validity of the baseline proforma was established by 11 experts from the fields of Medical-Surgical Nursing, Radiation Oncology and Medical Oncology. 100% agreement was achieved on all items. Pre-testing confirmed the clarity and appropriateness of all items, requiring no modifications. The PSS-10, a standardised tool, demonstrated good reliability. Cronbach’s alpha, measuring internal consistency, was 0.8, and test-retest reliability using Pearson correlation was 0.71.[16,17]
Statistical analysis
Statistical analyses were performed using Statistical Package for Social Sciences version 23. The baseline characteristics were represented through frequency and percentage. The Shapiro–Wilk test confirmed the normality of the data distribution. The effectiveness of Laughter Yoga on stress levels was evaluated using two-factor repeated measures of analysis of variance (ANOVA). An unpaired t-test was used to compare the post-intervention stress levels between the intervention and control groups. The Chi-square test examined the association between pre-intervention stress levels and baseline variables. For the purpose of association analysis with baseline variables, participants with moderate and high stress were included. Within this subgroup, the observed median score was 35, which was used as a data-driven cut-off to dichotomize participants into two categories (<35 vs. ≥35). This approach allowed for balanced group sizes and facilitated chi-square testing of associations between stress levels and baseline characteristics.
RESULTS
Table 1 presents the baseline characteristics of the 60 participants. In terms of demographics, 36.7% of the intervention group were aged 60–69 and 26.7% in the control group. The majority of participants were female, 53.3% in the intervention and 63.3% in the control group. Regarding education, 33.3% of the intervention group had no formal education, while 43.3% in the control group had only primary education. Most of the subjects, 30% of the intervention group, were unskilled workers, and 36.7% were semiskilled workers in the control group. Marital status showed 66.7% married in the intervention group and 50% in the control group. Family size varied, with 33.3% of the intervention group having one child and 30% of the control group having two children. 36.7% in the intervention group had a duration of illness of 7–12 months. 36.7% in the intervention group were in the second and third stages of cancer, whereas 43.3% in the control group were at the second stage of cancer. Both groups had a similar proportion 63.3% with no surgical history. Hospitalisation rates exceeding 3 times were observed in 33.3% of the intervention group and 30% of the control group. Insurance coverage was similar across groups, with 56.7% having coverage in both. Importantly, the p-values for pre-intervention stress levels were greater than 0.05, indicating no significant difference between the intervention and control groups, thus confirming the homogeneity of the groups.
| Sl. No. | Baseline variables | Intervention group | Control group | ||
|---|---|---|---|---|---|
| f | Percentage | f | Percentage | ||
| 1 | Age (in years): | - | 60.3±9.0 (mean age) | - | 60.5±9.1 |
| 40–49 | 4 | 13.3 | 7 | 23.3 | |
| 50–59 | 11 | 36.7 | 7 | 23.3 | |
| 60–69 | 9 | 30 | 8 | 26.7 | |
| 70–79 | 6 | 20 | 8 | 26.7 | |
| 2 | Gender | ||||
| Male | 14 | 46.7 | 11 | 36.7 | |
| Female | 16 | 53.3 | 19 | 63.3 | |
| 3 | Education status | ||||
| No formal education | 10 | 33.3 | 7 | 23.3 | |
| Primary school | 6 | 20.0 | 13 | 43.3 | |
| High school | 8 | 26.7 | 8 | 26.7 | |
| PUC/diploma | 6 | 20.0 | 2 | 6.7 | |
| 4 | Occupational status | ||||
| Professional | 5 | 16.7 | 2 | 6.7 | |
| Skilled worker | 6 | 20.0 | 4 | 13.3 | |
| Semi-skilled worker | 4 | 13.3 | 11 | 36.7 | |
| Unskilled worker | 9 | 30.0 | 7 | 23.3 | |
| Unemployed | 6 | 20.0 | 6 | 20.0 | |
| 5 | Marital status | ||||
| Married | 20 | 66.7 | 15 | 50.0 | |
| Unmarried | 3 | 10.0 | 6 | 20.0 | |
| Widow/widower | 5 | 16.7 | 5 | 16.7 | |
| Separated/divorced | 2 | 6.6 | 4 | 13.3 | |
| 6 | No. of children | ||||
| No children | 5 | 16.7 | 7 | 23.3 | |
| 1 | 10 | 33.3 | 8 | 26.7 | |
| 2 | 9 | 30.0 | 9 | 30.0 | |
| 3 and above | 6 | 20.0 | 6 | 20.0 | |
| 7 | Duration of illness | ||||
| ≤6 months | 7 | 23.3 | 11 | 36.7 | |
| 7–12 months | 11 | 36.7 | 11 | 36.7 | |
| 1–3 years | 9 | 30.3 | 8 | 26.6 | |
| >3 years | 3 | 10 | 0 | 0 | |
| 8 | Surgical history | ||||
| Yes | 11 | 36.7 | 11 | 36.7 | |
| No | 19 | 63.3 | 19 | 63.3 | |
| 9 | If yes, specify | ||||
| Gynaecological surgeries | 3 | 10 | 4 | 13.3 | |
| Neck and mouth surgeries, | 5 | 16.7 | 5 | 16.7 | |
| Gastrointestinal surgeries | 3 | 10 | 2 | 6.7 | |
| 10 | Co-morbidities | ||||
| Yes | 10 | 33.3 | 14 | 46.7 | |
| No | 20 | 66.7 | 16 | 53.3 | |
| 11 | If yes, specify | ||||
| DM | 1 | 3.3 | 4 | 13.3 | |
| Arthritis | 1 | 3.3 | 0 | 0 | |
| Thyroid | 0 | 0 | 1 | 3.3 | |
| HTN and DM | 4 | 13.3 | 1 | 10.1 | |
| HTN and cholesterol | 4 | 13.3 | 8 | 20 | |
| 12 | Family history of cancer | ||||
| Yes | 8 | 26.7 | 11 | 36.7 | |
| No | 22 | 73.3 | 19 | 63.3 | |
| 13 | Type of cancer | ||||
| Gynaecological | 9 | 30 | 7 | 23.3 | |
| Gastrointestinal | 8 | 26.7 | 9 | 30.0 | |
| Neck, tongue, mouth | 6 | 20 | 11 | 36.7 | |
| Skin | 6 | 20 | 2 | 6.7 | |
| Spine | 1 | 3.3 | 1 | 3.3 | |
| 14 | Mode of treatment | ||||
| Radiation therapy | 4 | 13.3 | 7 | 23.3 | |
| Chemotherapy and radiation | 15 | 50.1 | 12 | 40.1 | |
| Radiation therapy and Surgery | 4 | 13.3 | 4 | 13.3 | |
| Chemotherapy, radiation and surgery | 7 | 23.3 | 7 | 23.3 | |
| 15 | Stage of cancer | ||||
| First stage | 5 | 16.6 | 11 | 36.7 | |
| Second stage | 11 | 36.7 | 13 | 43.3 | |
| Third stage | 11 | 36.7 | 5 | 16.7 | |
| Fourth stage | 3 | 10.0 | 1 | 3.3 | |
| 16 | Number of hospitalisations for the treatment of the present illness | ||||
| First time | 5 | 16.7 | 6 | 20 | |
| 2nd time | 7 | 23.3 | 8 | 26.7 | |
| 3rd time | 8 | 26.7 | 7 | 23.3 | |
| >3-times | 10 | 33.3 | 9 | 30 | |
| 17 | Availability of insurance | ||||
| Yes | 17 | 56.7 | 17 | 56.7 | |
| No | 13 | 43.3 | 13 | 43.3 | |
p < 0.05 is significant. PUC: Pre University College, HTN: Hypertension, DM: Diabetes mellitus
The effectiveness of Laughter Yoga on the stress within the groups
In the pre-test, 16.7% of the participants in the intervention group had moderate, and 83.3% had severe levels of stress. In the control group, 20% had moderate levels of stress and 80% had severe stress [Figure 1]. Normality was assessed using the Shapiro–Wilk test, which indicated no significant deviation from normality (p > 0.05). Therefore, the assumption of normality was considered satisfied, and parametric tests were applied. Two way repeated measures of ANOVA was computed to evaluate the effectiveness of Laughter Yoga on stress reduction. In the intervention group, mean stress scores significantly decreased from 33.6 ± 5.74 on the pre-test to 18.9 ± 7.45 on the 30th day. Conversely, in the control group, mean stress scores slightly increased from 32.53 ± 5.72 on the pre-test to 32.73 on the 30th day. The analysis revealed a significant effect of Laughter Yoga on stress reduction (F = 383.4, p < 0.001), as evidenced by the marked decrease in stress scores within the intervention group [Figure 2].
Comparison of the mean stress scores between the intervention and control groups
The two-way repeated-measures ANOVA revealed a significant group × time interaction, F(1, 58) = 17.37, p < 0.001 [Table 2]. Stress scores in the intervention group decreased markedly from pre-test (M = 33.63) to post-test 3 (M = 18.90), whereas the control group showed no meaningful change (M = 32.53 to 32.73). These findings support rejection of the null hypothesis. The observed trajectory suggests that the beneficial impact of Laughter Yoga on stress reduction may strengthen with longer intervention duration
| Groups | Intervals | Mean | SD | F value | df value | p value |
|---|---|---|---|---|---|---|
| Intervention | Pre test | 33.63 | 5.74 | 17.347 | 1 and 58 | <0.001*** |
| Post test 1 | 27.80 | 6.33 | – | – | – | |
| Post test 2 | 23.70 | 7.01 | – | – | – | |
| Post test 3 | 18.90 | 7.45 | – | – | – | |
| Control group | Pre test | 32.53 | 5.72 | – | – | – |
| Post test 1 | 32.43 | 5.79 | – | – | – | |
| Post test 2 | 32.73 | 5.92 | – | – | – | |
| Post test 3 | 32.73 | 5.58 | – | – | – |
p < 0.001*** Very highly significant
Association between the pre-intervention level of stress and baseline variables in patients with cancer
The association between pre-intervention stress levels and various baseline variables was analysed using the Chi-square test [Table 3]. Statistically significant associations were found between pre-intervention stress levels and age (p = 0.001*), gender (p = 0.001***), marital status (p = 0.003**), duration of illness (p = 0.01**), type of surgeries (p = 0.003**), number of hospitalisations for the treatment of present illness (p = 0.02*) and type of cancer (p = 0.002**), indicating that the null hypothesis is rejected and the variables are significantly associated with pre-intervention stress levels in cancer patients.
| Variables | Pre-intervention stress score | Chi-square value | p-value | |||
|---|---|---|---|---|---|---|
| Median | ||||||
| <35 | ≥35 | |||||
| Age (in years) | ||||||
| 40–49 | 3 | 8 | 18.12 | 0.001*** | ||
| 50–59 | 4 | 14 | ||||
| 60–69 | 9 | 8 | ||||
| 70–79 | 13 | 1 | ||||
| Gender | ||||||
| Male | 24 | 1 | 38.9 | 0.001*** | ||
| Female | 5 | 30 | ||||
| Education status | ||||||
| No formal education | 11 | 6 | Fisher’s | 0.06 | ||
| Primary school | 11 | 8 | exact | |||
| High school | 6 | 10 | ||||
| PUC/diploma | 1 | 4 | ||||
| Occupational status | ||||||
| Professional | 1 | 6 | 0.12 | |||
| Skilled worker | 3 | 7 | Fisher’s | |||
| Semi-skilled worker | 8 | 7 | exact | |||
| Unskilled worker | 11 | 5 | ||||
| Unemployed | 6 | 6 | ||||
| Marital status | ||||||
| Married | 10 | 25 | Fisher’s | 0.003*** | ||
| Unmarried | 6 | 3 | exact | |||
| Widow/widower | 8 | 2 | ||||
| Separated/divorced | 5 | 1 | ||||
| No. of children | ||||||
| No children | 8 | 4 | 3.8 | 0.28 | ||
| 1 | 8 | 10 | ||||
| 2 | 6 | 12 | ||||
| 3 and above | 7 | 5 | ||||
| Duration of illness | ||||||
| ≤6 months | 5 | 13 | Fisher’s exact | 0.01** | ||
| 7–12 months | 9 | 13 | ||||
| 1–3 years | 12 | 5 | ||||
| >3 years | 3 | 0 | ||||
| Surgical history | ||||||
| Yes | 12 | 10 | 0.53 | 0.46 | ||
| No | 17 | 21 | ||||
| If yes, specify | ||||||
| Gynaecological surgeries | 0 | 7 | Fisher’s exact | 0.003*** | ||
| Neck and mouth surgeries | 8 | 2 | ||||
| Gastrointestinal surgeries | 4 | 1 | ||||
| Co-morbidities | ||||||
| Yes | 8 | 16 | 3.6 | 0.05 | ||
| No | 21 | 15 | ||||
| If yes, specify | ||||||
| DM | 3 | 2 | Fisher’s exact | 0.2 | ||
| Arthritis | 0 | 1 | ||||
| Thyroid | 0 | 1 | ||||
| HTN and DM | 1 | 4 | ||||
| HTN and cholesterol | 4 | 8 | ||||
| Family history of cancer | ||||||
| Yes | 10 | 9 | 0.2 | 0.65 | ||
| No | 19 | 22 | ||||
| Type of cancer | ||||||
| Gynaecological | 2 | 14 | Fisher’s exact | 0.002*** | ||
| Gastrointestinal | 11 | |||||
| Neck, Tongue, mouth | 12 | 5 | ||||
| Skin | 4 | 4 | ||||
| Spinal | 0 | 2 | ||||
| Mode of treatment | ||||||
| Radiation therapy | 4 | 3 | Fisher’s exact | 0.50 | ||
| Chemotherapy and radiation | 14 | 13 | ||||
| Radiation therapy and surgery | 4 | 4 | ||||
| Chemotherapy, radiation and surgery | 8 | 6 | ||||
| Stage of cancer | ||||||
| First stage | 8 | 8 | Fisher’s exact | 0.21 | ||
| Second stage | 15 | 9 | ||||
| Third stage | 5 | 11 | ||||
| Fourth stage | 1 | 3 | ||||
| Number of hospitalisations for the treatment of the present illness | ||||||
| 1st time | 1 | 10 | 9.2 | 0.02* | ||
| 2nd time | 7 | 8 | ||||
| 3rd time | 9 | 6 | ||||
| More than 3-times | 12 | 7 | ||||
| Availability of insurance/credit system | ||||||
| Yes | 19 | 15 | 1.79 | 0.18 | ||
| No | 10 | 16 | ||||
p < 0.05 is statistically significant, * Significant, ** Highly significant, ***Very highly significant
DISCUSSION
The diagnosis, treatment and outcomes of cancer can be highly stressful for individuals and their families. Without adequate support and coping strategies, the psychological impact may be severe and could potentially influence cancer progression. In the literature, many studies recommend that Laughter Yoga effectively reduces the stress of cancer patients.[17,18]
The study population primarily comprised older adults, with 60% of subjects falling within the 60–79 years age group. The mean age was found to be 60.39 ± 9.01. A similar finding in the literature mentioned that the mean age was more than 60 ± 17, in which 42.5%were in the intervention group and 47.5% were in the control group.[14] The same findings were evident in another study with a mean age of 60 ± 11.4.[18,19] The present study observed a higher proportion of female participants in both groups, consistent with findings from the literature and clinical experience, which suggest a higher prevalence of cancer among women. The study found that 53.3% of participants in the intervention group and 63.3% in the control group were female, aligning with previous research that reported 61% of patients in the intervention group and 39% in the control group were female.[11] A significant proportion (33.3%) of participants in the intervention group lacked formal education. In contrast, 43.3% of participants in the control group had only a primary school education. These findings align with existing literature, which indicates that a substantial portion of patients (56%) are illiterate.[19,20] In this study a majority of participants were married, with 66.7% in the intervention group and 50% in the control group falling into this category. This finding is supported by another study,[20,21] which reported that 70% of the intervention group and 65% of the control group were married. Furthermore, a separate study found that 92% of participants were married.[15]
The patients with cancer were subjected to immense stress physically, mentally, financially and socially. In the present study, the pre-test results indicated that a significant proportion of both groups experienced severe stress. 83% of the subjects in the intervention group and 80% of the control group reported severe levels of stress. A smaller percentage experienced moderate stress, with 17% in the intervention group and 20% in the control group [Figure 2]. The pre-test stress mean for the intervention group was 33.60 ± 5.74, and for the control group, it was 32.53 ± 5.72. Literature shows that cancer causes significant stress. The pre-test stress score in the intervention group due to cancer was 43.72 ± 4.73, and in the control group, it was 44.15 ± 4.6.[14] Laughter therapy is a non-pharmacological, easily accessible and acceptable alternative therapy to reduce stress through increased endorphin levels as well as reduced cortisol levels.[18,19] The study found that Laughter Yoga significantly reduced stress levels in the intervention group. Before the intervention, their average stress score was 33.6 ± 5.74. After 30 days of Laughter Yoga, this score dropped to 18.9 ± 7.45 on the 30th day (third post-test). In contrast, the control group’s average stress score slightly increased to 32.73 at the third post-test (day 30)”. These results were statistically significant. F = 383.4 [Table 2]. Studies have shown a decrease in stress scores from a mean of 43.72 ± 4.73 in the pre-test to 39.55 ± 4.65 in the post-test. The stress reduction resulting from Laughter Yoga exercises in cancer patients.[11,14]
Comparison of stress levels between cancer patients in the intervention and control groups revealed that the p-values for all three intervals were significant (p = 0.001), indicating a meaningful change from the pretest to the post-test. It can be inferred that the impact of laughter yoga on stress appears to intensify with a longer duration of intervention [Table 2]. The study[18,19] found that participants in the intervention group showed a decrease in stress scores (3.32 ± 2.09 to 1.26 ± 1.32), while the control group reported no changes (3.62 ± 1.95 to 3.72 ± 1.81) (p < 0.01). As the number of Laughter Yoga sessions increased, stress scores in the intervention group significantly decreased (p < 0.01). Post-session results showed that stress levels decreased (−2.55 ± 1.88) (p < 0.01) between pre-session scores and the first post-session scores, with no further significant changes. Another study showed that mental well-being is related to the reduction of stress. They revealed that the participants in the intervention group experienced a significant improvement in mental well-being compared to the control group. The average post-test mental well-being score was 50.0 ± 8.9 in the intervention group, which was significantly higher than the 47.9 ± 10.4 score in the control group (p = 0.004). Furthermore, the intervention group showed a significant increase in their mean post-test score according to repeated measures of ANOVA, p < 0.001.[21,22]
The relationship between the stress score and baseline variables was analysed using the Chi-square test [Table 3]. The statistical analysis revealed a significant association between the pre-intervention stress score and baseline variables, including age, gender, marital status, duration of illness, type of surgeries, type of cancer and number of hospitalisations for the treatment of the present illness. The results of this study support previous research findings that suggest there was a statistically significant relationship between lower education level and head-and-neck cancer with higher distress (p < 0.02) and other tumours, p < 0.001.[20,21] The current study indicates that stress is significantly associated with females (p = 0.001***). In addition, other literature supports this finding, showing that stress is linked to the female gender (p < 0.002) and is particularly notable in cases of breast cancer (p < 0.002). This association may be attributed to concerns about disfigurement, self-image and the impact on sexual drive.[19,20] The present study indicates a significant association between stress and marital status (p = 0.003***). These results align with previous research, demonstrating a statistically significant relationship between stress and marital status (p = 0.01).[18,19]
Study limitations
The use of purposive sampling limits the generalisability of the study findings. The study’s focus on a single hospital further restricts the applicability of the results to other settings. Additionally, the subjective nature of stress makes it difficult for researchers to control for individual variations in stress perception, potentially influencing the accuracy of stress scores.
CONCLUSION
Cancer is a personal crisis that imposes considerable stress on patients and their families. The present study demonstrates that Laughter Yoga significantly reduces perceived stress among patients with cancer. As a simple, non-pharmacological intervention, it offers a practical and acceptable approach to support psychological well-being during treatment. Complementary therapy services incorporating appropriate evidence-based interventions may be considered within multidisciplinary supportive care programmes.
Acknowledgement:
A sincere acknowledgement to the Management, Department of Oncology and the participants of this research study for their wholehearted support.
Ethical approval:
The research/study was approved by the Institutional Review Board at Father Muller institutional ethics committee (FMIEC), number Protocol NO: 067/2023; Ref No: FMIEC/CCM/083/2023, dated 23rd February 2023.
CTRI Number:
REF/2023/09/073736.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given consent for clinical information to be reported in the journal. The patients understand that the patient’s names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that the artificial intelligence (AI)-assisted technology was used for language correction.
Financial support and sponsorship: Nil.
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